Efficacy of Sensory Electrical Stimulation Versus Alternating Electromyography (EMG) on the Functional Recovery of the Hand in Chronic Stroke Survivors: Randomized Controlled Trial

Efficacy of Sensory Electrical Stimulation Versus Alternating Electromyography (EMG) on the Functional Recovery of the Hand in Chronic Stroke Survivors: Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Efficacy of Sensory Electrical Stimulation Versus Alternating Electromyography (EMG) on the Functional Recovery of the Hand in Chronic Stroke Survivors: Randomized Controlled Trial abd el-hamied el-Sherbini, Dany Alphonse Habib, Ahmed Ashraf, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7836628/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and purpose: Upper limb paresis among stroke survivors is the most common physical disability, significantly affecting their ability to perform Activities of Daily Living (ADL). Electrical stimulation is considered a promising approach to restore upper limb function. This study aimed to compare the effectiveness of Sensory Electrical Stimulation (SES) and alternating Electromyogram (EMG) Biofeedback in improving hand function in chronic stroke patients. Materials and Method: Sixty stroke participants were randomly divided into three groups: experimental group 1 received standard physical therapy plus SES; experimental group 2 received physical therapy with alternating EMG Biofeedback; and the control group received only standard physical therapy. Over a three-month period, hand function was evaluated using the Action Research Arm Test (ARAT), muscle strength was assessed via the Medical Research Council (MRC) Scale, and spasticity was measured using the Modified Ashworth Scale. Results: Statistical analysis showed significant improvements in motor function, muscle strength, and reduced spasticity in both experimental groups compared to the control group (p < 0.05). Notably, experimental group 2 (EMG Biofeedback) showed superior outcomes in ARAT subscales—grasp (89.74%), grip (97.62%), and pinch (69.08%)—and exhibited lower wrist spasticity (p = 0.014) than experimental group 1 (SES). Conclusion: The findings suggest that both SES and EMG Biofeedback are effective when integrated into structured hand-training programs for chronic stroke rehabilitation. However, alternating EMG Biofeedback showed greater efficacy in improving hand function, increasing muscular strength, and reducing spasticity, making it a more favorable intervention for this patient population. Trial registration: Registered at ClinicalTrials.gov on 20 th February 2025 (ClinicalTrials.gov identifier: NCT06836596). Health sciences/Diseases/Neurological disorders/Stroke Biological sciences/Neuroscience/Diseases of the nervous system/Stroke Sensory electrical stimulation Alternating electromyogram stimulation Rehabilitation Stroke Hand function Introduction Stroke is the most common reason for morbidity and mortality on a global scale; it occurs suddenly as a loss of brain function following disturbance or disruption in cerebral circulation (1; 2; 3; 4; 5; 6). Upper limb paresis is the most common physical disability among stroke survivors. An estimated 70% of all stroke survivors present with this condition (7). Restoration of upper limb functionality becomes essential in stroke rehabilitation as it opens independence in Activities of Daily Living (ADL) (8; 9). Weakness and loss of dexterity are consistently major contributors to post-stroke disability (10; 11; 12). Sensory Electrical Stimulation (SES) is a new aspect of treatment in propelling hand motor recovery (13). It is the delivery of a series of pulses of electrical discharge to the skin over peripheral nerves at regular intervals (14). A single session of SES applied on a paretic hand has been shown to slightly increase strength and induce cortical plasticity concerning the motor behavior of chronic and subacute stroke patients (15; 16). Although the effects of single-session SES studies, with few exceptions set by intensity, seem to indicate stronger stimulation intensities as giving more important effects at the end of the session, this seems to be consensus (17). However, despite numerous investigations into the repeated sessions of other forms of somatosensory or sensorimotor stimulation, there is still debate about the clinical effectiveness of several of these techniques, although some research showed possible advantages from, among others, neuromuscular stimulation, cutaneous stimulation, combined neuromuscular/cutaneous stimulation, constant- frequency TENS, and acupuncture; while others did not confirm these findings (11; 18). Neuromuscular Electrical Stimulation (NMES) is often applied in stroke rehabilitation for of motor impairments, either through facilitation or direct stimulation of voluntary movements (19; 20). Thus, NMES effectively