Original research| Volume 100, ISSUE 3, P401-411, March 2019

Improvement of Upper Limb Motor Control and Function After Competitive and Noncompetitive Volleyball Exercises in Chronic Stroke Survivors: A Randomized Clinical Trial

Published:November 09, 2018DOI:


      • Volleyball exercise results in improvement of upper limb motor function in chronic stroke survivors.
      • Volleyball exercise decreases the feedback dependency of motor control in chronic stroke survivors.
      • Performing volleyball exercise in a competitive form could enhance its positive effects in both functional and motor control levels.



      To investigate the effects of competitive and noncompetitive volleyball exercises on the functional performance and motor control of the upper limbs in chronic stroke survivors.


      Randomized clinical trial.


      Outpatient rehabilitation center.


      Chronic stroke survivors (N=48).


      Participants were randomly assigned to competitive (n=16) or noncompetitive (n=16) volleyball exercise groups (60min/d volleyball exercise+30min/d traditional rehabilitation, 3d/wk for 7wk) and control group (n=16).

      Main Outcome Measures

      Reach and grasp motor control measures were evaluated through kinematic analysis. Functional outcomes were assessed via Motor Activity Log, Wolf Motor Function Test (WMFT), Box and Block Test, and Wrist Position Sense Test.


      Significant improvement of functional performance was observed in both competitive (P<.0001) and noncompetitive volleyball exercise groups (P<.01), but not in the control group (P>.05), with the exception of WMFT score. Volleyball training, in general, resulted in more efficient spatiotemporal control of reach and grasp functions, as well as less dependence on feedback control as compared to the control group. Moreover, the competitive volleyball exercise group exhibited greater improvement in both functional performance and motor control levels.


      Volleyball team exercises, especially in a competitive format, resulted in enhancing the efficacy of the preprogramming and execution of reach and grasp movements, as well as a shift from feedback to feedforward control of the affected upper limb in chronic stroke survivors. This may well be a potential underlying mechanism for improving functional performance.


      List of abbreviations:

