Bilateral Arm Training

Evidence Reviewed as of before: 11-06-2018
Author(s): Annabel McDermott (OT); Dr Nicol Korner-Bitensky (PhD OT); Dr Tatiana Ogourtsova (PhD OT)
Patient/Family Information Table of contents

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 stroke 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 stroke 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 stroke, 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 stroke.

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 stroke. In particular, BAT and BAT with rhythmic auditory cueing were useful for patients with chronic stroke (more than 6 months after stroke) 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 therapist or physical therapist 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 therapist or an occupational therapist 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 (RCT) 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, 10 fair quality RCTs, 3 poor quality RCTs and 7 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 (2 studies), subacute (3 studies) or chronic (30 studies) phase of stroke recovery, or where the phase of stroke recovery is not specific to one period (3 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 (10 of which were considered suitable for inclusion in this Stroke Engine module), reported no statistically significant differences in performance of ADL, functional movement of the arm/hand or motor impairment between bilateral upper limb training vs. other specific upper limb (UL) interventions, usual care or no intervention, across all stages of stroke rehabilitation. The more recent systematic review (van Delden et al., 2012) included 9 RCTs (all of which are reviewed in this Stroke Engine module; 4 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 stroke 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 stroke 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 review and meta-analysis of bilateral arm training (Cauraugh et al., 2010) that included 16 comparison studies and 8 pre-post design studies (15 of which were considered suitable for inclusion in this Stroke 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 size for pure bilateral therapy. While similar conclusions are drawn in the Stroke Engine module, the systematic review also found a significant effect from BATRAC; discord with findings in the Stroke 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 stroke of participants and type of bilateral arm training used.

Results Table

View results table

Outcomes

Acute Phase

Dexterity
Conflicting
4

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 stroke.

The first high quality RCT (Morris et al., 2008) randomized patients to receive bilateral or unilateral arm training. Dexterity was measured by the Nine Hole Peg Test (9HPT) at post-treatment (6 weeks) and follow-up (18 weeks). A significant between-group difference was found at follow-up only, favoring unilateral vs. bilateral arm training.

The second high quality RCT (Morris & Van Wijck, 2012) randomized patients to receive bilateral or unilateral arm training. Dexterity was measured by the 9HPT at post-treatment (6 weeks) and follow-up (18 weeks). A significant between-group difference was found at post-treatment, favoring bilateral vs. unilateral arm training. This difference did not remain significant at follow-up.

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 stroke. While a first high quality RCT found that bilateral arm training was not more effective, in the long term, than unilateral arm training; a second high quality RCT found that bilateral arm training is more effective, in the short term, than unilateral arm training in improving dexterity of patients with acute stroke recovery.

Functional independence
Not effective
1b

One high quality RCT (Morris et al., 2008) investigated the effect of bilateral arm training on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. Functional independence was measured by the modified Barthel Index at post-treatment (6 weeks) and follow-up (18 weeks). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) in improving functional independence in patients with acute stroke.

Health-related quality of life
Not effective
1B

One high quality RCT (Morris et al., 2008) investigated the effect of bilateral arm training on health-related quality of life (HRQoL) in patients with acute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. HRQoL was measured by the Nottingham Health Profile at post-treatment (6 weeks) and follow-up (18 weeks). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) in improving health-related quality of life in patients with acute stroke.

Mood / affect
Not effective
1B

One high quality RCT (Morris et al., 2008) investigated the effect of bilateral arm training on mood/affect in patients with acute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. Mood/affect were measured by the Hospital Anxiety and Depression Scale at post-treatment (6 weeks) and follow up (18 weeks). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) in improving mood/affect in patients with acute stroke.

Motor function (upper extremity)
Not effective
1a

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 stroke.

The first high quality RCT (Morris et al., 2008) randomized patients to receive bilateral or unilateral arm training. Upper extremity motor function was measured by the Action Research Arm Test (ARAT – total, gross, grip, grasp, pinch scores) and the Rivermead Motor Assessment at post-treatment (6 weeks) and follow-up (18 weeks). A significant between-group difference was found for one measure of upper extremity motor function (ARAT – pinch score) at follow-up, favoring unilateral vs. bilateral arm training.

The second high quality RCT (Morris & Van Wijck, 2012) randomized patients to receive bilateral or unilateral arm training. Upper extremity motor function was measured by the ARAT at post-treatment (6 weeks) and follow-up (18 weeks). No significant between-group difference was found at either time point.

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 stroke.

Subacute Phase

Dexterity
Not effective
1B

One high quality RCT (Desrosiers et al., 2005) investigated the effect of bilateral arm training on dexterity in patients with subacute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. Dexterity was measured by the Box and Block Test and the Purdue Pegboard Test at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) for improving dexterity in patients with subacute stroke.

Functional independence
Not effective
1B

One high quality RCT (Desrosiers et al., 2005) investigated the effect of bilateral arm training on functional independence in patients with subacute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. Functional independence was measured by the Functional Independence Measure and the Assessment of Motor and Process Skills at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) for improving functional independence in patients with subacute stroke.

Grip strength
Not effective
1B

One high quality RCT (Desrosiers et al., 2005) investigated the effect of bilateral arm training on grip strength in patients with subacute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. Grip strength was measured by vigorimeter at post-treatment (5 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) for improving grip strength in patients with subacute stroke.

Kinematics
Not effective
2B

One poor quality RCT (Platz et al., 2001) investigated the effect of bilateral arm training on upper limb kinematics in patients with subacute stroke. This poor quality RCT 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 RCT 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 stroke.

