NeuroRehabilitation 41 (2017) 437–444 437

DOI:10.3233/NRE-162128
IOS Press

Effect of task specific training and

wrist-fingers extension splint on hand joints
range of motion and function after stroke
Mohamed E. Khallafa,∗ , Mariam A. Ameerb and Eman E. Fayedc
a Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy,

Cairo University, Giza, Egypt

b Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Giza, Egypt
c Department of Biomechanics, Faculty of Physical Therapy, Misr University for Sciences and Technology,

Giza, Egypt

Abstract.
BACKGROUND: Most stroke patients experience hand impairments that can result in persistent limitations in daily activities.
OBJECTIVE: This study aimed at estimating the immediate and retention effects of task specific training and wrist/fingers
extension splint on hand joints range of motion and function after stroke.
METHODS: Twenty-four right handed patients with first ever stroke represented the sample of the study. The participants
were randomly assigned into two equal groups. The study group received task specific exercises five times a week for an hour
concurrently with wrist/fingers extension splint which was used two hours for each three hours (day and night) excluding
exercises and sleeping hours for 16 weeks. The control group received traditional passive stretch and range of motion exercises.
Manual dexterity and upper limb function were assessed by nine holes peg test and Fugl-Meyer upper extremity and hand.
Goniometry was used for measuring wrist, metacarpophalangeal, thumb carpometacarpal joints active range of motion.
RESULTS: Significant improvements were observed in nine holes peg test, Fugl-Meyer upper extremity and hand scores
and ranges of motion at post-intervention and follow-up compared to pre-intervention at P ≤ 0.05.
CONCLUSIONS: The results of this study provide an evidence that task specific training and wrist/fingers extension splint
are effective in improving fingers dexterity, upper extremity function and wrist/hand range of motion.

Keywords: Task specific training, hand, splint, stroke

1. Introduction develop muscles shortening during the first year.

Wrist, metacarpophalangeal (MCP) and interpha-
Majority of patients after stroke experience hand langeal joints (IPJ) with associated either long
and upper extremity impairments that, if neglected, flexor or extensor muscles are especially at risk for
can result in unremitting disability and limitations contracture (Sackley et al., 2008).
in daily living and household activities (Hendricks Current approaches for the hand and upper extrem-
et al., 2002). Sixty percent of those patients will ity rehabilitation after stroke have been shown to
provide modest to moderate improvements (Malho-
∗ Address for correspondence: Mohamed Elsayed Khallaf, tra et al., 2011). These approaches have been applied
Department of Physical Therapy for Neuromuscular Dis-
orders and its Surgery, Faculty of Physical Therapy, Cairo
to stroke patients at different stages of recovery.
University, 7 Ahmed Elziat st, Doki, Giza, Egypt. E-mails: They are mainly passive with insufficient training
mekhallaf@gmail.com; khallaf mohamed@cu.edu.eg. intensity. Moreover, the study designs suffer from

1053-8135/17/$35.00 © 2017 – IOS Press and the authors. All rights reserved
438 M.E. Khallaf et al. / Effect of TSI and WFE splint on hand function after stroke

