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 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 105-108

Effect of hand arm bimanual intensive therapy on upper limb function in young stroke

MGM Physiotherapy Rehabilitation and Fitness Centre, MGM Department of Neurophysiotherapy, Aurangabad, Maharashtra, India

Date of Submission07-Feb-2022
Date of Decision24-May-2022
Date of Acceptance26-May-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Dr. Shradha Shah
MGM Institute of Physiotherapy, Aurangabad - 431 003, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_36_22

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Young stroke comprises of 10%–15% of all stroke patients. However, compared with stroke in older adults, stroke in the young have disproportionately large economic impact by leaving victims disabled before their most productive years. Stroke leads to chronic functional impairments of upper limb and hand. Hence, we aimed to explore the effect of hand-arm bimanual intensive training (HABIT) on the recovery of upper limb function in young stroke patient. The study is a case of a 30-year-old male patient admitted to the outpatient department with right-sided hemiplegia and sensory aphasia. The patient was engaged in HABIT for 2 h a day for a continuous duration of 3 months and the training showed remarkable improvement in Fugl-Meyer assessment-upper extremity and Motor Activity Log scores. The results suggest that HABIT appears to be efficacious in improving upper limb function in young stroke.

Keywords: Hand-arm bimanual intensive training, upper limb function, young stroke

How to cite this article:
Shah S, Kale A, Tiwari V. Effect of hand arm bimanual intensive therapy on upper limb function in young stroke. Arch Med Health Sci 2022;10:105-8

How to cite this URL:
Shah S, Kale A, Tiwari V. Effect of hand arm bimanual intensive therapy on upper limb function in young stroke. Arch Med Health Sci [serial online] 2022 [cited 2023 Feb 9];10:105-8. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/105/347969

  Introduction Top

Stroke is also referred as a cerebrovascular accident (CVA), or colloquially brain attack.[1] The WHO statistics have shown that CVA was the second cause of death worldwide in 2012; however, it was accounting for 6.7 million deaths in that year only.[2] Cerebral stroke is a medical emergency that may cause permanent neurological damage or even death. The clinical sequelae of acute stroke include hemiplegia, motor weakness, aphasia, hemianopia, neglect, and general cognitive dysfunction.[3] Physical impairment of the affected extremities includes paresis/paralysis, loss of sensory function, presentation of muscle function abnormalities, and loss of dexterity.[4] Moreover, in approximately 50% of acute stroke survivors, chronic functional impairment of the upper limbs and hands is seen.[5] These impairments severely impact the patients' daily life which can dampen the quality of life of the patient following stroke.[6] Thus, rehabilitation of upper-limb function is a crucial topic.

Previous studies have focused on post stroke rehabilitation management, including task-oriented training, constraint-induced movement therapy (CIMT), bilateral training, error-based feedback, robotic-assisted movements, impairment-oriented training, virtual reality therapy, gaming learning-based activities, mental imagery, noninvasive electrical stimulation, progressive task-specific repetitions, and skill acquisition training that is paired with motivational enhancement.[7] A meta-analysis suggested that among the aforementioned approaches, the most promising includes robot-assisted therapy and CIMT,[8] rather than bilateral training; however, quite convincing and novel findings provide evidence supporting bilateral trainings as effective rehabilitation protocols in stroke patients.[9] CIMT has not been consistently applied as a standard rehabilitation practice, due to restrictions on enrollment, reimbursement, high intensity, and compliance of both the patient and clinician.[10] Therefore, an approach with a similar efficacy which lacks the observed limitations was needed.

Hand-arm bimanual intensive training (HABIT) is a bimanual rehabilitation approach that addresses the impairments that are specific to the upper extremity (UE) in children presenting with unilateral cerebral palsy, which had demonstrated positive outcomes that were at least comparable to that of CIMT. HABIT is not only based on ordinary bilateral coupling or mirror movements, but also on asymmetrical movements of both hands, which uses the principles of motor learning (i.e., practice specificity, types of practice, and feedback) and neuroplasticity (i.e., practice-induced brain changes arising from repetition, increasing movement complexity, motivation, and reward). The HABIT approach also includes increasing the complexity of the functional activities that necessitate the use of both hands and repetitions to achieve functional goals.[11]

  Case Report Top

A 30-year-old male patient reported to physiotherapy outpatient department with right hemiplegia due to ischemic stroke. The patient presented with global aphasia and paralysis of right upper and lower limb. Magnetic resonance imaging reports revealed that middle cerebral artery infarct affecting left temporal, left frontal, left parietal lobes, and left perisylvian cortex was evident. On initial examination, the patient had spasticity (Grade 2 on modified Ashworth scale) in right upper and lower limb muscles with no sensory impairments. The biceps, supinator, quadriceps, and ankle jerk on the right side was exaggerated. According to Brunnstrom, voluntary control was absent in right upper limb and Grade 2 was present in the right lower limb. The patient was on antihypertensives and antispastic medications.

