Archives of Medicine and Health Sciences

: 2022  |  Volume : 10  |  Issue : 1  |  Page : 105--108

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

Shradha Shah, Ashwini Kale, Vibhuti Tiwari 
 MGM Physiotherapy Rehabilitation and Fitness Centre, MGM Department of Neurophysiotherapy, Aurangabad, Maharashtra, India

Correspondence Address:
Dr. Shradha Shah
MGM Institute of Physiotherapy, Aurangabad - 431 003, Maharashtra


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.

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;10:105-108

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 2022 Oct 1 ];10:105-108
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Full Text


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

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}{Table 2}

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}{Figure 2}


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]


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.


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