reduces compensatory movements, directing electrical current to specific muscles and eliciting repetitive sensorimotor experiences (21). Scientific evidence demonstrates that NMES targeting specific muscles, when done precisely, enhances motor performance, improves sensory feedback, and promotes muscle strength in a stroke patient [8, 28]. Other studies indicate that NMES reduces the spasticity of muscles, augments excitability in the corticospinal pathways, and develops neuroplasticity [29]. In the chronic phase of stroke recovery, repetitive, intensive, and goal-directed physical training is the core of restoration of motor activity (22; 5; 23; 24). Aim of the study: This study aimed to compare the effectiveness of sensory amplitude electrical stimulation and alternating EMG-stimulation in improving hand function in patients with chronic stroke. Materials and Methods Study Design: The study is a randomized controlled clinical trial which was conducted in the Faculty of Physical Therapy, Cairo University. It was registered in ClinicalTrials.gov (ID: P.T.REC/012/004916) and it received ethical approval by the local ethical committee of the Faculty of Physical Therapy, Cairo University (Approval No: P.T.REC/012/004916).” The participants were informed about the purpose and procedures of study completely, and written informed consent was requested before their entrant. Subjects: Sixty chronic stroke patients (42 Males and 18 Females) were recruited from outpatient clinics of neurology and internal medicine in Kasr Al-Aini Hospitals and outpatient clinic, Faculty of physical therapy, Cairo University. The inclusion criteria were :chronic stroke patients aged between 45-65, with a stroke duration of 6-18 months, spasticity of the upper extremity of not more than 1+ according to the modified Ashworth Scale (MAS), the mini-mental state examination score (MMSE) of the patients was 24 and the ability to open and hold at least one block with the Box and Block Test. The exclusion criteria are: Non-stroke patients, unstable underlying conditions that are associated with cardiac dysfunction, end-stage renal failure, or poorly controlled diabetes, and long-term use of the medications that can induce motor or sensory excitability, contractures, limitation of movement of the wrist joints, previously diagnosed musculoskeletal diseases that drastically affect physical movement, and having been injected with Botulinum Toxin into the hand muscles. Randomization: Patients were randomized into three equal groups (n=20 per group) using an online random number generator at the initial visit. Experimental group 1 received peripheral sensory electrical stimulation along with a standard physical therapy regimen. Experimental group 2 received the standard program of physical therapy using the regular EMG stimulation, which was interchanged. The control group received standard physical therapy. Procedures: Measurements were taken from all participants at baseline and after the 3-month intervention. Instrumentation for treatment: Sensory electrical stimulation: A TENS device (Elettronica Pagani Roland ET 20, made in Italy) was used to deliver electrical stimulation through skin electrodes for pain management. The device could be adjusted for different frequencies (starting at 50 Hz) and intensity levels from sensory to motor stimulation. Sensory intensity is when the patient experiences a strong yet comfortable sensation without triggering muscle contraction [13]. MyoTrac Infiniti device: A T9800 device (Thought Technology Ltd., Canada) uses surface EMG electrodes to detect muscle activity and automatically trigger electrical stimulation when the EMG reaches a preset threshold. This system helps patients promote voluntary muscle activation by stimulating target muscles and providing EMG feedback, allowing patients to practice replicating movements until they reach the desired muscle activation level(4; 7). Designed physical therapy program for all groups: Every therapeutic session included a standard program which began at passive range of motion (ROM) of the affected limb and continued with specific stretching of wrist joint and flexor finger muscles. Each subject received a personalized training program aimed at hand functions and a special home-based conditioning task. Experimental group 1 patients were simultaneously exposed to electrical sensory stimulation and the same physical therapy program that encourages hand use. Three pairs of surface adhesive electrodes (20 mm diameter) acted as the anode were then positioned on the distal forearm to elicit the stimuli via the median nerve, the ulnar nerve, and the radial nerve while proximally placed electrodes acted as the cathode. This electric stimulation protocol used 5 consecutive 1ms square pulses at 10 Hz frequency with 50% duty cycle (500ms on/off). Stimulation intensity was set