title: Sequencing bilateral and unilateral task-oriented training versus task oriented training alone to improve arm function in individuals with chronic stroke.
abstract: BACKGROUND
  Recovering useful hand function after stroke is a major scientific challenge for patients with limited motor recovery. We hypothesized that sequential training beginning with proximal bilateral followed by unilateral task oriented training is superior to time-matched unilateral training alone. Proximal bilateral training could optimally prepare the motor system to respond to the more challenging task-oriented training.
  
  
  METHODS
  
  
  
  METHODS
  Twenty-six participants with moderate severity hemiparesis Intervention: PARTICIPANTS received either 6-weeks of bilateral proximal training followed sequentially by 6-weeks unilateral task-oriented training (COMBO) or 12-weeks of unilateral task-oriented training alone (SAEBO). A subset of 8 COMB0 and 9 SAEBO participants underwent three functional magnetic resonance imaging (fMRI) scans of hand and elbow movement every 6 weeks.
  
  
  METHODS
  Fugl-Meyer Upper extremity scale, Modified Wolf Motor Function Test, University of Maryland Arm Questionnaire for Stroke, Motor cortex activation (fMRI).
  
  
  RESULTS
  The COMBO group demonstrated significantly greater gains between baseline and 12-weeks over all outcome measures (p = .018 based on a MANOVA test) and specifically in the Modified Wolf Motor Function test (time). Both groups demonstrated within-group gains on the Fugl-Meyer Upper Extremity test (impairment) and University of Maryland Arm Questionnaire for Stroke (functional use). fMRI subset analyses showed motor cortex (primary and premotor) activation during hand movement was significantly increased by sequential combination training but not by task-oriented training alone.
  
  
  CONCLUSIONS
  Sequentially combining a proximal bilateral before a unilateral task-oriented training may be an effective way to facilitate gains in arm and hand function in those with moderate to severe paresis post-stroke compared to unilateral task oriented training alone.
authors.affiliation: School of Medicine, Department of Physical Therapy and Rehabilitation Science, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA. smccombewaller@som.umaryland.edu.
authors.forename: Sandy
authors.initials: S
authors.lastname: McCombe Waller
authors.affiliation: School of Medicine, Department of Physical Therapy and Rehabilitation Science, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA. jwhitall@som.umaryland.edu.
authors.forename: Jill
authors.initials: J
authors.lastname: Whitall
authors.affiliation: School of Medicine, Department of Physical Therapy and Rehabilitation Science, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA. tojenkins@som.umaryland.edu.
authors.forename: Toye
authors.initials: T
authors.lastname: Jenkins
authors.affiliation: Department of Epidemiology and Public Health, University of Maryland, 660 W. Redwood Street, Baltimore, MD, 21201, USA. lmagder@epi.umaryland.edu.
authors.forename: Laurence S
authors.initials: LS
authors.lastname: Magder
authors.affiliation: Acute Care Neurology, Director, Division of Brain Injury Outcomes, The Johns Hopkins Medical Institutions, 1550 Orleans Street, Baltimore, MD, 21231, USA. dhanley@jhmi.edu.
authors.forename: Daniel F
authors.initials: DF
authors.lastname: Hanley
authors.affiliation: Geriatric Research, Education and Clinical Center (GRECC), Baltimore VA Medical Center, University of Maryland School of Medicine, 10 North Greene Street, BT/18/GR, Baltimore, MD, 21201, USA. agoldber@medicine.umaryland.edu.
authors.forename: Andrew
authors.initials: A
authors.lastname: Goldberg
authors.affiliation: Department of Neurology, University and University Hospital Zurich, Frauenklinikstrasse 26, Zürich, 8091, Switzerland. andreas.luft@uzh.ch.
authors.forename: Andreas R
authors.initials: AR
authors.lastname: Luft
mesh_terms: D000328:Adult; D000368:Aged; D001132:Arm / Q000503:physiopathology*; D002908:Chronic Disease; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D006225:Hand / Q000503:physiopathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010291:Paresis / Q000150:complications / Q000209:etiology / Q000534:rehabilitation*; D000071939:Stroke Rehabilitation; D016896:Treatment Outcome