Motor coordination (upper extremity
Not effective
1B

One high quality RCT (Desrosiers et al., 2005) investigated the effect of bilateral arm training on upper extremity motor coordination in patients with subacute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. Upper extremity motor coordination was measured by the Finger-to-Nose Test at post-treatment (5 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) for improving upper extremity motor coordination in patients with subacute stroke.

Motor function (upper extremity)
Not effective
1B

One high quality RCT (Desrosiers et al., 2005) investigated the effect of bilateral arm training on upper extremity motor function in patients with subacute stroke. This high quality RCT randomized patients to receive bilateral or unilateral arm training. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity subtest (FMA-UE) and the Upper Extremity Performance Test for the Elderly (TEMPA – Unilateral, Bilateral, Total scores) at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training) for improving upper extremity motor function in patients with subacute stroke.

Subacute Phase - Device-driven bilateral arm training

Dexterity
Not effective
1B

One high quality RCT (Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on dexterity in patients with subacute stroke. This high quality RCT randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. Dexterity was measured by the Box and Block Test at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that robot-assisted bilateral arm training + task-oriented training is not more effective than a comparison intervention (time-matched task-oriented training alone) in improving dexterity in patients with subacute stroke.

Fatigue
Not effective
1B

One high quality RCT (Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on fatigue in patients with subacute stroke. This high quality RCT randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. Fatigue was measured by an 11-point self-report fatigue scale at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that robot-assisted bilateral arm training + task-oriented training is not more effective than a comparison intervention (time-matched task-oriented training alone) in reducing fatigue in patients with subacute stroke.

Functional independence
Not effective
1B

One high quality RCT (Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on functional independence in patients with subacute stroke. This high quality RCT randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. Functional independence was measured by the Functional Independence Measure and the modified Rankin Scale at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that robot-assisted bilateral arm training + task-oriented training is not more effective than a comparison intervention (time-matched task-oriented training alone) in improving functional independence in patients with subacute stroke.

Grip strength
Not effective
1b

One high quality RCT (Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on grip strength in patients with subacute stroke. This high quality RCT randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. Grip strength was measured by the Jamar Plus Digital Hand Dynamometer at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that robot-assisted bilateral arm training + task-oriented training is not more effective than a comparison intervention (time-matched task-oriented training alone) in improving grip strength in patients with subacute stroke.

Motor function (upper extremity)
Conflicting
4

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 stroke.

The first high quality RCT (Hesse et al., 2005) randomized patients to receive computerized bilateral arm training or electromyography-initiated (EMG) electrical stimulation of paretic wrist extensors. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity subscale (FMA-UE) at post-treatment (6 weeks) and follow-up (3 months). Significant between-group difference was found at both time points, favoring computerized bilateral arm training vs. EMG electrical stimulation of paretic wrist extensors.

The second high quality RCT (Hsieh et al., 2017) randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). No significant between-group difference was found.

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 stroke. 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
1B

One high quality RCT (Hesse et al., 2005) investigated the effect of device-driven bilateral arm training on spasticity in patients with subacute stroke. This high quality RCT randomized patients to receive computerized bilateral arm training or electromyography-initiated electrical (EMG) electrical stimulation of paretic wrist extensors. Spasticity was measured by the Modified Ashworth Scale (total score) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computerized bilateral arm training is not more effective than a comparison intervention (EMG electrical stimulation of paretic wrist extensors) for reducing spasticity in patients with subacute stroke.

Stroke outcomes
Not effective
1B

One high quality RCT (Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on stroke outcomes in patients with subacute stroke. This high quality RCT randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. Stroke outcomes were measured by the Stroke 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.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that robot-assisted bilateral arm training + task-oriented training is not more effective than a comparison intervention (time-matched task-oriented training alone) in improving stroke outcomes in patients with subacute stroke.

Wrist activity / rest cycles
Not effective
1B

One high quality RCT (Hsieh et al., 2017) investigated the effect of device-driven bilateral arm training on the activity/rest cycles of the wrist in patients with subacute stroke. This high quality RCT randomized patients to receive robot-assisted bilateral arm training + task-oriented training or time-matched task-oriented training alone. Wrist activity/rest cycles were measured by a Mini-Motionlogger Actigraph at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral robot-assisted arm training + task-oriented training is not more effective than a comparison intervention (time-matched task-oriented training alone) in improving wrist activity/rest cycles in patients with subacute stroke.

Wrist strength
Effective
1B

One high quality RCT (Hesse et al., 2005) investigated the effect of device-driven bilateral arm training on wrist strength in patients with subacute stroke. This high quality RCT randomized patients to receive computerized bilateral arm training or electromyography-initiated (EMG) electrical stimulation of paretic wrist extensors. Wrist strength was measured by the Medical Research Council Scale (total score) at post-treatment (6 weeks) and follow-up (3 months). A significant between-group difference was found at both time points, favoring computerized bilateral arm training vs. EMG electrical stimulation of paretic wrist extensors.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that computerized bilateral arm training is more effective than a comparison intervention (EMG electrical stimulation of paretic wrist extensors) for improving wrist strength in patients with subacute stroke.

Chronic Phase

Dexterity
Effective
1b

One high quality RCT (Lee et al., 2017) investigated the effect of bilateral arm training on dexterity in patients with chronic stroke. This high quality RCT randomized patients to receive bilateral arm training using daily activities or time-matched occupational therapy using the Bobath approach; both groups received conventional occupational therapy. Dexterity was measured by the Box and Block Test 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 moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is more effective than a comparison intervention (time-matched occupational therapy using the Bobath approach) in improving dexterity in patients with chronic stroke.