just below motor threshold trying to avoid muscle contractions, producing a tickling/mild tingling sensation. Electrodes were placed on the wrist with 20mm separation (anode dorsal, cathode ventral). Treatment consisted of 30-minute sessions every three days for 12 weeks. Experimental group 2 received electrical muscle stimula-tion through alternating electromyography besides physical therapy protocols aimed at restoration of hand functions. The use of electromyography made it easy to accurately identify the level of stimulation of each patient and the output level of electricity is automatically adjusted to the target stimulation level during the treatment session. Since the MyoTrac Infiniti system was used in the working phase to stimulate the target muscle contraction through electrical stimuli applied. The subjects performed voluntary muscle contractions followed by hand function training. The paralyzed Extensor Digitorum Communis (EDC) was the target muscle. Electrodes were positioned on the dorsal surface of paretic forearm: active electrode near the muscle belly (3/4 distance between olecranon and ulnar styloid), second electrode 1 inch distal for additional stimulation, and ground electrode at was placed at least 3 inches away. This setup allowed simultaneous EMG recording and targeted stimulation. Stimulation parameters were adjusted to allow full joint movement without causing discomfort. The waveform was biphasic, the pulse length was 300 µs, the frequency of the participant in the choice (20 to 40 Hz), the duty cycle alternated each 5 s of stimulating with 20 s of rest. The duration of treatment session was 30 minutes and was performed three times per week during a tone of twelve weeks. An equal amount of time was distributed on the various learning activities, and the rest period of 60 seconds was provided among all the activities [12]. The control group was exposed to the standardized physical therapy regimen apart from which electrodes were used as a dummy treatment. The physical therapy program for hand function improvement consisted of progressively difficult tasks. Patients weekly advanced based on performance - moving to the next level once they were able to complete the current task successfully within 6 attempts and 60 seconds. Function activities included grasping, gripping, pinching, button- pressing, and finger-spreading exercises using rubber bands as assistive tools. Home Program: The physiotherapist also provided the participants with instructions to practice the performance of functional tasks using the hemiplegic arm 2 times in 30 minutes per day. Picked up bath sponge, small juice can and poured into glass, cup, picked up and held a 4- oz juice jar with one hand as the other unscrewed the lid, and picked up and released a 2.5-cm block (cube) and a 7.5-cm diameter ball. Data analysis: Box and whisker plot were used to identify outliers, which were removed, and subsequently, it was analyzed that the data are normally distributed using the Shapiro-Wilk test, and the P -value was greater than 0.05. The test of homogeneity of variance by Levene also determined that the results supported the presence of homogeneity of variance (P¿0.05). As a result, parametric statistics procedures were applied. The statistical analysis was made with the help of the statistical SPSS Package program version 25 under Windows (SPSS, Inc., Chicago, IL). The measures of quantitative variables, which include clinical general characteristics, Action Research Arm Test and muscle power are presented in mean +/- standard deviation. A priori sample size estimation was performed using G*Power (version 3.1.9.4) for a MANOVA design (special effects and interactions) with Pillai’s trace and the O’Brien– Shieh algorithm. The analysis was based on an assumed effect size of f 2 ( V ) = 0 . 199, an alpha level of 0 . 05, desired statistical power of 0 . 80, three groups, two predictors, and nine response variables. Results indicated a required total sample size of 59 participants (approximately 20 per group). Qualitative attribute includes gender, affected size, handedness, and modified Ashworth scale, which is displayed as a frequency (percentage) and compared between three groups using Chi-square test. The comparison of the clinical general characteristics of patients was conducted with one-way analysis of variance (ANOVA test). The mixed-design MANOVA was 3 (Experimental group 1, Experimental group 2 and control group) by 2 (pre-treatment, post-treatment). Under the between subjects, and within- subjects factors are group and measuring period respectively. Action Research Arm Test and muscle power were the Dependent variables. To present a pair-wise comparison among and between the significant variables that were statistically significant as established by the MANOVA, Bonferroni test was used. All the tests were significant with the level of analysis set at 0.05. Results General and clinical features of the patients are provided in Table 1 . which presents the mean values of the data for all groups and proves that there are no significant differences (P > 0.05) of the demographic variables under analysis across these groups. Table 1. Clinical general characteristics of patients among groups Items Exp 1 (n=20) Exp 2 (n=20) Control (n=20) P- value Quantitative variables (Mean ± SD) Age (year) 53 . 