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Comparison of Bilateral and Unilateral Training for Upper Extremity

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Comparison of Bilateral and Unilateral Training for Upper Extremity Hemiparesis in Stroke
Mary Ellen Stoykov, Gwyn N. Lewis and Daniel M. Corcos
Neurorehabil Neural Repair 2009 23: 945 originally published online 16 June 2009
DOI: 10.1177/1545968309338190

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 Neurorehabilitation and
Neural Repair
Volume 23 Number 9
November/December 2009 945-953
© 2009 The Author(s)

Comparison of Bilateral and Unilateral Training 10.1177/1545968309338190

http://nnr.sagepub.com

for Upper Extremity Hemiparesis in Stroke

Mary Ellen Stoykov, PhD, Gwyn N. Lewis, PhD, and Daniel M. Corcos, PhD

Background. Upper extremity hemiparesis is the most common poststroke disability. Longitudinal studies have indicated that 30% to 66%
of stroke survivors do not have full arm function 6 months poststroke. One promising treatment approach is bilateral training. To date,
no randomized, blinded study of efficacy comparing 2 groups (bilateral training vs unilateral training) using analogous tasks has been
performed in chronic stroke survivors with moderate upper extremity impairment. Objective. To compare the effectiveness of bilateral
training with unilateral training for individuals with moderate upper limb hemiparesis. The authors hypothesized that bilateral training
would be superior to unilateral training in the proximal extremity but not the distal one. Methods. Twenty-four subjects participated in a
randomized, single-blind training study. Subjects in the bilateral group (n = 12) practiced bilateral symmetrical activities, whereas the
unilateral group (n = 12) performed the same activity with the affected arm only. The activities consisted of reaching-based tasks that
were both rhythmic and discrete. The Motor Assessment Scale (MAS), Motor Status Scale (MSS), and muscle strength were used as
outcome measures. Assessments were administered at baseline and posttraining by a rater blinded to group assignment. Results. Both
groups had significant improvements on the MSS and measures of strength. The bilateral group had significantly greater improvement
on the Upper Arm Function scale (a subscale of the MAS-Upper Limb Items). Conclusion. Both bilateral and unilateral training are
efficacious for moderately impaired chronic stroke survivors. Bilateral training may be more advantageous for proximal arm function.

Keywords:  Stroke; Bilateral; Upper extremity

S troke is a leading cause of disability in the United States

with more than 1 100 000 Americans reporting poststroke
functional limitations.1 Upper extremity hemiparesis is one of
the most common conditions requiring extensive rehabilita-
tion. Approximately 30% to 36% of all individuals with hemi-
paresis have poor arm function 6 months poststroke.2
Therapeutic techniques are needed to address the problem.
One technique that has been described at length in the litera-
ture is constraint-induced movement therapy.3-5 Although
positive therapeutic benefits have been demonstrated, a major
limitation is that the majority of stroke survivors are not eli-
gible because of the strict inclusion criteria that specifically
target patients with mild impairment.
Alternative treatments are needed that target more impaired
survivors. One example of an alternative treatment is bilateral
arm training. This promising technique has been shown to be
efficacious not only with stroke survivors who are only mildly
impaired6-9 but also those with moderate10-13 and severe motor
impairments.14,15 To date, however, no study comparing 2 dif-
ferent training groups has addressed the comparative efficacy
of bilateral training versus unilateral training using similar
treatment activities for chronic, moderately impaired patients.
Some studies have used unilateral control groups with
dissimilar training protocols,10,15-17 whereas others have com-
pared unilateral versus bilateral training with mildly impaired
subjects.6,8
There are no universally accepted specifications in the lit-
erature for stratifying subjects. Kwakkel et al2 have deter-
mined that, at 4 weeks poststroke, a stroke survivor with a
Fugl-Meyer Test of Arm Function Upper Extremity (FMUE)
score of less than 19 has a 9% probability of developing
dexterity. We used this prognostic indicator as a cutoff for
stroke survivors with “severe” upper extremity impairment.
Individuals with severe impairments typically have no use of
their affected arm. An upper-level FMUE score of 40 to 60
was determined as “mildly” impaired. Typically, these indi-
viduals have some degree of wrist and finger extension and
have the potential to perform fine motor activities with their
affected hand. These individuals are eligible for constraint-
induced therapy. We used the middle range of FMUE scores
(19-40) as our definition of “moderately” impaired. Moderately
impaired individuals may or may not use their arm but have,
at the very least, the potential to use the arm as a stabilizer, and
some may be able to use the arm as a functional assist.
Researchers have suggested that bilateral training may be
more advantageous for the proximal limb.18 This speculation is