After taking the consent from the patient, pre- and post-treatment assessment was done using Fugl-Meyer Assessment- UE (FMA-UE) and motor activity log (MAL) as a primary outcome measure as depicted in [Table 1] and [Table 2]. The FMA-UE scale assesses motor function, sensations, and joint range of motion of upper limb determining severity of upper limb impairment.[12] This scale is reliable, valid, and widely acknowledged assessment tool for assessing upper limb function post stroke (r = 0.94–0.95, intraclass correlation coefficient = 0.95, Sensitivity = 77%, Specificity = 89%).[13]
Table 1: Assessment of tone of upper limb muscles pre- and post-treatment

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Table 2: Pre- and post-assessment of Fugl -Meyer assessment-upper extremity and motor activity log 14

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MAL-14 is a structured interview which objectifies How well (Quality of Movement) and How much (Amount of Use) the patient performs his/her activities of daily livings. This scale is reliable (r > 0.91), valid (0.71–0.90) with internal consistency (α > 0.81).[14]

The treatment protocol consisted of HABIT and included the following guidance: (1) training in pectoral girdle control ability: strengthening the pectoral girdle muscle and improving myodynamia and stability of the pectoral girdle on weight bearing and against resistance conditions; (2) haptic perception training: processing bimanual training in terms of tactile sense, perception, and discrimination, and the option of using articles of different texture, shape, and size; (3) bimanual coordination training involving both sides of the body, such as putting on and taking off different clothes, and manually dressing with buttoned clothes of different shapes; and (4) functional training of the hands including writing and painting with crossing of the center line, and the use of scissors and folding paper. For example, the patient was asked to fold and unfold the sheet of paper having a line in the middle of the paper with both the hands, drawing a picture where the left hand drew the left part of the picture and right hand drew the right part, respectively. Later, cutting the figures with a scissor drawn by the patient. These activities were performed for 2 h a day, thrice a week for 12 weeks.[15] The type of exercise utilized in HABIT was functional activities including the majority of bimanual coordination of hands in conjunction with haptic perception training, pectoral girdle training, and pectoral strength training (as shown in [Figure 1] and [Figure 2]).[16]
Figure 1: Folding and unfolding piece of paper

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Figure 2: Buttoning and Unbuttoning of clothes

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  Discussion Top

This study aimed to explore the efficiency of the HABIT strategy at improving upper arm function in adult patients with acute stroke. This case report has depicted the positive effects of HABIT in the acute stroke patients through remarkable improvement in FMA and MAL scores. During the earlier phase of rehabilitation, the case had minimal voluntary control in right upper as well as lower extremity. However, HABIT has proven to significantly improve the voluntary control.

Stroke affects the interlimb coordination control of bilateral hands which leads to movement disorders.[17] As most of the day life activities requires the usage of both the hands for accomplishing a task. Whereas the majority of the rehabilitation procedures focuses on improving the hand function of the affected hand rather than bilateral training. This may limit the transfer of unimanual capability to a spontaneous arm use and hence affects the functional recovery.[18]

According to Gordon et al., activities when practiced unilaterally initially can transfer the improvements during bimanual coordination of a task. This suggests that the activities can enhance the poor bimanual coordination. Hence, training with bimanual tasks directly can have better effects on bimanual coordination. HABIT is a form of functional training performed bimanually which focuses on improving the coordination of the two hands. This uses a structured task practice involving bimanual play and functional activities. It works under the premise of neuroplasticity and motor learning.[16]

Since bimanual intensive training has scarcely been systematically investigated in acute stroke, the eventual benefits in stroke rehabilitation remain poorly understood. Evidence from previous studies is lacking at this point for a meaningful comparative analysis and assessment. Nevertheless, we can still obtain a perspective based on other bilateral trainings and application of HABIT in other relevant population, which have shown the capacity for intensive training to improve hand function after HABIT therapy, which is consistent with motor learning theories.[19] The human corticospinal system undergoes reconstruction after stroke, manifesting as functional recovery, which leads to the hypothesis that HABIT could improve UE function after acute stroke. Additional studies aimed at comparing multiple approaches and focusing on mechanisms of bimanual intensive motor recovery should be performed.[15]