Functional independence
Not effective
1A

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 RCT (Shim & Jung, 2015) investigated the effect of bilateral arm training on functional independence in patients with chronic stroke.

The first high quality RCT (van der Lee et al., 1999) randomized patients to receive bilateral arm training based on neurodevelopmental techniques or forced use therapy. Functional independence was measured by the Rehabilitation Activities Profile (Personal care, Occupation scores) at post-treatment (3 weeks) and follow-up (6 weeks, 6 months, 12 months). No significant between-group difference was found at any time point.

The second high quality RCT (Lin et al., 2009) randomized patients to receive bilateral arm training, modified constraint induced movement therapy (mCIMT) or dose-matched conventional rehabilitation comprising neurodevelopmental therapy and compensatory practice of functional tasks. Functional independence was measured by the Functional Independence Measure (FIM – Total, Self-care, Sphincter control, Transfers, Locomotion, Communication, Social cognition scores) at post-treatment (3 weeks). Significant between-group differences were found for one component (FIM – Locomotion), favouring mCIMT vs. bilateral arm training and conventional rehabilitation. No significant difference was found between bilateral arm training and conventional rehabilitation were found.

The third high quality RCT (Lin et al., 2010) randomized patients to receive bilateral arm training using functional tasks or occupational therapy upper limb training using neurodevelopmental techniques. Functional independence was measured by the FIM at post-treatment (3 weeks). No significant between-group difference was found.

The fourth high quality RCT (Lee et al., 2017) randomized patients to receive bilateral arm training using daily activities 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.

The fair quality RCT (Shim & Jung, 2015) randomized patients to receive bilateral or unilateral arm training using functional tasks. Functional independence was measured by the FIM (Motor, Cognitive, Total scores) at post-treatment (6 weeks). Significant between-group differences (FIM – Motor, Total scores) were found, favouring bilateral vs. unilateral arm training.

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 stroke. In fact, one of these high quality RCTs found a significant between-group differences on a subscale of a measure of functional independence in favor of a TCIMm compared to bilateral arm training.

Note: However, one high quality RCT and one fair quality RCT 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 stroke. The difference in measurement tools used and treatment duration across studies could potentially account for the discrepancies in findings.

Grip strength
Not effective
1B

One high quality RCT (Suputtitada et al., 2004) and one fair quality RCT (Stoykov et al., 2009) investigated the effect of bilateral arm training on grip strength in patients with chronic stroke.

The high quality RCT (Suputtitada et al., 2004) randomized patients to receive bilateral arm training based on neurodevelopmental techniques or constraint induced movement therapy (CIMT). Grip strength was measured by dynamometer at post-treatment (2 weeks). No significant between-group difference was found.

The fair quality RCT (Stoykov et al., 2009) randomized patients to receive functional bilateral or unilateral arm training. Grip strength was measured by dynamometer at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that bilateral arm training is not more effective than comparison interventions (CIMT, unilateral arm training) for improving grip strength in patients with chronic stroke.

Kinematics (upper extremity)
Effective
1a

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 stroke.

The first high quality RCT (Summers et al., 2007) randomized patients to receive bilateral movement training or unilateral movement training. Upper extremity movement kinematics (movement time, velocity, curvature of arm trajectories and elbow angle) were measured at each training session (6 sessions). No significant between-group differences were found.

The second high quality RCT (Lin et al., 2010) randomized patients to receive bilateral arm training using functional tasks or occupational therapy upper limb training using neurodevelopmental techniques. Upper extremity movement kinematics (NMT, NTD, PPV) were measured during unilateral and bilateral reach movements at post-treatment (3 weeks). Significant between-group differences were found during unilateral (NMT, NTD) and bilateral (NMT, NTD, PPV) reach movements, favouring bilateral arm training vs. neurodevelopmental techniques.

The third high quality RCT (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 RCT (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 stroke.

Note: However, one high quality RCT 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
1A

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 RCT (Wu et al., 2010) investigated the effect of bilateral arm training on upper extremity motor activity in patients with chronic stroke.

The first high quality RCT (van der Lee et al., 1999) randomized patients to receive bilateral arm training based on neurodevelopmental techniques or forced use therapy. Upper extremity motor activity was measured by the Motor Activity Log – Amount of Use (MAL-AOU), Quality of Movement (MAL-QOM) and Problem (MAL-Problem) scores at post-treatment (3 weeks) and follow-up (6 weeks, 6 months, 12 months). No significant between-group differences were found at any time points.

The second high quality RCT (Lin et al., 2009) randomized patients to receive bilateral arm training, modified constraint induced movement therapy (mCIMT) or dose-matched conventional rehabilitation comprising neurodevelopmental therapy and compensatory practice of functional tasks. Upper extremity motor activity was measured by MAL-AOU and MAL-QOM scores at post-treatment (3 weeks). Significant between-group differences on both upper extremity motor activity measures were found, favouring mCIMT vs. bilateral arm training. There were no significant differences between bilateral arm training and conventional rehabilitation.

Note: There were significant differences on both upper extremity motor activity measures, favouring mCIMT vs. conventional rehabilitation.