70 ± 5 . 91 57 . 25 ± 3 . 97 57 . 90 ± 4 . 29 0.161 Duration of Illness (month) 9 . 50 ± 2 . 98 10 . 30 ± 2 . 63 10 . 60 ± 2 . 87 0.195 Stroke impairment assessment (Touch) 3 . 00 ± 0 . 00 3 . 00 ± 0 . 00 3 . 00 ± 0 . 00 1.000 Stroke impairment assessment (Position) 3 . 00 ± 0 . 00 3 . 00 ± 0 . 00 3 . 00 ± 0 . 00 1.000 Mini-mental 27 . 40 ± 0 . 99 27 . 40 ± 1 . 18 27 . 25 ± 0 . 96 0.874 Qualitative variables (Number (%)) Gender (males : females) 12 (60%) : 8 (40%) 14 (70%) : 6 (30%) 16 (80%) : 4 (20%) 0.386 Affected side (Right : Left) 16 (80%) : 4 (20%) 13 (65%) : 7 (35%) 16 (80%) : 4 (20%) 0.449 Handedness (Right : Left) 18 (90%) : 2 (10%) 18 (90%) : 2 (10%) 19 (95%) : 1 (5%) 0.804 Exp 1 : received peripheral sensory electrical stimulation program; Exp 2 : received alternating EMG stimulation; control:received program for hand functions training only. Quantitative data are expressed as mean ± standard deviation (SD) and compared statistically by ANOVA test. Qualitative data are expressed as number (percentage) and compared statistically by Chi-square test. P-value > 0.05: non-significant. 1. Action Research Arm Test Results Table (2) presents the mean values of Action Research Arm Test scores across three groups. (Supp 1) Grasp Subscale: ANOVA revealed no significant base- line differences between groups (P=0.177), but significant post-treatment differences emerged (P=0.0001). Post-hoc LSD testing showed significant differences between experimental group 1 and control group (P=0.004) and between experimental group 2 and control group (P=0.0001), while both experimental groups did not differ significantly (P=1.000). The mean differences indicated improvement per- centages of 79.74%, 89.74%, and 18.79% for experimental group 1, 2, and control group respectively, with experimental group 2 demonstrating the highest post-treatment performance. Grip Subscale: ANOVA showed no significant baseline differences between groups (P=0.918), but significant post- treatment differences (P=0.001). Post-hoc LSD analysis revealed significant differences between experimental group 1 and control (P=0.040) and between experimental group 2 and control (P=0.0001), with no significant difference between both experimental groups (P=0.470). Mean differences showed improvement percentages of 76.83% in experimental group 1, 97.62% in experimental group 2, and 22.73% in control group. experimental group 2 achieved the highest ARAT grip subscale scores post-intervention, with large effect sizes compared to both experimental group 1 (0.57) and control (1.60). Pinch Subscale: ANOVA indicated no significant baseline differences (P=0.117), but significant post-treatment differences (P=0.014). Post-hoc LSD testing showed a significant difference only between experimental group 2 and control (P=0.018), while differences between experimental groups (P=0.069) and between experimental group 1 and control (P=1.000) were not significant. Mean differences revealed significant improvements in all three groups (P ¡ 0.05), with experimental group 2 showing the best post-treatment performance in the pinch subscale. Gross Subscale: ANOVA showed no significant differences at baseline (P=0.090) or post-treatment (P=0.590). Mean differences indicated improvement percentages of 68.97%, 68.89%, and 32.71% for experimental group 1, 2 and control respectively, with experimental group 1 recording the highest post-treatment results in the gross subscale. Total ARAT Score: ANOVA revealed no significant base- line differences (P=0.062), but significant post-treatment differences between groups (P=0.0001). Post-hoc LSD testing showed significant differences between experimental group 2 and control (P=0.0001) and between experimental group 1 and control (P=0.040), with no significant difference experimental groups (P=0.126). Mean differences demonstrated significant improvements in all groups (P=0.0001), with experimental group 2 achieving the highest total ARAT score post-treatment. 