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Background  The dramatic consequences of stroke on patient autonomy in daily living activities urged the need for new reliable therapeutic strategies. Recently, bimanual training has emerged as a promising tool to improve the functional recovery of upper-limbs in stroke patients. However, who could benefit from bimanual therapy and how it could be used as a part of a more complete rehabilitation protocol remain largely unknown. A possible reason explaining this situation is that coupling and symmetry-breaking mechanisms, two fundamental principles governing bimanual behaviour, have been largely under-explored in both research and rehabilitation in stroke.    Discussion  Bimanual coordination emerges as an active, task-specific assembling process where the limbs are constrained to act as a single unit by virtue of mutual coupling. Consequently, exploring, assessing, re-establishing and exploiting functional bimanual synergies following stroke, require moving beyond the classical characterization of performance of each limb in separate and isolated fashion, to study coupling signatures at both neural and behavioural levels. Grounded on the conceptual framework of the dynamic system approach to bimanual coordination, we debated on two main assumptions: 1) stroke-induced impairment of bimanual coordination might be anticipated/understood by comparing, in join protocols, changes in coupling strength and asymmetry of bimanual discrete movements observed in healthy people and those observed in stroke; 2) understanding/predicting behavioural manifestations of decrease in bimanual coupling strength and/or increase in interlimb asymmetry might constitute an operational prerequisite to adapt therapy and better target training at the specific needs of each patient. We believe that these statements draw new directions for experimental and clinical studies and contribute in promoting bimanual training as an efficient and adequate tool to facilitate the paretic upper-limb recovery and to restore spontaneous bimanual synergies.    Summary  Since bimanual control deficits have scarcely been systematically investigated, the eventual benefits of bimanual coordination practice in stroke rehabilitation remains poorly understood. In the present paper we argued that a better understanding of coupling and symmetry-breaking mechanisms in both the undamaged and stroke-lesioned neuro-behavioral system should provide a better understanding of stroke-related alterations of bimanual synergies, and help clinicians to adapt therapy in order to maximize rehabilitation benefits.

Bimanual training in stroke: How do coupling and symmetry-breaking matter?