The third high quality RCT (Lin et al., 2010) randomized patients to receive bilateral arm training using functional tasks or occupational therapy upper limb training using neurodevelopmental techniques. Upper extremity motor activity was measured by the MAL-AOU and MAL-QOM at post-treatment (3 weeks). No significant between-group differences were found.

The fourth high quality RCT (Wu et al., 2011) randomized patients to receive bilateral arm training, mCIMT or conventional rehabilitation. Upper extremity motor activity was measured by the MAL-AOU and MAL-QOM at post-treatment (3 weeks). Significant between-group differences on both measures of upper extremity motor activity were found, favouring mCIMT vs. bilateral arm training. No significant differences were found between bilateral arm training and conventional rehabilitation.

Note: Comparison of mCIMT and conventional rehabilitation revealed significant between-group differences on both measures of upper extremity motor activity, favouring mCIMT.

The fifth high quality RCT (Wu et al., 20122) randomized patients to receive therapist-led bilateral arm training, robot-assisted bilateral arm training or conventional rehabilitation. Upper extremity motor activity was measured by the MAL-AOU and MAL-QOM 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.

The first fair quality RCT (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 RCT (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 evidence in the conclusion below.

The poor quality RCT (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 evidence 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 stroke. In fact, two high quality RCTs found that mCIMT was more effective than bilateral arm training.

Note: However, one fair quality RCT 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
4

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 RCT (Wu et al., 2010) investigated the effect of bilateral arm training on upper extremity motor function in patients with chronic stroke.

The first high quality RCT (van der Lee et al., 1999) randomized patients to receive bilateral arm training based on neurodevelopmental techniques or forced use therapy. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT) at post-treatment (3 weeks) and follow-up (6 weeks, 6 months, 12 months). No significant between-group differences were found in any of the measurements, at any time points.

The second high quality RCT (Suputtitada et al., 2004) randomized patients to receive bilateral arm training based on neurodevelopmental techniques or constraint induced movement therapy (CIMT). Upper extremity motor function was measured by the ARAT (Total, Grasp, Grip, Pinch, Gross scores) at post-treatment (2 weeks). Significant between-group differences were found on all upper extremity motor function measures at post-treatment, favouring CIMT vs. bilateral arm training.

The third high quality RCT (Summers et al., 2007) randomized patients to receive bilateral or unilateral movement training. Upper extremity motor function was measured by the modified Motor Assessment Scale (Upper arm function, Hand movements, Advanced hand movements) at post-treatment (6 days). Significant between-group differences were found on all upper extremity motor function measures at post-treatment, favouring bilateral vs. unilateral movement training.

The fourth high quality RCT (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 fifth high quality RCT (Lin et al., 2010) randomized patients to receive bilateral arm training using functional tasks or occupational therapy upper limb training using neurodevelopmental techniques. Upper extremity motor function was measured by the FMA-UE at post-treatment (3 weeks). A significant between-group difference was found at post-treatment, favouring bilateral arm training vs. occupational therapy using neurodevelopmental techniques.

The sixth high quality RCT (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 RCT (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 RCT (Lee et al., 2017) randomized patients to receive bilateral arm training using daily activities 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 RCT (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 activities, 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 second fair quality RCT (Hayner et al., 2010) randomized patients to receive bilateral arm training or mCIMT. Upper extremity motor function was measured by the WMFT at post-treatment (10 days) and follow-up (6 months). No significant between-group difference was found at either time point.

The third fair quality RCT (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 RCT (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 evidence in the conclusion below.

The poor quality RCT (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 evidence 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 stroke. 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 RCT and one fair quality RCT found that mCIMT was more effective than bilateral arm training.

Pinch strength
Not effective
1B

One high quality RCT (Suputtitada et al., 2004) investigated the effect of bilateral arm training on pinch strength in patients with chronic stroke. This high quality RCT randomized patients to receive bilateral arm training based on neurodevelopmental techniques or constraint induced movement therapy (CIMT). Pinch strength was measured by dynamometer at post-treatment (2 weeks). A significant between-group difference was found, favouring CIMT vs. bilateral arm training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that bilateral arm training is not more effective than a comparison intervention (CIMT) for improving pinch strength in patients with chronic stroke. In fact, the high quality RCT found that CIMT was more effective than bilateral arm training.

Strength (upper extremity)
Conflicting
4

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 stroke.

The first fair quality RCT (Stoykov et al., 2009) randomized patients to receive functional bilateral or unilateral arm training. Upper extremity strength (shoulder flexion/extension, internal/external rotation; elbow flexion/extension; wrist flexion/extension) was measured by dynamometer at post-treatment (8 weeks). No significant between-group differences were found.

The second fair quality RCT (Shim & Jung, 2015) randomized patients to receive bilateral or unilateral arm training using functional tasks. Arm strength (paretic side) was measured by the Manual Function Test at post-treatment (6 weeks). A significant between-group difference was found, favouring bilateral vs. unilateral arm training.

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 stroke. While a first fair quality RCT found that bilateral arm training was not more effective than unilateral arm training; a second fair quality RCT found that bilateral arm training is more effective than unilateral arm training in improving upper extremity strength in patients with chronic stroke.

Stroke outcomes
Not effective
1A

Two high quality RCTs (Lin et al., 2009; Wu et al., 2012) investigated the effects of bilateral arm training on stroke outcomes in patients with chronic stroke.