From the Department of Kinesiology and Nutrition, the University of Illinois at Chicago (MES, DMC); Sensorimotor Performance Program, Rehabilitation
Institute of Chicago, Chicago, Illinois (MES, GNL); and the Health and Rehabilitation Research Centre, AUT University, Northcote, Auckland, New Zealand
(GNL). Address correspondence to Mary Ellen Stoykov, PhD, Department of Kinesiology and Nutrition, the University of Illinois at Chicago, 1919 W Taylor
Street, 690 CMET, Chicago, IL 60612. E-mail: mphillips@ric.org.

945
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946   Neurorehabilitation and Neural Repair
based on the presence of descending motor pathways that are
bilateral and support postural and proximal limb function.19,20
Also, there is recent evidence that bilateral training is better
for proximal control than constraint-induced therapy.21 Thus,
we hypothesized that the bilateral training group would
improve more in proximal function than the unilateral training
group.
The bilateral training protocols reported in the literature are
diverse. A recent review organized protocols presented in
training studies into the following categories: (a) repetitive
reaching with hand fixed, (b) isolated muscle repetitive train-
ing, and (c) whole arm functioning.22 In the current study, the
tasks emphasized repetitive reaching with the hand fixed as
well as whole arm functioning. For the latter, the requirements
of the distal musculature were minimized by having the thera-
pist place the objects in the hand and assist with grip mainte-
nance and release. Thus, whole arm functioning tasks required
no or very minimal grasp or manipulation.
Rhythmic auditory cueing has been used in a number of
bilateral training studies, and it is coupled with repetitive
reaching with hand-fixed activities.10-13,23 Thaut et al24 suggest
that rehabilitation professionals explore rhythmic movement
for upper extremity rehabilitation based on findings demon-
strating significantly improved kinematic measures in a rhyth-
mic condition when compared with a discrete condition in
individuals with chronic stroke. Rhythmic and discrete move-
ments are controlled by somewhat different patterns of neural
activation.25 Evidence from functional magnetic resonance
imaging (fMRI) studies confirms that there is stronger activity
in contralateral sensorimotor cortex during rhythmic move-
ment when compared with discrete movement.25 However,
discrete movement has a more extensive network that includes
structures associated with motor planning. Thus, we used both
types of movement in our training protocols.
Methods
Subjects
Twenty-four participants were involved in the training study.
Sample size was determined by reviewing previous training
studies that had demonstrated significant improvements in func-
tion in individuals with upper extremity hemiparesis.6,7,10,26-31
Inclusion criteria included an FMUE score of 19 to 40 (moder-
ate impairment), at least 6 months poststroke, and no evidence
of involvement in the cerebellum or brainstem. A full list of
inclusion and exclusion criteria is included in Table 1. Subjects
were recruited from the Clinical Neuroscience Registry, which
provides researchers at Northwestern University and the
Rehabilitation Institute of Chicago with a pool of possible
stroke subjects. Prior to randomization, the participants were
stratified into 2 impairment levels based on FMUE scores. The
more impaired subset of subjects had scores ranging from 19
through 28 on the FMUE, whereas the less impaired subset
of subjects had scores from 29 through 40. Stratification was
performed to minimize differences in impairment between the
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Table 1
Inclusion and Exclusion Criteria for Subjects
Inclusion Criteria Exclusion Criteria
FMUE score between, and Symptomatic cardiac failure or
   inclusive of, 19 and 40    unstable angina
Cortical or subcortical lesion Lesion in cerebellum or brainstem
Chronic—at least 6 months
   since onset
Ability to follow 2 step commands Uncontrolled hypertension
No evidence of field cut— Inability to give consent
   (confrontational field testing)
No evidence of neglect Significant orthopedic or pain
   (H-cancellation test)    conditions in affected upper
   extremity
Age 18 to 80 years Severe obstructive pulmonary disease
Abbreviation: FMUE, Fugl-Meyer Test of Arm Function Upper Extremity.
2 training groups. Within each group of 12 subjects, a random-
ized computer-generated list provided group assignment into
bilateral or unilateral training groups. Both subsets of impair-
ment levels had 6 subjects in the unilateral training group and 6
in the bilateral training group. The first author enrolled subjects
and provided both treatment interventions.
The study was conducted over 2 years. The institutional
review boards of both Northwestern University and the University
of Illinois at Chicago approved study procedures. Written
informed consent was obtained prior to enrollment. To determine
that subjects did not have a lesion in the cerebellum or brainstem,
MRI scans from previous studies were examined with the sub-
jects’ consent and/or subjects gave permission for their physi-
cians to respond to a letter requesting lesion site information.
Training
Both groups participated in an 8-week training protocol.
Dependent variables were measured at baseline and immedi-
ately posttraining. Both groups received 3 training sessions of
1 hour duration per week, amounting to 24 hours of training
for all subjects. If a session was missed during any given
week, an extra session was added to the following week or at
the end of the 8 weeks. At least 24 hours elapsed between
consecutive training sessions.
We chose tasks that were similar to or had similar move-
ment patterns to those performed in other bilateral or unilateral
reach training studies.13,16,32,33 Tasks were selected because
they could easily be completed in both the unilateral and bilat-
eral conditions (see Table 2 for details). Both groups had the
same amount of time in training on the affected upper extrem-
ity. There were a total of 6 training tasks that incorporated both
discrete movements (2 tasks) and rhythmic movements (4
tasks) paced by a metronome.
Subjects performed the tasks using blocked practice.
Individual instructions were relative to each task, such as
“reach and point to the target and touch the target in time with
the beat of the metronome.” For most tasks, subjects initially
performed 20 repetitions (2 sets of 10 repetitions) and then
 Stoykov et al / Bilateral Versus Unilateral Training   947  