2. Modified Ashworth Scale Results Table (3) presents the mean values of Modified Ashworth Scale scores across three groups. (Supp 2) Shoulder: ANOVA revealed no significant baseline differences (P=0.783) and no significant post-treatment differences (P=0.102) among the three groups. Mean differences indicated that experimental group 2 and control achieved the highest post-treatment Modified Ashworth Scale scores for shoulder spasticity. Elbow: ANOVA showed no significant baseline differences (P=0.106) or post-treatment (P=0.053). Mean differences showed that experimental group 1 recorded the highest post-treatment Modified Ashworth Scale scores for elbow spasticity. Wrist: ANOVA indicated no significant baseline differences (P=0.825), but significant post-treatment differences (P=0.014). Post-hoc LSD testing showed significant differences between experimental group 1 vs control (P=0.048) and between experimental group 2 vs control (P=0.025), while no significant difference was found between experimental group 1 vs experimental group 2 (P=0.465). Mean differences revealed that experimental group 2 achieved the highest post-treatment Modified Ashworth Scale scores for wrist spasticity. 3. Muscle Power Results Table (4) presents the mean values of muscle power measurements across three groups for finger flexors, finger extensors, finger adductors, finger abductors, wrist flexors, and wrist extensors. (Supp 3) Finger Flexors: ANOVA revealed no significant baseline differences (P=0.814), but significant post-treatment differences (P=0.024). Post-hoc LSD testing showed significant differences between experimental group 1 and experimental group 2 (P=0.021) and between experimental group 2 vs control (P=0.013), with no significant difference between experimental group 1 vs control (P=1.000). Mean differences indicated improvement percentages of 36.84%, 55.26%, and 17.07% for experimental group 1, 2, and control respectively, with experimental group 2 achieving the highest post- treatment finger flexor muscle power. Finger Extensors: ANOVA showed no significant baseline differences (P=0.711), but significant post-treatment differences (P=0.003). Post-hoc LSD analysis revealed significant differences between experimental group 1 and experimental group 2 (P=0.001) and between experimental group 2 and control (P=0.001), with no significant difference between experimental group 1 and control (P=1.000). Mean differences demonstrated improvement percentages of 10.81%, 41.46%, and 0.00% for experimental group 1, 2, and control respectively, with experimental group 2 recording the highest post-treatment finger extensor muscle power. Finger Adductors: ANOVA indicated no significant base- line differences (P=0.711), but significant post-treatment differences (P=0.003). Post-hoc LSD testing showed significant differences only between experimental group 1 and experimental group 2 (P=0.012), while no significant differences were found between experimental group 1 and control (P=0.766) or experimental group 2 and control (P=0.225). Mean differences revealed improvement percent- ages of 5.41%, 18.75%, and 2.22% for experimental group 1, 2, and control respectively, with experimental group 2 achieving the highest post-treatment finger adductor muscle power. Finger Abductors: ANOVA showed no significant baseline differences (P=0.868), but significant post-treatment differences (P=0.022). Post-hoc LSD analysis revealed significant differences between groups experimental group 1 and experimental group 2 (P=0.049) and between experimental group 2 and control (P=0.049), with no significant difference between experimental group 1 and control (P=1.000). Mean differences indicated improvement percentages of 2.63%, 29.27%, and 0.00% for experimental group 1, 2, and control respectively, with experimental group 2 recording the highest post-treatment finger abductor muscle power. Wrist Flexors: ANOVA revealed no significant baseline differences (P=0.822), but significant post-treatment differences (P=0.019). Post-hoc LSD testing showed significant differences only between experimental group 2 and control (P=0.026), while no significant differences were found between experimental group 1 and experimental group 2 (P=1.000) or experimental group 1 and control (P=0.078). Mean differences demonstrated improvement percentages of 23.91%, 37.21%, and 4.55% for experimental group 1, 2, and control respectively, with experimental group 2 achieving the highest post-treatment wrist flexor muscle power. Wrist Extensors: ANOVA indicated no significant baseline differences (P=0.914), but significant post-treatment differences (P=0.021). Post-hoc LSD analysis revealed significant differences experimental group 1 and experimental group 2 (P=0.028) and between experimental group 2 and control (P=0.036), with no significant difference between experimental group 1 and control (P=1.000). Mean differences showed improvement percentages of 4.76%, 25.00%, and 0.00% for experimental group 1, 2, and control respectively, with experimental group 2 recording the highest post- treatment wrist extensor muscle power. Discussion This study demonstrated that the integration of either Sensory Electrical Stimulation (SES) or Alternating Electromyogram (EMG) stimulation