methodological weaknesses such as small sample long hand Flexor) and avoid pain. MCP is in exten-
sizes, and lack of blinding of outcome measurements. sion to neutralize tone, fully stretch the multi-joint
Impairments of the hand after stroke can be over- muscles of the hand and so prevent catch with exten-
come by an intensive program of active exercise sion and encourage volitional control. The angle of
therapy that involves active, repetitive functional wrist extension within this splint was progressively
movements (Van Peppen et al., 2004; Kwakkel et al., increased as the point of stretch reflex move more
2003). Presently, motor learning approaches indicate into wrist extension. The position of the thumb was
that therapeutic interventions should be task-specific, also gradually moved to abduction with extended dis-
tailored to the patient’s abilities and goals, and pro- tal interphalangeal joint as the point of stretch reflex
vide sufficient active repetition to ensure learning of fades away (adductor pollicis and Flexor pollicis
motor tasks (Barreca et al., 2003). It can further take longus). We hypothesized that TSI program together
advantage of using visual, proprioceptive feedback with WFE splint may improve wrist and hand joints
to provide knowledge of results and/or performance active ROM, manual dexterity and functional use.
(Hubbard et al., 2009; Cirstea & Levin, 2007).
Hand splints are commonly used to prevent or stop
long flexors shortening after stroke. There are many 2. Subjects and methods
studies which support or oppose the use of hand
splints. Such controversy is largely as a result of the A sample of 24 right handed chronic stroke
lack of scientific evidence to document the type, fre- survivors was recruited from Faculty of Physical
quency of use and even effectiveness of splinting. Therapy outpatient clinic in Cairo, Egypt. Inclusion
Despite the controversies associated with splinting criteria were: first ever chronic stroke (>3months)
the hemiplegic hand, splints continue to be used in in the territory of the middle cerebral artery con-
the clinical setting (Lannin & Herbert, 2003). firmed by CT scan and a motor deficit of the paretic
Previous clinical trials on splinting the hand after upper extremity with some capacity for active wrist
stroke either did not include a control group (Dobkin, and fingers movements with scores of 4 out of 7
2005; Steultjens et al., 2003) or suffered from on the arm, hand and shoulder pain components of
methodological limitations such as short follow-up the Chedoke McMaster Stroke Assessment (CMSA)
or lack of blinded assessment of outcomes (Lannin [7]. Of 43 consecutive patients receiving care in the
& Herbert, 2003; Rose & Shah, 1987). Moreover, clinic 17 patients were excluded because they did not
splinting the hand in neutral or functional position meet the inclusion criteria or having one of the fol-
does not fully stretch the long flexor, multi-joint, lowing exclusion criteria: moderate cognitive deficits
muscles of the hand. Patient’s active participation to (assessed by mini mental state examination); visual
maintain the gained range and improve hand func- field defect; visuospatial neglect; finger flexor spas-
tion is also ignored by the authors specially when ticity (a Modified Ashworth Scale [MAS] score of
the hand splint is applied alone or even with pas- >2) (Ansari, 2009), spastic dystonia or any other con-
sive stretch. There are also several reviews examined dition interfering with upper extremity movements
the effectiveness of hand splinting after stroke. Each other than stroke. Patients on muscle relaxant were
review has concluded that there is insufficient evi- also excluded from the study. Two patients who were
dence to either support or refute the efficiency of hand eligible selected not to participate in the study. The
splinting (Dobkin, 2005, Steultjens, et al., 2003). study was approved by the Institutional Ethics Com-
In this study, we developed a task specific, inten- mittee and written informed consent was obtained
sive training (TSI) program with sufficient repetitions from each patient.
and structured biofeedback with an aim to estimate Participants were assessed on clinical outcomes at
the immediate and retention effects of 16-weeks baseline, post-intervention (week-16), and at follow-
training program applied concurrently with exten- up (week- 20). Subjects were randomly allocated to
sion wrist/fingers splint (WFE) on ranges of motion control (G2 ) and experimental (G1 ) groups after base-
(ROM), manual dexterity, functional use of upper line measurement by selecting one concealed card
extremity and hand in chronic stroke survivors. corresponding the group. Therapist who did base
Wrist/finger extension splint was tailored for each line evaluation and follow up measures had no idea
patient according to passive wrist, MCP, and IPJ about patients’ allocation. The experimental group
range of motion to gradually push the point of stretch wore WFE splint for 2 hours for each 3 hours (day
reflex as far back into wrist extension (wrist and and night) excluding exercises and sleeping hours for
 M.E. Khallaf et al. / Effect of TSI and WFE splint on hand function after stroke 439

Nine-Hole Peg Test (9HPT) and wrist, metacar-

pophalangeal (MCP), and thumb extension active
ROM. The ROMs were obtained by using univer-
sal goniometers (de Carvalho et al., 2012). Scores of
ROM and 9HPT were based on the average of 3 trials
of measurement and time taken to complete the test
activity.
Fig. 1. Wrist/finger extension (WFE) splint.
2.1. Statistical analysis