Table 2 patterns. Our rationale for increasing speed is that there is

Task Protocol fMRI evidence that increasing the rate of synchronized move-
ment facilitates an increase in brain activity in the sensorimo-
Unilateral Treatment Activities Bilateral Treatment Activities tor cortex.35 The number of movements and the frequencies for
1. Pushing and pulling activity 1. Pushing/pulling with both arms each task were recorded at each session.
(open/close drawer) (open/close 2 identical drawers)
Rhythmic task Rhythmic task Dependent Variables
2. Wipe a table with a towel using 2. Wipe a table with both arms using
the affected arm both arms symmetrically Our objective was to compare the outcomes of bilateral and
Discrete task Discrete task
unilateral training for the proximal upper extremity using analo-
3. One arm cycling using 3. Bilateral in-phase cycling
BTE 181 using BTE gous treatment activities in moderately impaired stroke survi-
Rhythmic task Rhythmic task vors. Thus, primary outcome measures that differentiated
4. Reaching and placing objects. 4. Bilateral reaching and placing proximal and distal function were selected. They included the
Moving small and medium-sized objects. Moving 2 identical small Motor Assessment Scale (MAS-Upper Limb Items)36 and the
grocery items from kitchen or medium-sized grocery objects
counter to shelves using only from countertop to shelf with
Motor Status Scale (MSS).37 The MAS-Upper Limb Items has 3
affected arm both hands separate subscales: Upper Arm Function, Hand Movements, and
Discrete task Discrete task Advanced Hand Activities.36,38 Each subscale consists of 6 items
5. Shoulder and elbow coupling. 5. Bilateral shoulder and elbow with increasing difficulty. A score of 0 to 6 is possible for each
Aim to target with affected hand coupling. Aim with both hands
subscale, with a total score of 18 for the MAS-Upper Limb
in various areas of work space to parallel targets (using varying
(using varying levels of arm levels of arm support, postural Items. We used all 3 scales because they are specific for proximal
support, postural sets, and sets, and positions in respect to and distal function. Upper Arm Function addresses shoulder
positions in relation to gravity). gravity). Includes a total of stability and movement at the task level. Hand Movement exam-
Includes a total of 4 subtasks 4 subtasks ines tasks that require gross distal function (eg, picking up a cup).
Rhythmic task Rhythmic task
6. Elbow extension during 6. Bilateral elbow extension during
Advanced Hand Activities addresses fine motor function.
horizontal reach horizontal reach The MSS is divided into 2 subscales including the Shoulder/
Rhythmic task Rhythmic task Elbow scale and the Wrist/Hand scale. It is based on the
FMUE, and the correlation between the 2 scales is high.37

