Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial

Abstract

Background and purpose: This randomized controlled trial tests the efficacy of bilateral arm training with rhythmic auditory cueing (BATRAC) versus dose-matched therapeutic exercises (DMTEs) on upper-extremity (UE) function in stroke survivors and uses functional magnetic resonance imaging (fMRI) to examine effects on cortical reorganization.

Methods: A total of 111 adults with chronic UE paresis were randomized to 6 weeks (3×/week) of BATRAC or DMTE. Primary end points of UE assessments of Fugl-Meyer UE Test (FM) and modified Wolf Motor Function Test Time (WT) were performed 6 weeks prior to and at baseline, after training, and 4 months later. Pretraining and posttraining, fMRI for UE movement was evaluated in 17 BATRAC and 21 DMTE participants.

Results: The improvements in UE function (BATRAC: FM Δ = 1.1 + 0.5, P = .03; WT Δ = -2.6 + 0.8, P < .00; DMTE: FM Δ = 1.9 + 0.4, P < .00; WT Δ = -1.6 + 0.7; P = .04) were comparable between groups and retained after 4 months. Satisfaction was higher after BATRAC than DMTE (P = .003). BATRAC led to significantly higher increase in activation in ipsilesional precentral, anterior cingulate and postcentral gyri, and supplementary motor area and contralesional superior frontal gyrus (P < .05). Activation change in the latter was correlated with improvement in the WMFT (P = .01).

Conclusions: BATRAC is not superior to DMTE, but both rehabilitation programs durably improve motor function for individuals with chronic UE hemiparesis and with varied deficit severity. Adaptations in brain activation are greater after BATRAC than DMTE, suggesting that given similar benefits to motor function, these therapies operate through different mechanisms.

Conflict of interest statement

Declaration of Conflicting Interests

The author(s) declared a potential conflict of interest (e.g. a financial relationship with the commercial organizations or products discussed in this article) as follows: As inventors of the subject technology, Jill Whitall and Sandy McCombe Waller anticipate receiving licensing income from their institution (UMB), under its Intellectual Property Policy.

Figures

Figure 1

Study flow Abbreviations: BATRAC, bilateral arm training with rhythmic auditory cueing; DMTE, dose-matched therapeutic exercise.

Figure 2

Two primary regions of interest (ROIs), precentral gyrus (blue) and superior frontal gyrus (green), are presented superimposed onto a T1-weighted scan of an exemplary participant. These ROIs were prespecified based on prior studies and defined using the Automated Anatomical Labeling atlas

Figure 3

The increase in activation in the contralesional superior frontal gyrus (ipsilateral to the moving paretic limb) correlated with faster performance in the WMFT (time posttraining − time pretraining) in BATRAC-trained participants (r = −0.62; P = .010). No such correlation was found in the DMTE group Abbreviations: WMFT, Wolf Motor Function Test; BATRAC, bilateral arm training with rhythmic auditory cueing; DMTE, dose-matched therapeutic exercise.