16 weeks. Thermoplastic material was used in fab- Descriptive statistics were calculated to summarize
rication of WFE splint allowing the researchers to the demographic characteristics of the sample and
change the angle of the wrist progressively with no all outcome measures at baseline (1st measurement),
pain or even cost (Fig. 1). post-intervention (2nd measurement), and one month
The exercise session of G1 participants included: after intervention (3rd measurement) for each group.
moving the extended upper extremity between two Demographic data was compared between groups by
targets, picking an object off the floor in sagittal t-test (P < 0.05). Effects of the applied treatment pro-
and later frontal plane, elbow extensor strengthen- grams, between groups, were compared using t-test
ing in supine lying with/out weights, bending the with level of significance was set at P<0.05. Repeated
wrist to a target, bending the wrist while holding measures of ANOVA were employed to calculate,
a cup, finger and thumb flexor strengthening using within group, the effect of treatment programs in the
foam, forearm supination and pronation to a wall tar- study or control groups at probability level less than
get, rotating the forearm to targets, fingers flexor and 0.05. In addition, Post-hoc test gave detailed compar-
intrinsic muscles strengthening using foam, cupping ison between the measures (baseline and follow up at
the hand on a table, cupping the hand while picking P < 0.05).
up a plate, controlling grip force by lifting a sealed
bottle and straw and rolling a ball between the thumb
and fingertips. Throughout five sessions a week, each 3. Results
exercise was repeated 10 times for five sets over The characteristics of the participants are shown in
16 weeks. The participants were guided to visual- Table 1. The two groups were matched for age and
ize, copy similar motions by the contralateral arm sex (p = 0.635, 1.00), body mass index (p = 0.581),
simultaneously. Analysis of the abnormal pattern of time since onset of stroke (p = 0.519). There were nine
movement with simple explanation was done in order patients with left sided hemiparesis in both groups
to understand the differences between normal and (p = 0.531). Hypertension and diabetes mellitus were
abnormal pattern of movements. The intended move- represented in both groups with a percentage of 71%
ments were reinforced to be done correctly through and 68% in group 1 and 67% and 69% in group 2,
clear, simple verbal feedback and encouraged the respectively. Sixty-three percent of the participants in
feel of specific motions as well as applying sensory group 1 while 59% of people who were presented in
stimuli simultaneously to movements with care not group 2 have cardiac problems.
overload the patient with excessive or wordy com-
mands especially those with right sided hemiparesis.
Table 1
As initial practice progresses, the patients were asked Subject characteristics, values presented as (mean ± SD) and
to self-examine performance and identify problems, percentages
specifically, what difficulties exist, what can be done Group 1 Group 2 P
to correct the difficulties, and what movements can n = 12 n = 12
be eliminated or refined. Participants in G2 received Age(years) 50.17 ± 2.76 49.5 ± 3.85 0.635
ROM exercises, passive stretching, strengthening of Sex(males/females) 8/4 8/4 1.00
the hand grip using stress ball and grip device. BMI(Kg/m 2 ) 27.74 ± 1.78 27.15 ± 3.01 0.581
Duration of illness(month) 21.67 ± 4.68 20.42 ± 5.05 0.519
Three outcome measures were recorded. These Paretic left side 5 4 0.531
were measures are upper extremity functional recov- Hypertension 71% 67% —
ery using Fugl-Meyer (FM) assessment upper Diabetes 68% 69% —
Cardiac problems 63% 59% —
extremity and hand, fingers’ dexterity using
440 M.E. Khallaf et al. / Effect of TSI and WFE splint on hand function after stroke

Table 2
Between group comparison. Data is presented as mean and standard deviations (SD) in seconds (9HPT) and degrees (ROMs)
Variables Measures Group 1 Group 2 t P
Mean ± SD Mean ± SD
9HPT (Seconds) 1st 75.83 ± 13.02 73.00 ± 13.64 0.568 0.582
2nd 53.42 ± 9.48 70.58 ± 11.39 –4.753 0.001∗
3rd 55.50 ± 9.94 70.67 ± 11.69 3.371 0.006∗
FM (UE) 1st 38.33 ± 3.60 36.16 ± 3.66 1.672 0.123
2nd 43.16 ± 2.75 37.66 ± 3.74 4.350 0.001
3rd 42.91 ± 3.28 37.25 ± 3.19 4.507 0.001
FM (hand) 1st 6.16 ± 0.93 6.91 ± 1.24 –1.828 0.095
2nd 8.08 ± 1.50 6.75 ± 1.13 2.402 0.035
3rd 7.91 ± 0.90 6.50 ± 1.5 2.679 0.021
Wrist extension (Degrees) 1st 14.42 ± 2.27 14.47 ± 2.74 1.036 0.322
2nd 25.58 ± 2.84 13.75 ± 2.28 17.997 0.002∗
3rd 25.83 ± 2.33 14.00 ± 2.55 9.894 0.001∗
MCP Extension (Degrees) 1st 7.75 ± 1.76 9.00 ± 2.25 –1.850 0.091
2nd 13.08 ± 2.39 10.33 ± 2.49 2.380 0.037∗
3rd 12.58 ± 2.35 9.42 ± 2.31 3.354 0.006∗
Thumb CMC extension (Degrees) 1st 7.17 ± 2.04 8.912 ± 2.64 0.873 0.401
2nd 10.92 ± 3.34 9.25 ± 1.48 2.968 0.013∗
3rd 10.33 ± 2.49 9.67 ± 1.67 3.218 0.008∗
9HPT: Nine Holes Peg Test; FM: Fugl-Meyer; UE: Upper Extremity; MCP: Metacarpo-phalangeal joint, CMC: Carpometacarpal
joint P is significant at P ≤ 0.05.