However, the MSS has more items than the FMUE, and it
gradually increased this to 40 repetitions (4 sets of 10). An focuses on isolated movement while excluding synergy. The
exception to this was the task of opening and closing drawer(s), MSS-Shoulder/Elbow scale is a comprehensive examination
which all subjects performed 100 times per session. The task of the movements of the shoulder, elbow, and forearm. The
of reaching to different areas of the workspace included 4 MSS-Wrist/Hand scale examines hand and wrist movement
separate subtasks, each requiring approximately 5 minutes with more specificity than the FMUE hand section.
with a total task time of 20 minutes. Time taken on the other 5 Secondary outcome measures included selected measures
tasks approximated 5 to 6 minutes each. We chose to provide of arm strength. Shoulder, elbow, and wrist strength were mea-
a 1 or 2 minute rest period between each task because that was sured using a Chatillion MSC Muscle Strength Comparator
the time required to set up the next task. A 30-second rest was Dynamometer (Ametek, Inc, Largo, FL). Specifically, the
provided between each set. Thus, subjects were active for most tested muscle groups were flexors/extensors and external/
of the session. The order of the tasks was pseudo-randomized internal rotators of the shoulder, flexors/extensors of the
by the training therapist on a daily basis. elbow, and flexors/extensors of the wrist. Grip strength (finger
To set the initial movement frequency on the first day of flexor muscle strength) was measured using a standard, adjust-
treatment, subjects were given several trials to perform the able-handle JAMAR hydraulic hand dynamometer (JA Preston
activity, and the frequency of the metronome was increased. Corp, Jackson, MI).
The subject was given the instruction “move to the beat of the Primary and secondary outcome measurements were admin-
metronome.” When the subject was unable to keep up with the istered at baseline, 1 to 3 weeks before initiation of the training,
metronome, the frequency of the previously successful task and at posttraining, within 1 week after the training was com-
was used for training. Frequencies ranged from 0.25 to 1.5 Hz pleted. Measurements were administered using a single rater
depending on the ability of the subject. who was blinded to group assignment and methodology of the
Therapeutic challenge throughout the 8-week training study. The rater was trained on the assessment measures prior
period was increased by increasing speed requirements for the to commencement of the study. At the conclusion of the study,
rhythmic tasks, decreasing external support of the affected the rater reported that the blind was 100% successful and that
arm, and increasing cues to improve quality of movement she was not able to guess group assignment of any subjects.
(knowledge of performance). Knowledge of performance has
been shown to be more effective than knowledge of results for
Analysis
changing poststroke motor patterns.34 Although increasing the
speed of movement was a goal, subjects were not encouraged Because the behavioral scales are ordinal in nature, we
to increase speed if they were using compensatory movement analyzed the MAS and MSS using nonparametric statistics.
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948   Neurorehabilitation and Neural Repair
Table 3
Baseline Participant Characteristics
Bilateral Unilateral
Characteristic Group Group
Age (years), mean (SD) 63.8 (12.6) 64.75 (11.1)
Years poststroke, mean (SD) 9.5 (5.4) 10.2 (10.1)
Fugl-Meyer Assessment Score, mean (SD)a 28.75 (5.95) 27.16 (4.8)
Male 9 7
Female 3 5
Married 5 4
Paresis of prestroke dominant side 7 7
Cortical stroke 5 2
Subcortical stroke 2 4
Cortical and subcortical 5 6
Race with a 14% improvement in each group (Figure 2B). The MSS-
   White 8 11
   African American 3 1
   Hispanic 1 0
a
Maximum score, 66. Higher scores indicate better function.
Outcomes from the behavioral scales (difference between pre-
intervention scores and postintervention scores) were com-
pared between the bilateral and unilateral training groups
using the Mann–Whitney U test. Preintervention and postint-
ervention data from each group were then analyzed separately
