This is a case-control study conducted on 30 Egyptian chronic stroke patients (19 men and 11 women; age range 45–65 years). Patients were recruited from the outpatient clinic of the Faculty of Physical Therapy, as they were diagnosed as having an ischemic cerebrovascular stroke in the domain of the carotid system. After, they have received individualized examinations to estimate their suitability according to the following inclusion criteria: not less than 6 months after the onset of stroke, mild spasticity (1:1+: Modified Ashworth Scale) on all joints of the paretic upper extremity [17, 18], active range of motion in the wrist extensors and supinators (grade 3 or more according to the manual muscle test) [19], mild or less cognitive impairment (score > 24: Mini-Mental Status Examination) [20], patients able to sit and maintain balance in a sitting position, and no serious visual perception or vision problems (National Institutes of Health Stroke Scale: subtest, the best gaze and visual) [21]; so that the patient can understand and perform hand motor functional movements that practiced and tested during this study (like writing, turning over 3 by 5-inch cards, picking up small common objects, simulated feeding, stacking checkers, picking up large objects, and picking up large heavy objects).
The following are the exclusion criteria: hand dysfunction due to causes other than ischemic stroke (as musculo-skeletal disorder, orthopedic disease, other neurologic or neuromuscular disorders, surgical intervention in the upper limb), seizure, recurrent stroke, fixed contracture in upper limb joints, or severe spasticity of the affected upper limb. Patients with a grade of muscle power 0 or 1, patients with acute or recurrent stroke, patients with bony blocks, and patients with any surgical interventions in the upper extremities have been excluded from the study. The aim and procedures were explained to all patients, and informed consents were taken prior to participation. Patients were divided into two equal groups. The study group (15 patients) received a selected physical therapy program and MT while the control group (15 patients) received the same program but without MT.
Pre-test and post-test clinical evaluations were conducted by a physical therapist that was blinded to the participant group. The range of motion of the wrist extension and forearm supination, hand grip strength, and hand motor functional skills were measured to evaluate the improvements in flexibility, motor power, hand motor functional skills, and daily activities.
Assessment procedures
Patients were submitted to the following: measurement of range of motion by the electronic goniometer (protractor; model: PTHT1015, china 2013), which is a tool used to measure the range of motion of wrist extensors and forearm supinator. It consists of two straight arms, one for the starting point and the other slides with the wrist or fingers to measure the amount of distance moved by them. The electronic goniometer is positioned distal to the axis of motion [22].
Measurement of the hand grip strength has been done by handheld dynamometer (jamar, model number: 63785, China 2013), which is used to measure the hand muscles’ maximum isometric strength. It is a hydraulic system, and it has a digital dial for reading results and an adjustable handle with five handle positions [23].
Assessment of hand motor functional skills using the Jebson Hand Function Test (health and care, UK) is a used to evaluate the functional capabilities of patients. This test includes seven items: picking up small common objects, card turning, simulated feeding (bean spooning), picking up large light objects, stacking checkers, picking up large heavy objects, and writing a short sentence. The time of performance was recorded for each test [24].
Stopwatch is a handheld time piece used to measure the time elapsed from the time where it is activated to the time of activation. In this study, it has been used to calculate the Jebson Hand Function Test.
All patients in the study group received a selected physical therapy training program for 40 min/day, 3 days/week, for 8 weeks. Training sessions were conducted by trained physical therapists and started with warming-up exercises for 5 min as passive ROM and stretching exercises for the wrist and fingers flexors and extensors then simultaneously symmetrical bilateral hand movements training program for 25 min: a mirror sized 35 × 35 cm made of plastic with a mirror coating was placed across the midline (between the affected and unaffected limbs), so that the affected hand was hidden behind the mirror, and the mirror reflects the image of the non-paretic hand as if it were the paretic hand; in this way, the mirror was large enough for patients to see the whole length of their reflected unaffected hand. Patients were required to perform simultaneously symmetrical bilateral hand movements while observing the reflection of the non-paretic hand in the mirror with the hope to create a visual imaginary, whereby movement of the non-paretic hand may be perceived as a movement of the paretic hand. During this arrangement, any jewels should be removed and any scars or tattoo; if present, it has been covered in both limbs before the treatment procedure. The symmetrical bilateral hand movements include wrist extension, finger flexion and extension, forearm supination, gross motor, and fine motor activities. At the end of the session, for 10 min, the patients were subjected to muscle reeducation (for wrist extensors through resting their affected limb on a table while it is pronated, and they were asked to extend the wrist as much as possible; forearm supinator through resting their affected limb on a table while flexing the elbow at 90°, they were asked to supinate the forearm, the therapist may help the patient at first to extend the wrist or supinate the forearm then asked the patient to do it without help); strengthen hand grip (the patients were asked to flex the fingers as fist as much as possible, sometimes the patients were asked to flex the thumb only or make opposition movements by thumb and other fingers); functional training activities (based on task-oriented treatment principles; both fine motor tasks as grasp and grip, and gross motor tasks as reaching) were practiced. The patients in the control group received the same exercise program as the active treatment group last with the same sequence and timings but without the use of the mirror, and the patients were free to observe their affected limb during any exercise.
All statistical tests were performed through the statistical package for social studies (SPSS) {version 19 for windows, Armonk, NY, 2012}. Paired t test was conducted for comparison of pre- and post-treatment measures of wrist extension ROM, forearm supination ROM, hand grip strength, and JHFT in each group. Unpaired t test was conducted for comparison of pre- and post-treatment measures of wrist extension ROM, forearm supination ROM, hand grip strength, and JHFT between both groups.