Between groups comparison showed that there are 0.674 respectively). Post-hoc test showed significant
non-significant differences between the two groups differences between the first and second or third
at the baseline measurements of all values including measurements (p = 0.001) and a nonsignificant differ-
9HPT (p = 0.582); FM upper extremity (p = 0.123) ence between the 2nd and 3rd measures (p = 0.754).
FM hand (0.095); wrist extension (p = 0.322); MCP Pairwise comparison of G2 revealed nonsignificant
Extension (p = 0.091) and thumb CMC extension difference between the three measures (p > 0.05).
(p = 0.401). On the other hand, there were statistically There were significant increases in the wrist exten-
significant differences between the second and third sion ROM in G1 (p = 0.001) on the other hand in G2
follow up measures (Table 2, Fig. 2a, b, c) of the 9HPT there were a non-significant differences (p = 0.125).
(p = 0.001, 0.006 respectively); FM upper extremity Post-hoc test showed significant differences between
(p = 0.001) FM hand (0.035, 0.021); wrist exten- the first and second or third measurements (p = 0.001)
sion (p = 0.002, 0.001 respectively); MCP Extension and a nonsignificant difference between the 2nd and
(p = 0.037, 0.006 respectively); thumb CMC exten- 3rd measures (p = 0.102). Pairwise comparison of G2
sion (p = 0.013, 0.008 respectively). revealed nonsignificant difference between the three
A repeated measures of ANOVA was employed measures (p > 0.05). In G1 , there were significant
to measure within groups changes after treatments. increase in the MCP extension ROM (p = 0.001) on
In addition, Post-hoc test gave detailed compar- the other hand in G2 there were a non-significant
ison between the measures (baseline and follow differences (p = 0.196). Post-hoc test showed signifi-
up) (Table 3). In the study group (G1 ), there were cant differences between the first and second or third
significant decrease in the 9HPP time of perfor- measurements (p = 0.001) and a nonsignificant differ-
mance (p = 0.001) on the other hand in the control ence between the 2nd and 3rd measures (p = 0.275).
group (G2 ) there were a non-significant differences Pairwise comparison of G2 revealed nonsignificant
(p = 0.152). Post-hoc test showed significant differ- difference between the three measures (p > 0.05). In
ences in G1 between the first and second or third the study group (G1 ), there were significant increase
measurements (p = 0.001) and a nonsignificant differ- in the CMC thumb extension ROM (p = 0.001) on
ence between the 2nd and 3rd measures (p = 0.188). the other hand in the control group (G2) there were
Pairwise comparison of measurements of G2 revealed a non-significant differences (p = 0.242). Post-hoc
nonsignificant difference between the three mea- test showed significant differences between the first
sures (p > 0.05). Similarly, FM upper extremity and and second or third measurements (p = 0.001) and a
hand showed significant change in G1 (P = 0.001) nonsignificant difference between the 2nd and 3rd
and non-significant change in G2 (P = 0.143 and measures (p = 0.368). Pairwise comparison of G2
 M.E. Khallaf et al. / Effect of TSI and WFE splint on hand function after stroke 441

WREXROM
70
60
50
40
ROM in degrees
30
20
10
0
-10 1 2 3 4 5 6 7 8 9 10 11 12
-20
-30
-40
(a) SPre SPost S1MFU CPre CPost C1MFU

ThmbCMCEXROM
20

10
ROM in degrees

0
1 2 3 4 5 6 7 8 9 10 11 12
-10

-20

(b) SPre SPost S1MFU Pre Post 1MFU

MCPEXROM
30
20
10
ROM in degrees

0
1 2 3 4 5 6 7 8 9 10 11 12
-10
-20
-30
-40
(c) SPre SPost S1MFU CPre CPost C1MFU