The first high quality RCT (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. Stroke outcomes were measured by the Stroke Impact Scale (SIS – Total score, Strength, Memory, Emotion, Communication, ADL/IADL, Mobility, Hand function, Social participation) at post-treatment (3 weeks). Significant between-group differences were found on three domains (SIS – Total score, ADL/IADL, Social participation), 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 RCT (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. Stroke 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 stroke outcomes in patients with chronic stroke. In fact, one of the high quality RCTs found that mCIMT was more effective than bilateral arm training for improving stroke outcomes.

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

Dexterity
Effective
2B

One fair quality RCT (Cauraugh & Kim, 2002) investigated the use of bilateral arm training with EMG stimulation on dexterity in patients with chronic stroke. This fair quality RCT randomized patients to receive bilateral arm training + EMG-triggered neuromuscular stimulation of wrist and finger extensors, unilateral arm training + EMG-triggered neuromuscular stimulation of wrist and finger extensors, or active wrist and finger extension exercises. Dexterity was measured by the Box and Block Test 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.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that bilateral arm training with EMG stimulation is effective in improving dexterity in patients with chronic stroke.

Kinematics (upper extremity)
Effective
2B

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 stroke.

The first fair quality RCT (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 RCT (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 stroke.

Wrist strength
Effective
2B

One fair quality RCT (Cauraugh & Kim, 2002) investigated the effect of bilateral arm training with EMG stimulation on wrist strength in patients with chronic stroke. This fair quality RCT 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. Wrist strength was 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.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that bilateral arm training with EMG stimulation is effective in improving wrist strength in patients with chronic stroke.

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

Dexterity
Not effective
1a

Two high quality RCTs (Dispa et al., 2013; Waller et al., 2014) and one poor quality RCT (Rosa et al., 2010) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on dexterity in patients with chronic stroke.

The first high quality cross-over RCT (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 second high quality RCT (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). Dexterity was measured by the Box and Block Test at post-phase 1 (6 weeks), post-phase 2 (12 weeks) and follow-up (18 weeks). No significant between-group difference was found at any time points.

The poor quality RCT (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 evidence 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 stroke.

Fine motor coordination
Not effective
2b

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 stroke. 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 stroke.

Functional use (upper extremity)
Not effective
1b

One high quality RCT (Luft et al., 2004) 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 functional use of the upper extremity in patients with chronic stroke.

The high quality RCT (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 Stroke (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.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than a comparison intervention (unilateral upper limb exercises based on neurodevelopmental techniques) in improving functional use of the upper extremity in patients with chronic stroke.

Note: However, 2 non-randomized studies reported significant improvements in functional use of the upper limb following BATRAC.

Grip strength
Not effective
1b

One high quality RCT (Dispa et al., 2013) and one non-randomized study (Whitall et al., 2000) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on grip strength in patients with chronic stroke.

The high quality cross-over RCT (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.

Conclusion: There is moderate evidence (Level 1b) from one high-quality RCT that bilateral arm training is not more effective than a comparison intervention (unilateral movement therapy with rhythmic auditory cueing) in improving grip-lift force coordination in patients with chronic stroke. Furthermore, one non-RCT design study also reported no significant gains in grip strength following BATRAC.

Kinematics (upper extremity)
Not effective
2a

One fair quality RCT (McCombe Waller, Liu & Whitall, 2008) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on upper extremity movement kinematics in patients with chronic stroke. This fair quality RCT randomized patients to receive BATRAC or unilateral upper limb training based on neurodevelopmental techniques. Upper extremity movement kinematics (distance moved, movement time, peak acceleration, peak velocity, movement units of the paretic hand on bilateral reach, and hand path accuracy of paretic/non-paretic hand on bilateral reach) were measured at post-treatment (6 weeks). Significant between-group differences in two measures of upper extremity kinematics (movement units of the paretic hand on bilateral reach; hand path accuracy of paretic and non-paretic hands on bilateral reach task) were found, favouring BATRAC vs. unilateral neurodevelopmental techniques.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that BATRAC is not more effective than a comparison intervention (unilateral neurodevelopmental techniques) for improving unilateral measures of upper extremity movement kinematics in patients with chronic stroke. However, results showed that BATRAC was more effective than unilateral neurodevelopmental techniques in improving some kinematic measures during bilateral reach tasks.

Motor function (upper extremity)
Not effective
1A

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 RCT (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 stroke.

The first high quality RCT (Luft et al., 2004) randomized patients to receive BATRAC or dose-matched upper limb exercises based on neurodevelopmental techniques. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE) and the Wolf Motor Function Test (WMFT – Time, Strength scores) at post-treatment (6 weeks). No significant between-group differences were found.

The second high quality RCT (Whitall et al., 2011) randomized patients to receive BATRAC or dose-matched unilateral therapeutic exercises based on neurodevelopmental techniques. Upper extremity motor function was measured by the FMA-UE and the WMFT (Time, Strength, Function scores) at post-treatment (6 weeks) and follow-up (4 months). No significant between-group differences were found at either time point.

The third high quality cross-over RCT (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 fourth high quality RCT (Shahine & Shafshak, 2014) randomized patients to receive BATRAC or unilateral upper extremity rehabilitation. Upper extremity motor function was measured by the FMA-UE at post-treatment (8 weeks). No significant between-group difference was found.

The fifth high quality RCT (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 Stroke (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 RCT (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 evidence in the conclusion below.

The poor quality RCT (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 evidence 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 stroke. A poor quality RCT reported poorer outcomes following BATRAC vs. unilateral training.

Note: However, one high quality RCT reported long-term benefits of BATRAC vs. unilateral task-oriented training. Furthermore, one fair quality RCT and two non-randomized studies reported significant improvements in upper extremity motor function following BATRAC.