      ADL (activities of daily living), AOU (amount of use), BBT (Box and Block Test), FAS (functional ability scale), MAL (Motor Activity Log), MGA (maximum grip aperture), NMT (normalized movement time), NTD (normalized total distance), PMGA (percentage of movement time in which MGA occurs), PPV (percentage of movement time in which PV occurs), PV (peak velocity), QOM (quality of movement), WMFT (Wolf Motor Function Test), WPST (Wrist Position Sense Test)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Alwan A.
        • Armstrong T.
        • Bettcher D.
        • Chisholm D.
        • Ezzati M.
        Global status report on noncommunicable diseases.
        WHO, Geneva2016
        • Carr J.
        • Shepherd R.
        Movement science. Foundations for physical therapy in rehabilitation.
        Aspen, Gaithersburg, MD2000
        • Billinger S.A.
        • Arena R.
        • Bernhardt J.
        • et al.
        Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 2532-2553
        • Schuck S.O.
        • Whetstone A.
        • Hill V.
        • Levine P.
        • Page S.J.
        Game-based, portable, upper extremity rehabilitation in chronic stroke.
        Top Stroke Rehabil. 2011; 18: 720-727
        • Wu C.-Y.
        • Huang P.-C.
        • Chen Y.-T.
        • Lin K.-C.
        • Yang H.-W.
        Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2013; 94: 1023-1030
        • Hartman-Maeir A.
        • Soroker N.
        • Ring H.
        • Avni N.
        • Katz N.
        Activities, participation and satisfaction one-year post stroke.
        Disabil Rehabil. 2007; 29: 559-566
        • Shatil S.
        • Ivanova T.D.
        • Mochizuki G.
        • Garland S.J.
        Effects of therapeutic golf rehabilitation on golf performance, balance, and quality of life in individuals following stroke: pilot study.
        Physiother Canada. 2005; 57: 101-112
        • Goršič M.
        • Cikajlo I.
        • Novak D.
        Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity.
        J Neuroeng Rehabil. 2017; 14: 23
        • Goršič M.
        • Novak D.
        Design and pilot evaluation of competitive and cooperative exercise games for arm rehabilitation at home.
        Conf Proc IEEE Eng Med Biol Soc. 2016; 2016: 4690-4694
        • Levin M.F.
        Interjoint coordination during pointing movements is disrupted in spastic hemiparesis.
        Brain. 1996; 119: 281-293
        • Lin K.C.
        • Wu C.Y.
        • Wei T.H.
        • Gung C.
        • Lee C.Y.
        • Liu J.S.
        Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study.
        Clin Rehabil. 2007; 21: 1075-1086
        • Wu C.Y.
        • Chen C.L.
        • Tang S.F.
        • Lin K.C.
        • Huang Y.Y.
        Kinematic and clinical analyses of upper-extremity movements after constraint-induced movement therapy in patients with stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2007; 88: 964-970
        • Bailey M.J.
        • Riddoch M.J.
        • Crome P.
        Evaluation of a test battery for hemineglect in elderly stroke patients for use by therapists in clinical practice.
        NeuroRehabilitation. 2000; 14: 139-150
        • Figlewski K.
        • Blicher J.U.
        • Mortensen J.
        • Severinsen K.E.
        • Nielsen J.F.
        • Andersen H.
        Transcranial direct current stimulation potentiates improvements in functional ability in patients with chronic stroke receiving constraint-induced movement therapy.
        Stroke. 2017; 48: 229-232
        • 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: 2493-2496
        • Rand D.
        • Weingarden H.
        • Weiss R.
        • et al.
        Self-training to improve UE function at the chronic stage post-stroke: a pilot randomized controlled trial.
        Disabil Rehabil. 2017; 39: 1541-1548
        • Carey L.M.
        • Oke L.E.
        • Matyas T.A.
        Impaired limb position sense after stroke: a quantitative test for clinical use.
        Arch Phys Med Rehabil. 1996; 77: 1271-1278
        • Carr J.H.
        • Shepherd R.B.
        Stroke rehabilitation: guidelines for exercise and training to optimize motor skill.
        Butterworth-Heinemann Medical, Edinburgh2003
        • Pang M.Y.
        • Harris J.E.
        • Eng J.J.
        A community-based upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2006; 87: 1-9
        • Yavuzer G.
        • Senel A.
        • Atay M.
        • Stam H.
        “Playstation eyetoy games” improve upper extremity-related motor functioning in subacute stroke: a randomized controlled clinical trial.
        Eur J Phys Rehabil Med. 2008; 44: 237-244
        • Buccino G.
        • Solodkin A.
        • Small S.L.
        Functions of the mirror neuron system: implications for neurorehabilitation.
        Cogn Behav Neurol. 2006; 19: 55-63
        • Celnik P.
        • Stefan K.
        • Hummel F.
        • Duque J.
        • Classen J.
        • Cohen L.G.
        Encoding a motor memory in the older adult by action observation.
        Neuroimage. 2006; 29: 677-684
        • Sabes P.N.
        The planning and control of reaching movements.
        Curr Opin Neurobiol. 2000; 10: 740-746
        • Tyč F.
        • Boyadjian A.
        • Devanne H.
        Motor cortex plasticity induced by extensive training revealed by transcranial magnetic stimulation in human.
        Eur J Neurosci. 2005; 21: 259-266
        • Desmurget M.
        • Grafton S.
        Forward modeling allows feedback control for fast reaching movements.
        Trends Cogn Sci. 2000; 4: 423-431
        • Cooke A.
        • Kavussanu M.
        • McIntyre D.
        • Ring C.
        The effects of individual and team competitions on performance, emotions, and effort.
        J Sport Exerc Psychol. 2013; 35: 132-143
        • Walker C.J.
        Experiencing flow: is doing it together better than doing it alone?.
        J Posit Psychol. 2010; 5: 3-11
        • Le Bouc R.
        • Pessiglione M.
        Imaging social motivation: distinct brain mechanisms drive effort production during collaboration versus competition.
        J Neurosci. 2013; 33: 15894-15902
        • Maclean N.
        • Pound P.
        • Wolfe C.
        • Rudd A.
        The concept of patient motivation.
        Stroke. 2002; 33: 444-448