Fig. 2. Between group comparison (a) wrist extension (b) Thumb carpometacarpal joint extension (c) Metacarpophalangeal joint extension.
SPre: study group pre-intervention measure, SPost: Study group post-intervention measure, S1MFU: study group one month follow up, CPre:
control group pre-intervention measure, CPost: Control group post-intervention measure, C1MFU: Control group one month follow up.

revealed nonsignificant difference between the three of task specific training when applied concurrently
measures (p > 0.05). with WFE splint on fingers dexterity, upper extrem-
ity function and wrist and hand joints ROM in chronic
stroke patients.
4. Discussion
In the present study, participants experienced an
The results of the present study identified a sta- enhancement in the functional use of the paretic upper
tistically significant immediate and retained effect extremity as a result of the task specific, intensive
442 M.E. Khallaf et al. / Effect of TSI and WFE splint on hand function after stroke

training (TSI) program with sufficient repetitions and increases gradually as the as spasticity and muscle
structured biofeedback. The results can be attributed tightness yield, which allows more ROM without
to specificity of the intervention, which involved catch (due to either spasticity or passive insufficiency)
repeated practice of wrist and fingers movements during exercises or functional activities. The differ-
while promoting speed and movement accuracy. ence between splinting the hand in functional position
Other contributing factors include the establishment and WFE is that splinting the hand in functional
of visual/auditory–motor coactivation induced by position does not provide full stretch on the wrist
training. These results are consistent with Villeneuve and hand flexors which with time enhances passive
and colleague who reported that task specific, inten- insufficiency of long finger flexors during movement.
sive and repetitive training intervention can lead Moreover, there was no evidence of clinically sig-
to improvements in manual dexterity, finger move- nificant effects of such splinting on hand function
ment coordination, and functional use of the upper (Wang et al., 2011). In addition, the WFE immo-
extremity that persist 3 weeks after the intervention bilizes the muscles in a lengthening position which
(Villeneuve et al., 2014). keeps the number of sarcomeres in series to maintain
Moreover, the results of this study are consistent the greatest functional overlap of actin and myosin
with Fujii et al., who reported that auditory feedback filaments. This may lead to a relatively permanent
may facilitate the learning of upper limb joint coor- (plastic) form of muscle lengthening if the newly
dination pattern when it is provided during practice gained length is used on a regular basis in func-
trials (Fujii et al., 2016). On the same theme, Kim tional exercises or activities (Lannin et al., 2003;
et al. reported that greater improvements in upper Tr˛ebacz, 2005).
extremity functional performance of daily activities The WFE was used to stretch the soft tissues of
and motor control during reaching movements after the muscles (non-neural component of spasticity).
target reaching training based on visual biofeedback Prolonged and slowly applied stretch is less likely
versus traditional rehabilitation (Kim et al., 2015). to increase tensile stresses on connective tissues or
We also used WFE splint for 16 weeks as adjustable to activate the stretch reflex. In addition, a slow rate
mean to stretch the long flexors of the hand. Our stretch affects the viscoelastic properties of connec-
aim behind utilization of this splint was to apply tive tissue, making them more compliant (Lannin et
prolonged stretch on these multijoint muscles which al., 2003; Tr˛ebacz 2005). During day times, WFE
act over four joints. The applied stretch force was used two hours in each 3 hours. The rationale

Table 3
Within group effect of interventions with pairwise comparison
Variables Measure Group 1 Group 2 Pairwise comparison
Group 1 Group 2
F P F P 1st 2nd 3rd 1st 2nd 3rd
9HPT 1st 15.62 0.001 2.29 0.152 0.001 0.001 0.072 0.056
2nd 0.001 0.188 0.072 0.881
3rd 0.001 0.188 0.056 0.881
FM (UE) 1st 36.01 0.001 2.15 0.143 0.001 0.001 0.079 0.204
2nd 0.001 0.463 0.079 0.539
3rd 0.001 0.463 0.204 0.539
FM (hand) 1st 12.259 0.001 0.392 0.674 0.001 0.000 0.723 0.435
2nd 0.001 0.754 0.723 0.586
3rd 0.000 0.754 0.435 0.586
Wrist extension 1st 19.31 0.001 2.58 0.125 0.001 0.001 0.310 0.422
2nd 0.001 0.102 0.310 0.491
3rd 0.001 0.102 0.422 0.491
MCP Extension 1st 17.18 0.001 1.92 0.196 0.001 0.001 0.124 0.655
2nd 0.001 0.275 0.124 0.160
3rd 0.001 0.275 0.655 0.160
CMC thumb extension 1st 14.33 0.001 1.64 0.242 0.001 0.001 0.160 0.084
2nd 0.001 0.368 0.160 0.658
3rd 0.001 0.368 0.084 0.658
9HPT: Nine Holes Peg Test; FM: Fugl-Meyer; UE: Upper Extremity; MCP: Metacarpo-phalangeal joint, CMC:
Carpometacarpal joint P is significant at P ≤ 0.05.
 M.E. Khallaf et al. / Effect of TSI and WFE splint on hand function after stroke 443