Motor recovery (upper extremity)
Effective
1B

One high quality RCT (Shahine & Shafshak, 2014) investigated the effect of BATRAC on upper extremity motor recovery in patients with chronic stroke. This high quality RCT randomized patients to receive BATRAC or unilateral upper extremity rehabilitation. Upper extremity motor recovery was measured by Motor Evoked Potentials (transcranial magnetic stimulation threshold, motor condition time, amplitude ratio) of the paretic abductor pollicis brevis at post-treatment (8 weeks). Significant between-group differences were found on all measures of upper extremity motor recovery, favouring BATRAC vs. unilateral upper extremity rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is more effective than a comparison intervention (unilateral upper extremity rehabilitation) in improving upper extremity motor recovery in patients with chronic stroke.

Range of motion (upper extremity)
Not effective
2B

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 stroke. 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 stroke.

Note: However, the study found significant and sustained improvements in wrist flexion and thumb opposition.

Satisfaction with activities and participation
Not effective
1B

One high quality RCT (Dispa et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on satisfaction with activities and participation in patients with chronic stroke. This high quality cross-over RCT randomized patients to receive BATRAC or unilateral arm training with rhythmic auditory cueing. Satisfaction with activities and participation 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 RCT that bilateral arm training is not more effective than a comparison intervention (unilateral arm training with rhythmic auditory cueing) in improving satisfaction with activities and participation in patients with chronic stroke.

Spasticity
Not effective
1B

One high quality RCT (Waller et al., 2014) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on spasticity in patients with chronic stroke. This high quality RCT 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). Spasticity was measured by the Modified Ashworth Scale at post-phase 1 (6 weeks), post-phase 2 (12 weeks) and follow-up (18 weeks). No significant between-group difference was found at any time points.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than a comparison intervention (unilateral task-oriented training) in reducing spasticity in patients with chronic stroke.

Strength (upper extremity)
Not effective
1A

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 stroke.

The first high quality RCT (Luft et al., 2004) randomized patients to receive BATRAC or dose-matched upper limb exercises based on neurodevelopmental techniques. Strength of the paretic shoulder and elbow was measured by a dynamometer at post-treatment (6 weeks). No significant between-group difference was found.

The second high quality RCT (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
1B

One high quality RCT (Whitall et al., 2011) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive BATRAC or dose-matched unilateral therapeutic exercises based on neurodevelopmental techniques. Stroke outcomes were measured with the Stroke 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.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than a comparison intervention (unilateral neurodevelopmental techniques) in improving stroke outcomes in patients with chronic stroke.

Chronic Phase - Bilateral video game training

Motor function (upper extremity)
Effective
2B

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 stroke. 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 stroke.

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
2a

One fair quality RCT (Byl et al., 2013) investigated the effect of device-driven bilateral arm training on cognitive function in patients with chronic stroke. This fair quality RCT 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. Cognitive function was measured by the Saint Louis University Mental Status Examination at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in improving cognitive function in patients with chronic stroke.

Depression
Not effective
2A

One fair quality RCT (Byl et al., 2013) investigated the effect of device-driven bilateral arm training on depression in patients with chronic stroke. This fair quality RCT 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. Depression was measured by the Beck 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 RCT that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in improving depression in patients with chronic stroke.

Dexterity
Not effective
2A

One fair quality RCT (Byl et al., 2013) investigated the effect of device-driven bilateral arm training on dexterity in patients with chronic stroke. This fair quality RCT 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. Dexterity was measured by the Motor Skill Performance Score (Box and Block Test + Tapper Test combined scores) at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in improving dexterity in patients with chronic stroke.

Functional independence
Not effective
1b

One high quality RCT (Lum et al., 2002) and one fair quality RCT (Byl et al., 2013) investigated the effect of device-driven bilateral arm training on functional independence in patients with chronic stroke.

The high quality RCT (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.

The fair quality RCT (Byl et al., 2013) randomized patients to receive 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. Functional independence was measured by the CAFÉ 40 + Stroke Impact Scale (Self-care domain) combined score at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT 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 stroke.

Note: The high quality RCT found long-term gains in functional independence in favour of bilateral device-driven bilateral arm training vs. neurodevelopmental techniques.

Grip strength
Not effective
2A

One fair quality RCT (Stinear et al., 2008) and one non-RCT design study (Chang et al., 2007) investigated the effect of device-driven bilateral arm training on grip strength in patients with chronic stroke.

The fair quality RCT (Stinear et al., 2008) randomized patients to receive active-passive bilateral therapy using a mechanical device + motor practice or motor practice alone. Grip strength was measured by a dynamometer at post-treatment (4 weeks) and follow-up (8 weeks). No significant between-group difference was found at either time point.

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.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that device-driven bilateral arm training is not more effective than a comparison intervention (motor practice alone) for improving grip strength in patients with chronic stroke.

Note: However, a non-randomized study reported a significant improvement in grip strength following robot-aided bilateral training.

Kinematics
Effective
1a

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 stroke.

The first high quality RCT (Lum et al., 2002) randomized patients to receive robot-assisted bilateral movement training using the MIT-MANUS robot manipulator or conventional upper limb rehabilitation using neurodevelopmental techniques. Movement kinematics during reaching at tabletop and shoulder heights (forward-lateral, lateral, forward-medial, forward) were measured at post-treatment (2 months). Significant between-group differences were found for reach kinematics at tabletop height (forward-lateral, lateral) and shoulder height (forward-lateral, lateral, forward-medial, forward), favouring robot-assisted bilateral movement training vs. neurodevelopmental techniques.