  Conclusion Top

HABIT significantly improved the upper limb function in young stroke suggesting that HABIT may be an effective therapeutic strategy to improve upper limb function poststroke.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hameed Shahin MA. Ischemic cerebral stroke case report, complications and associated factors. Int Ann Med 2017;1:1-5.  Back to cited text no. 1
Sims NR, Muyderman H. Mitochondria, oxidative metabolism and cell death in stroke. Biochim Biophys Acta 2010;1802:80-91.  Back to cited text no. 2
Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient 1 a method for evaluation of physical performance. Scand J Rehabil Med 1975;7:13-31.  Back to cited text no. 3
Meyer S, De Bruyn N, Krumlinde-Sundholm L, Peeters A, Feys H, Thijs V, et al. Associations between sensorimotor impairments in the upper limb at 1 week and 6 months after stroke. J Neurol Phys Ther 2016;40:186-95.  Back to cited text no. 4
Cordo P, Wolf S, Lou JS, Bogey R, Stevenson M, Hayes J, et al. Treatment of severe hand impairment following stroke by combining assisted movement, muscle vibration, and biofeedback. J Neurol Phys Ther 2013;37:194-203.  Back to cited text no. 5
Lin JH, Hsueh IP, Sheu CF, Hsieh CL. Psychometric properties of the sensory scale of the fugl-meyer assessment in stroke patients. Clin Rehabil 2004;18:391-7.  Back to cited text no. 6
Mehrholz J, Pohl M, Platz T, Kugler J, Elsner B. Electromechanical and Robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev 2015;11:CD006876.  Back to cited text no. 7
Dobkin BH. Strategies for stroke rehabilitation. Lancet Neurol 2004;3:528-36.  Back to cited text no. 8
Cauraugh JH, Lodha N, Naik SK, Summers JJ. Bilateral movement Training and stroke motor recovery progress: A structured review and Meta-analysis. Hum Mov Sci 2010;29:853-70.  Back to cited text no. 9
Fleet A, Page SJ, MacKay-Lyons M, Boe SG. Modified constraint-induced movement therapy for upper extremity recovery post stroke: What is the evidence? Top Stroke Rehabil 2014;21:319-31.  Back to cited text no. 10
Ferre CL, Brandão MB, Hung YC, Carmel JB, Gordon AM. Feasibility of caregiver-directed home-based hand-arm bimanual intensive training: A brief report. Dev Neurorehabil 2015;18:69-74.  Back to cited text no. 11
Kiper P, Szczudlik A, Agostini M, Opara J, Nowobilski R, Ventura L, et al. Virtual reality for upper limb rehabilitation in subacute and chronic stroke: A randomized controlled trial. Arch Phys Med Rehabil 2018;99:834-42.e4.  Back to cited text no. 12
Lundquist C, Maribo T. The Fugyl Meyer assessment of upper extremity: Reliability, responsiveness and validity of Danish Version. Disabil Rehabil 2016:39:934-9.  Back to cited text no. 13
Uswatte G, Taub E, Morris D, Vignolo M, McCulloch K. Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use. Stroke 2005;36:2493-6.  Back to cited text no. 14
Meng G, Meng X, Tan Y, Yu J, Jin A, Zhao Y, et al. Short-term efficacy of hand-arm bimanual intensive training on upper arm function in acute stroke patients: A randomized controlled trial. Front Neurol 2018;8:726.  Back to cited text no. 15
Gordon AM, Schneider JA, Chinnan A, Charles JR. Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: A randomized control trial. Dev Med Child Neurol 2007;49:830-8.  Back to cited text no. 16
Lai CH, Sung WH, Chiang SL, Lu LH, Lin CH, Tung YC, et al. Bimanual coordination deficits in hands following stroke and their relationship with motor and functional performance. J Neuroeng Rehabil 2019;16:101.  Back to cited text no. 17
Kantak S, Jax S, Wittenberg G. Bimanual coordination: A missing piece of arm rehabilitation after stroke. Restor Neurol Neurosci 2017;35:347-64.  Back to cited text no. 18
Li S. Spasticity, motor recovery, and neural plasticity after stroke. Front Neurol 2017;8:120.  Back to cited text no. 19


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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