behind that is to provide an interval of prolonged Conflict of interest

stretch (mainly to decrease reflex-mediated spastic-
ity) each 3 hours and allow the functional use of the None to report.
hand which enhance the sensory inputs from the hand
and other upper limb joints. This also prevent hand
swelling, pain (Ahtikoski et al., 2003), decreased cor- References
tical activation and long term functional limitations
(Andringa et al., 2013; Gambhir, 2015). Ahtikoski, A. M., Koskinen, S. O., Virtanen, P., Kovanen, V., Ris-
These results are not consistent with the results of teli, J., & Takala, T. E. (2003). Synthesis and degradation of
type IV collagen in rat skeletal muscle during immobiliza-
Lannin and colleagues who reported that an intensive tion in shortened and lengthened positions. Acta Physiology
4-week extension splinting program did not increase Scandinavia, 177, 473-481.
the extensibility of the wrist and long finger flexor Andringa, A., van de Port, I., & Meijer, J. W. (2013). Long-
muscles in adults after stroke (Lannin et al., 2007). In term use of a static hand-wrist orthosis in chronic stroke
Lannin’s study, only four weeks were used as a treat- patients: A pilot study. Stroke Research and Treatment, 2013,
546093.
ment duration, in addition they only used the splint Ansari, N. N., Naghdi, S., Hasson, S., Fakhari, Z., Mashayekhi, M.,
without any other intervention which is considered a & Herasi M. (2009). Assessing the reliability of the Modified
passive intervention. Ashworth Scale between two physiotherapists in adult patients
The effects of the treatment still persisted at follow- with hemiplegia. Neurorehabilitation, 25, 235-240.
up, indicating that the process of motor relearning has Barreca, S., Wolf, S. L., Fasoli, S., & Bohannon, R. (2003).
Treatment interventions for the paretic upper limb of stroke
been completed with improved progression, timing survivors: A critical review. Neurorehabilitation and Neural
and dexterity of movement. This can be attributed to Repair, 17, 220-226.
the effect of repeated practice of specific motor tasks Cirstea, M. C., & Levin, M. F. (2007). Improvement of arm
for the hand with extrinsic visual/auditory–motor movement patterns and end point control depends on type of
coactivation. This is consistent with Geiger et al. feedback during practice in stroke survivors. Neurorehabilita-
tion and Neural Repair, 21, 398–411.
and Van Peppen et al., who stated that motor learn- Dobkin, B. H. (2005). Rehabilitation after stroke. New England
ing and recovery indicate that intervention should be Journal of Medicine, 352, 1677-1684.
meaningful, task-specific, and tailored to the person’s de Carvalho, R. M., Mazzer, N., & Barbieri, C. H. (2012). Analysis
capacity and interests and provide sufficient repe- of the reliability and reproducibility of goniometry compared
tition and challenge to induce training effects (Van to hand photogrammetry. Acta Ortopedica Brasileira, 20,
139-149.
Peppen et al., 2004; Geiger et al., 2001). Fujii, S., Lulic, T., & Chen, J. L. (2016). More feedback is better
In this study, we have limitations of a small sample than less: Learning a novel upper limb joint coordination pat-
size, One-to-one manual interactions with patients tern with augmented auditory feedback. Frontiers in Human
and treatment protocols entail daily therapy for sev- Neuroscience, 10(6), 251.
eral weeks. Nevertheless, we were able to show the Gambhir, P. K. (2015). Evidence base of stroke and hand splinting.
International Journal of Science and Research, 5, 1648-1651.
benefits of using task specific biofeedback and exer- Geiger, R. A., Allen, J. B., O’Keefe, J., & Hicks, R. R. (2001).
cises and WFE splint, to hand rehabilitation after Balance and mobility following stroke: Effects of physical
stroke. This trend of changes that we observed war- therapy interventions with and without biofeedback/force plate
rants further study with a larger sample size, studying training. Physical Therapy, 81(4), 995-1005.
the effect of UL partial weight support rehabilitation Hendricks, H. T., van-Limbeek, J., Geurts, A. C., & Zwarts, M.
J. (2002). Motor recovery after stroke: A systematic review of
programs to improve hand function and minimize the the literature. Archive Physical Medicine and Rehabilitation,
effect of gravity on increasing spasticity. 83, 1629-1637.
Hubbard, I. J., Parsons, M. W., Neilson, C., & Carey, L. M.
(2009). Task-specific training: Evidence for and translation
5. Conclusions to clinical practice. Occupational Therapy International, 16,
175-189.
Kim, C. Y., Lee, J. S., Lee, J. H., Kim, Y. G., Shin, A. R., Shim,
In this study, the wrist/fingers extension splint and Y. H, & Ha, H. K. (2015). Effect of spatial target reaching
task specific exercise training were immediately and training based on visual biofeedback on the upper extremity
in one-month follow-up were effective in improv- function of hemiplegic stroke patients. Journal of Physical
ing fingers dexterity, upper extremity function and Therapy Scince, 27, 1091-1096.
Kwakkel, G., Kollen, B. J., van der Grond, J., & Prevo A. J. (2003)
wrist/hand range of motion. These results may help Probability of regaining dexterity in the flaccid upper limb:
to decrease the debate about the use of hand splints Impact of severity of paresis and time since onset in acute
after stroke. stroke. Stroke, 34, 2181-2186.
444 M.E. Khallaf et al. / Effect of TSI and WFE splint on hand function after stroke