using Wilcoxon signed rank tests to determine if there was a
pre–post training effect within groups. Strength measurements
were analyzed using 3-way repeated-measures analysis of
variances with factors of group, time, and impairment level.
All analyses were calculated using the software package SPSS
15.0 (SPSS, Inc, Cary, NC). An α level of .05 was set for all
analyses.
Results
Baseline Characteristics
Table 3 presents baseline characteristics of the 24 partici-
pants. Mann–Whitney U tests revealed no between-group dif-
ferences in age, years poststroke, or baseline FMUE score.
Primary Outcomes
There was evidence of a superior effect of bilateral training
in the MAS. Figure 1A-D presents the mean and standard error
for all 4 MAS scales. A Mann–Whitney U test for the MAS-
Upper Arm Function scale (Figure 1A) revealed a significant
between-groups effect (P = .021), with the bilateral group hav-
ing a higher mean change than the unilateral group. There were
no significant differences between the bilateral and unilateral
treatment groups for any other MAS scale (all P > .05).
There were significant preintervention to postintervention
changes detected in the bilateral group for the MAS-Upper
Arm Function scale (P = .014; Figure 1A) and the MAS-Upper
Limb Items (P = .02; Figure 1D). The changes represent a 27%
and 18% improvement, respectively. The unilateral group had
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no significant differences between preintervention and postint-
ervention (Figure 1A-D).
There were no between-group differences for the MSS for
any of the 3 scales. Figure 2 presents the means and standard
errors of the preintervention and postintervention data for the
MSS scales. Results revealed significant preintervention to
postintervention changes for all 3 scales for both the bilateral
and unilateral groups. The MSS-Total scale detected significant
preintervention to postintervention changes for the bilateral
group (P = .003) and the unilateral group (P = .002), indicating,
respectively, a 14% and 19% improvement (Figure 2A). The
MSS-Shoulder/Elbow scale revealed improvement for the
bilateral group (P = .002) and the unilateral group (P = .002),
Wrist/Hand scale showed significant improvement for both the
bilateral (P = .045) and unilateral (P = .005) groups, with a
14% and a 26% improvement, respectively (Figure 2C).
Secondary Outcomes
There was no evidence for a beneficial effect of bilateral
training, when compared with unilateral training, in the mea-
sures of arm strength because both groups improved in
strength measures (Figure 3). There were no significant inter-
actions with group for any of the strength measures (all P >
.05). There were significant main effects of time found for
shoulder flexion (P = .002), wrist flexion (P = .029), and wrist
extension (P = .05), indicating higher strength measures
following training (see Figure 3).
Discussion
The present study is important because, to our knowledge,
it is the first intervention study to compare the outcome of
equivalent unilateral and bilateral training conditions in sepa-
rate groups of subjects with moderate upper extremity hemipa-
resis. Significant differences were found between the bilateral
and unilateral groups in improvements in function measured
by the MAS-Upper Arm Function subscale. However, there
were no between-group differences in the MSS or in strength
measures. Both groups significantly improved from baseline
to posttreatment in these outcome measures.
Benefits of Bilateral Training
Previously, comparisons of unilateral and bilateral training
have documented positive effects for bilateral training over
unilateral training, but these studies have only examined
mildly impaired subjects.6,9 For example, Summers et al9 com-
pared a 1-week training course of either unilateral or bilateral
training using the MAS as the outcome measure. Both the
present study and Summers et al found significantly greater
improvement in the bilateral groups on selected measures
from the MAS. The training protocol of the latter study com-
prised 1 whole arm functioning task. Improvement was most
evident in the MAS-Upper Limb Items scale, which evaluates
 Stoykov et al / Bilateral Versus Unilateral Training   949  