The second high quality RCT (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 RCT (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 stroke. 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
1A

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 stroke.

The first high quality RCT (Wu et al., 2012) randomized patients with chronic stroke to receive robot-assisted bilateral arm training using the Bi-Manu-Track arm trainer, therapist-led bilateral arm training, or conventional rehabilitation. Upper extremity motor activity was measured by the Motor Activity Log – Amount of Use (MAL-AOU) and – Quality of Movement (MAL-QOM) at post-treatment (4 weeks). There were no significant differences between robot-assisted bilateral arm training and therapist-led bilateral arm training, or between robot-assisted bilateral arm training and conventional rehabilitation.
Note: Therapist-led bilateral arm training results are reported in the bilateral arm training section.

The second high quality RCT (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 activity was measured by the MAL-AOU, MAL-QOM and the ABILHAND Questionnaire at post-treatment (4 weeks). No significant between-group differences were found in any of the measurements.

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, unilateral robot-assisted arm training) for improving upper extremity motor activity in patients with chronic stroke.

Motor function (upper extremity)
Not effective
1A

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 stroke.

The first high quality RCT (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. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE – Proximal, Distal scores) at mid-treatment (1 month), post-treatment (2 months) and follow-up (6 months). A significant between-group difference (FMA-UE Proximal score only) was found at mid-treatment and at post-treatment, favouring bilateral robot-assisted movement training vs. neurodevelopmental techniques. This difference was not maintained at 6-month follow-up.

The second high quality RCT (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. Upper extremity motor function was measured by the FMA-UE (Proximal, Distal, Total scores) at post-treatment (4 weeks). There were no significant differences between robot-assisted bilateral arm training and conventional rehabilitation, or 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.

The third high quality RCT (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 fair quality RCT (Stinear et al., 2008) randomized patients to receive bilateral therapy using a mechanical device + motor practice or motor practice alone. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks) and follow-up (8 weeks). A significant between-group difference was found at follow-up, favouring bilateral therapy + motor practice vs. motor practice alone.

The second fair quality RCT (Byl et al., 2013) 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. Upper extremity motor function was measured by the FMA-UE and the Motor Proficiency Speed Score (Wolf-Motor Function Test + Digital Reaction Time Test combined scores) at post-treatment (6 weeks). No significant 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 stroke. In fact, one high quality RCT 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 RCT 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 RCT 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 RCT 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
2a

One fair quality RCT (Stinear et al., 2008) investigated the effect of device-driven bilateral arm training on neurological recovery in patients with chronic stroke. This fair quality RCT randomized patients to receive active-passive bilateral arm therapy using a mechanical device and motor practice or motor practice alone. Neurological recovery was measured by the National Institutes of Health Stroke Scale at post-treatment (4 weeks) and follow-up (8 weeks). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that bilateral arm therapy using a mechanical device is not more effective than a comparison intervention (motor practice alone) for improving neurological recovery in patients with chronic stroke.

Pain
Not effective
2A

One fair quality RCT (Byl et al., 2013) investigated the effect of device-driven bilateral arm training on pain in patients with chronic stroke. This fair quality RCT 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. Pain was measured by a self-rated 0-10 ordinal scale at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in reducing pain in patients with chronic stroke.

Range of motion
Not effective
2A

One fair quality RCT (Byl et al., 2013) investigated the effect of device-driven bilateral arm training on range of motion in patients with chronic stroke. This fair quality RCT 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. Active range of motion of the upper extremity (shoulder flexion/extension, abduction/adduction, internal/external rotation; elbow flexion/extension; wrist flexion/extension) was measured by goniometer at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in improving range of motion in patients with chronic stroke.

Spasticity (upper extremity)
Not effective
2A

One fair quality RCT (Byl et al., 2013) and two non-randomized studies (Hesse et al., 2003; Chang et al., 2007) investigated the effect of device-driven bilateral arm training on upper extremity spasticity in patients with chronic stroke.

The fair quality RCT (Byl et al., 2013) 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. Upper extremity spasticity was measured by the Modified Ashworth Scale (MAS) at post-treatment (6 weeks). No significant 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. Elbow spasticity 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 spasticity 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 RCT that device-driven bilateral arm training is not more effective than comparison interventions (unilateral robotic training, unilateral therapist-led training) in reducing upper extremity spasticity in patients with chronic stroke. Further, two non-randomized studies found no improvements in upper extremity spasticity following device-driven bilateral arm training.

Spasticity (wrist/finger)
Effective
2b

One non-randomized study (Hesse et al., 2003) investigated the effect of device-driven bilateral arm training on wrist/finger spasticity in patients with chronic stroke. This non-randomized study assigned patients to receive bilateral arm training using a robotic arm trainer and conventional rehabilitation. Wrist/finger spasticity 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 spasticity in patients with chronic stroke in the short term.

Strength (upper extremity)
Effective
1B

One high quality RCT (Lum et al., 2002), one fair quality RCT (Byl et al., 2013) and one non-RCT design study (Chang et al., 2007) investigated the effect of device-driven bilateral arm training on upper extremity strength in patients with chronic stroke.

The high quality RCT (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 fair quality RCT (Byl et al., 2013) 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. Arm strength was measured by the Manual Muscle Test (total upper extremity score) at post-treatment (6 weeks). No significant between-group differences were found.