Lannin, N. A., Cusick, A., McCluskey, A., & Herbert, R. D. (2007). and depression in the year after a severely disabling stroke.
Effects of splinting on wrist contracture after stroke: A random- Stroke, 39, 3329-3334.
ized controlled trial. Stroke, 38, 111-116. Steultjens, E. M., Dekker, J., Bouter, L. M., van de Nes, J. C., Cup,
Lannin, N. A., Horsley, S. A., Herbert, R., McCluskey, A., & E. H., & van den Ende, C. H. (2003). Occupational therapy for
Cusick, A. (2003). Splinting the hand in the functional position stroke patients: A systematic review. Stroke, 34, 676-687.
after brain impairment: A randomized controlled trial. Archive Tr˛ebacz, H. (2005). Effect of immobilization in a lengthened posi-
Physical Medicine Rehabilitation, 84, 297-302. tion on mechanical properties of the Achilles tendon in growing
Lannin, N. A., & Herbert, R. D. (2003). Is hand splinting effective rats. Acta Bioengineering Biomechanics, 7, 81-86.
for adults following stroke? A systematic review and method- Van Peppen, R. P., Kwakkel, G., Wood-Dauphinee, S., Hendriks,
ologic critique of published research. Clinical Rehabilitation, H. J., VanderWees, P. J., & Dekker, J. (2004). The impact of
17, 807-816. physical therapy on functional outcomes after stroke: What’s
Malhotra, S., Pandyan, A. D., Rosewilliam, S., Roffe, C., & Her- the evidence? Clinical Rehabilitation, 18, 833-862.
mens, H. (2011). Spasticity and contractures at the wrist after Villeneuve, M., Penhune, V., & Lamontagne, A. (2014). A piano
stroke: Time course of development and their association with training program to improve manual dexterity and upper
functional recovery of the upper limb. Clinical Rehabilitation, extremity function in chronic stroke survivors. Frontiers in
25, 184-191. Human Neuroscience, 8(22), 662.
Rose, V., & Shah, S. (1987). A comparative study on the immediate Wang, Y. C., Magasi, S. R., Bohannon, R. W., Reuben, D. B.,
effects of hand orthoses on reduction of hypertonus. Australian McCreath, H. E., Bubela, D. J., Gershon, R. C., & Rymer,
Occupational Therapy Journal, 34, 59-64. W. (2011). Assessing dexterity function: A comparison of two
Sackley, C., Brittle, N., Patel, S., Ellins, J., Scott, M., Wright, alternatives for the NIH Toolbox. Journal of Hand Therapy,
C., & Dewey, M. E. (2008). The prevalence of joint 24, 313-320.
contractures, pressure sores, painful shoulder, other pain, falls,