Figure 1
Motor Assessment Scales (MAS) Preintervention and Postintervention Group Means and Standard Errors

Note: MAS-Upper Limb Items (D) is the combined score of the 3 scales (A-C). Note that scales are different values. *Significant at P < .05.

the entire arm. It should be noted that the subjects in this study
were at a much higher level with a mean baseline MAS-Upper
Arm Function scale score of 5.5 out of a possible 6, compared
with 1.8 for subjects in the present study. Cauraugh and Kim6
showed a benefit of bilateral training for the wrist over unilat-
eral training in mildly impaired subjects, but this was for distal
function. When comparing the 3 studies, it is clear that the
beneficial differential effect of bilateral training over unilateral
training was most evident in the portion of the limb that was
emphasized in the training protocols.
Using the standards reported by van der Lee et al,39 the dif-
ference in the change score of the MAS-Upper Arm Function
scale between the groups was 8.6% of the total scale, which
approaches the minimal clinical important difference of 10%.
Thus, the difference is clinically relevant to some of the sub-
jects in the bilateral group. After training, some subjects in the
bilateral training group reported that it was easier to perform
activities such as bathing and carrying objects. Subjects in the
unilateral group were more likely to report greater ease with
activities having more distal requirements (ie, grasping com-
munion between the fingers).
Some studies, investigating bilateral training for lower func-
tioning subjects, have used training tasks for control groups that
were not comparable with the bilateral tasks.10,15,17 For example,
neurodevelopment treatment has been used as the control inter-
vention in 2 studies.10,17 Another study used electric stimulation
for control treatment.15 In this study, the control electric stimu-
lation group performed 60 to 80 wrist extension repetitions
per session compared with 800 forearm and wrist repetitions
performed by the experimental group who received bilateral
robotic training. Therefore, differences in the intensity of the
training also could explain why the bilateral groups in both stud-
ies had a superior outcome. Our protocol of including the same
training tasks in the unilateral and bilateral treatment groups is
a superior test of the benefits of bilateral training as it allows for
a direct comparison between the 2 training modalities.

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950   Neurorehabilitation and Neural Repair
Figure 2
Motor Status Scales (MSS) of Preintervention and
Postintervention Group Means and Standard Errors
Note: MSS-Total scale (A) is the combined score of the 2 scales (B and C).
*P < .05, **P < .01.
Our results can also be compared with unilateral training
studies that have used equivalent outcome measures. One
study, using a robotics-based upper limb intervention (N = 42),
reported a 6% improvement in the MSS.40 In comparison, the
present study found a 14% and 19% change in the bilateral and
unilateral groups, respectively. This difference is partially due
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Figure 3
Shoulder and Wrist Strength Measures
Note: *P < .05, **P < .01.
to the improvements in distal movement found in the present
study that were not manifest in the robotics-based study.
The improvements in distal movement found in the present
study are similar to a previous study that also found changes
in distal movement following bilateral training targeting only
the proximal arm.11 These authors speculated that changes in