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 RCT that device-driven bilateral arm training is more effective than a comparison intervention (neurodevelopmental techniques) for improving upper extremity strength in patients with chronic stroke. One non-randomized study also found improvements in elbow strength following robot-aided bilateral training.

Note: However, a fair quality RCT 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
1B

One high quality RCT (Wu et al., 2012) investigated the effect of device-driven bilateral arm training on stroke outcomes in patients with stroke. This high quality RCT randomized patients to receive robot-assisted bilateral arm training using the Bi-Manu-Track arm trainer, therapist-led bilateral arm training, or conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale (SIS – Total, Strength, Memory, Emotion, Communication, ADL/IADL, Mobility, Hand function, Social participation, 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 stroke 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 RCT that device-drive bilateral arm training is more effective than a comparison intervention (conventional rehabilitation) for improving some stroke outcomes in patients with chronic stroke. 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
1B

One high quality RCT (Van Delden et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on dexterity in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive BATRAC, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. Dexterity was measured by the Nine Hole Peg Test at post-treatment (6 weeks) and follow-up (12 weeks). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than comparison interventions (mCIMT, conventional rehabilitation) in improving dexterity in patients with stroke.

Motor activity (upper extremity)
Not Effective
1B

One high quality RCT (van Delden et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on upper extremity motor activity in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive BATRAC, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. Upper extremity motor activity was measured by the Motor Activity Log (Amount of Use, Quality of Movement) at post-treatment (6 weeks) and follow-up (12 weeks). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than comparison interventions (mCIMT, conventional rehabilitation) in improving upper extremity motor activity in patients with stroke.

Motor function (upper extremity)
Not Effective
1B

One high quality RCT (van Delden et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on upper extremity motor function in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive BATRAC, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. Upper extremity motor function was measured by the Action Research Arm Test (Grasp, Grip, Pinch, Gross movement scores) and the Fugl-Meyer Assessment – Upper Extremity at post-treatment (6 weeks) and follow-up (12 weeks). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than comparison interventions (mCIMT, conventional rehabilitation) in improving upper extremity motor function in patients with stroke.

Sensation
Not Effective
1B

One high quality RCT (van Delden et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on sensation in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive BATRAC, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. Sensation was measured by the Erasmus modification of the Nottingham Sensory Assessment at post-treatment (6 weeks) and follow-up (12 weeks). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than comparison interventions (mCIMT, conventional rehabilitation) in improving sensation in patients with stroke.

Strength (upper extremity)
Not Effective
1B

One high quality RCT (van Delden et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on upper extremity strength in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive BATRAC, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. Upper extremity strength was measured by the Motricity Index (upper extremity score) at post-treatment (6 weeks) and follow-up (12 weeks). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that BATRAC is not more effective than comparison interventions (mCIMT, conventional rehabilitation) in improving upper extremity strength in patients with stroke.

Stroke outcomes
Not Effective
1B

One high quality RCT (van Delden et al., 2013) investigated the effect of bilateral arm training with rhythmic auditory cueing (BATRAC) on stroke outcomes in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive BATRAC, modified constraint induced movement therapy (mCIMT) or conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale (SIS – Strength, Memory, Emotion, Communication, ADL/IADL, Mobility, Hand function, Social participation 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 RCT that BATRAC is not more effective than comparison interventions (mCIMT, conventional rehabilitation) in improving stroke outcomes in patients with stroke.

Note: In fact, BATRAC was found to be less effective than conventional rehabilitation in improving two stroke outcomes.

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

Grip strength
Not effective
2B

One non-randomized study (Stinear & Byblow, 2004) investigated the effect of device-driven bilateral arm training on grip strength in patients with stroke. This non-randomized study assigned patients with subacute/chronic stroke 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 stroke.

Motor function (upper extremity)
Effective
2B

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 stroke.

The first non-randomized study (Stinear & Byblow, 2004) assigned patients with subacute/chronic stroke 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 stroke 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 evidence 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 stroke. A second study also reported improvements following bilateral training using a device.

Strength (upper extremity)
Not effective
2B

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 stroke.

The first non-randomized study (Stinear & Byblow, 2004) assigned patients with subacute/chronic stroke 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 stroke 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 evidence 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 stroke.

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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 stroke: 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 bilateral robot-assisted arm therapy and constraint-induced therapy improves reach to press and trunk kinematics in patients with stroke. 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 activities of daily living of stroke patients. Journal of Physical Therapy Science, 25(4), 449-452.

Reason for exclusion: not RCT; outcomes of interest available in RCTs for the population studied (i.e. patients with chronic stroke).

Lee, S., Kim, Y., & Lee, B. H. (2016). Effect of Virtual Reality‐based Bilateral Upper Extremity Training on Upper Extremity Function after Stroke: 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 stroke: effects of bilateral practice. Journal of NeuroEngineering and Rehabilitation, 10, 167-84.

Reason for exclusion: not RTC; results for similar outcomes and similar treatment available in RCTs.

Mudie, M.H. & Matyas, T.A. (2000). Can simultaneous bilateral movement involve the undamaged hemisphere in reconstruction of neural networks damaged by stroke? Disability and Rehabilitation, 22(1/2), 23-7.

Reason for exclusion: not RTC; results for similar outcomes and similar treatment available in RCTs.

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 stroke: 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 activities of daily living in stroke 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 stroke patients. NeuroRehabilitation, (Preprint), 1-8.

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

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