distal movement were the result of neural mechanisms inherent
in bilateral training. In the present study, there were distal
improvements in both the bilateral and unilateral groups.
Therefore, the mechanism cannot be specific to bilateral train-
ing. We can speculate that the mechanism may be because of the
effects of rhythmic, synchronized movement, which, according
to Ackerley et al,41 facilitates a generalized increase in cortical
excitability, possibly leading to use dependent plasticity.
Results of the MAS-Upper Arm Function scale indicated
significant differences between the bilateral and unilateral
groups; however, the results of the MSS-Shoulder/Elbow scale
detected no such differences. The differences in findings may be
because of the characteristics of the respective scales and which
component(s) of movement they measure. The MAS-Upper
Arm Function scale has only 6 items and measures the stability
and movement of the shoulder in various postures including
supine, sitting, and standing. Because scores on this scale range
from 0 to 6, improvement on the scale requires a considerable
increase in trunk and shoulder stability. The improvement on the
MAS-Upper Arm Function scale for the bilateral group is prob-
ably because of increased proximal stability. In contrast, the
MSS-Shoulder/Elbow scale measures the magnitude and con-
trol of a variety of isolated shoulder and elbow joint movements
in unsupported sitting. The total possible score is 40 points.
Thus, the MSS-Shoulder/Elbow scale detects improvements in
isolated joint movement. The absence of a differential bilateral
effect on the MSS may indicate that both bilateral and unilateral
training are efficacious for training of isolated joint motion.
Possible Mechanisms of Bilateral Training
In support of the hypothesis that greater improvements in the
bilateral group in the MAS-Upper Arm Function scale are
related to improved trunk stability, a study examining the effect
of upper extremity exercises on the trunk found that a bilateral
symmetrical exercise produced greater electromyography activ-
ity in the trunk muscles than unilateral exercises.42 Trunk stabil-
ity is extremely important to proximal upper extremity control.
Sitting unsupported or standing while reaching symmetrically
with both arms promotes trunk extension43 and requires signifi-
cantly more coactivation in the trunk musculature. Physical
therapists have used bilateral symmetrical arm exercises to
improve core stabilization in a variety of populations.44 Also,
others have indicated that changes in postural stability can
improve poststroke upper extremity control.45
Neural mechanisms underlying bilateral training have been
speculated on. Bilateral movement training may facilitate
rebalancing of the asymmetry of poststroke hemispheric corti-
comotor excitability. Typically, the contralesional cortex
increases in excitability and the lesioned cortex decreases.46
Rebalancing of hemispheric asymmetry occurs because of a
change in inhibitory mechanisms including both short interval
intracortical inhibition and interhemispheric inhibition. In
several bilateral training studies, a decrease in cortical excit-
ability in contralesional motor cortex was associated with an
improvement in motor skill of the affected arm.9,47 A recent
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Stoykov et al / Bilateral Versus Unilateral Training   951  
study reported evidence of normalization of inhibitory mecha-
nisms following rhythmic bilateral symmetrical movements of
the wrist.48 This study was unique as bilateral movement was
used as a motor priming technique prior to training in func-
tional hand tasks. In comparison to a control group performing
only functional tasks, the bilateral priming group demon-
strated reestablishment of interhemispheric inhibition from the
ipsilesional on to the contralesional cortex as well as normal-
ization of short-interval intracortical inhibition in the contral-
esional hemisphere. These changes in inhibitory mechanisms
are most likely responsible for the decrease in excitability of
the contralesional cortex.
Some of the previously reported beneficial effects of bilat-
eral training10-13 and that seen in our study may be, in part,
because of neural mechanisms controlling rhythmic move-
ment. Synchronized movement to a beat produces a general-
ized increase in cortical excitability, not exclusive to the
cortical areas associated with the muscle being trained.41
Neurophysiological studies have also indicated that both bilat-
eral and unilateral synchronized movements facilitate cortical
excitability.41,49 The increased cortical excitability during
rhythmic movement may result in longer-term improvements
in synaptic efficacy in the motor cortex. These neural changes
provide optimal conditions for learning a motor task and can
account for translation to nonrhythmic movement conditions.
Indeed, there is ample evidence documenting improvements in
behavioral measures after rhythmic movement training for a
number of neurorehabilitation populations.11-13,50-55 Further
evidence in support of rhythmic movement includes a bilateral
training study that did not use rhythmic movement and subse-
quently found no improvements following a course of bilateral
training.56 However, others have speculated that discrete
movement may be more beneficial to bilateral training than
rhythmic movement.57 Future studies should compare discrete
and rhythmic training with auditory feedback in both unilat-
eral and bilateral conditions to more specifically identify the
effective components of rehabilitation protocols.
Study Limitations
The sample size was small and may have affected the abil-
ity to detect differences between the groups in the MSS. It is
also important to note that, although the rater was blinded to
group assignment, the principal investigator enrolled subjects,
provided the training, and analyzed the data. This could intro-
duce bias in the delivery of treatment. We believe this is
unlikely, however, because both groups improved equally on
the majority of measures. Another limitation is that restraining
of the trunk did not include a uniform method such as a piece
of equipment. Instead, the therapist used verbal or tactile cues
to restrain subjects.
Conclusion
We concur with previous studies that have found bilateral
training to be efficacious for stroke survivors.6-15 We have
952   Neurorehabilitation and Neural Repair
extended the bilateral training research findings by including a
unilateral training group that performed nearly identical activities.
Although Summers et al9 found significant improvements in a
short-term bilateral versus unilateral training study with mildly
impaired subjects, our results also suggest a superior outcome
with long-term bilateral training with subjects who were much
more impaired. Our working hypothesis was that there would be
differences between the 2 groups in proximal arm improvement.
However, the hypothesis is only partially supported as both
groups improved on the MSS scales. We also had secondary find-
ings of improvement in distal function, which, although unex-
pected, confirmed results of previous studies that investigated
bilateral proximal training and distal movement outcomes.11
Previous studies have examined the effect of bilateral training
on unilateral activities rather than on bilateral ones.22 This is, in
part, because of an absence of motor assessments dedicated to
bimanual performance. More information about bilateral skill
may better differentiate the benefits of bilateral versus unilateral
training. It is likely that both unilateral and bilateral training
should be used during stroke rehabilitation. Indeed, others have
provided evidence that exclusive unilateral training may limit an
individual’s movement repertoire.58 The amount of time spent on
each may be based on individual clinical presentations and goals.
Acknowledgments
This study was supported by an AHA predoctoral fellow-
ship, No. 0610000Z, and NIH grants RO1 NS28127 and RO1
NS40902. The authors thank James Cauraugh, PhD, for his
insightful comments on an earlier draft of this manuscript.
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