into a standardized physical therapy program significantly enhanced hand function, reduced spasticity, and improved muscle power in chronic stroke survivors when compared to physical therapy alone. A notable finding was the general superiority of Alternating EMG stimulation (experimental group 2) across several key metrics. This included more pronounced improvements in fine motor control, as evidenced by the grasp, grip, and pinch subscales of the Action Research Arm Test (ARAT), and a higher overall ARAT total score. Furthermore, experimental group 2 exhibited a significant reduction in wrist spasticity and greater improvements in muscle power across most assessed finger and wrist muscles. Conversely, SES (experimental group 1) demonstrated a better outcome in the Gross ARAT subscale, suggesting a differential impact on broader motor movements (1). The nuanced finding that while Alternating EMG stimulation generally outperformed SES, SES showed superior results in the Gross ARAT subscale, suggests that these two modalities might target distinct aspects of motor recovery (e.g., fine motor control versus gross motor movements). This is a critical observation that moves beyond a simple” better/worse” comparison to a more sophisticated understanding of how each intervention contributes to the rehabilitation process, potentially informing more tailored treatment approaches. Effectiveness of Sensory Electrical Stimulation (SES) Sensory electrical stimulation has been shown to enhance both sensory and motor functions in stroke patients. The mechanism involves delivering electrical currents through electrodes placed on the skin, which stimulate sensory nerves without necessarily causing overt muscle contractions. This continuous sensory input is believed to modulate the excitability of the motor cortex, thereby improving sensory discrimination and motor performance. This is achieved by enhancing the neural plasticity of the sensory cortex and regulating motor plasticity and recovery (12). It also increases sensorimotor cortex activity and connectivity, which is crucial for enhancing motor skill acquisition and consolidation, as observed through changes in visuomotor task performance and cortical adaptations using electroencephalography (12). Activation of sensory afferent inputs, particularly when combined with stimulation of specific motor areas, appears to be an efficient means of promoting plastic changes at both cortical and spinal levels (13). In this study, experimental group 1, which received Sensory electrical stimulation, showed significant improvements in hand function as measured by the Action Research Arm Test (ARAT) and the Modified Ashworth Scale. The improvements in grasp, grip, pinch, and gross motor functions were substantial, indicating that SES can effectively enhance hand function in chronic stroke patients. These findings are consistent with Ikuno et al (25) who recommended Peripheral sensory nerve stimulation for clinical use to improve the outcomes of task-oriented training in patients with subacute stroke. Wu et al (26) also concluded that electric sensory stimulation in combination with training protocols may enhance the benefit of customary neuro rehabilitative treatments and possibly motor learning. The result of this study was inconsistent with Ghaziani et al (14) who stated that Sensory electrical stimulation prior to arm training was equally beneficial as arm training alone. The improvement of upper limb muscles spasticity in sensory electrical stimulation post treatment is in accordance with Moon et al (15) who found that repeated applications of TENS can reduce spasticity and improve voluntary functions in hemiparetic patients. The results also agreed with Peurala et al (16) who investigated whether cutaneous electrical stimulation using a flexible mesh glove has a role in the enhancement of sensorimotor function in chronic stroke. They concluded that cutaneous stimulation had positive effects on voluntary motor performance, limb sensation and spasticity in chronic stroke patients. In the current study, the improvement in the muscle tone did not target the hand and wrist muscles yet it had extended to whole upper limb muscles (elbow flexors and shoulder flexors). These findings agreed with Dimitrijevic and Soroker (17) who examined the effects of whole – hand afferent electrical stimulation via a wired mesh- glove upon the residual motor control of the upper extremity. The results indicated beneficial effects in the form of reduction in muscle hypertonia and facilitation of isolated hand movements. The anti-spastic and analgesic effects of transcutaneous electrical nerve stimulation (TENS) can be explained in view of in et al (18) who stated that at the spinal level, there are different opioids released with different stimulation frequencies and thus possibly different opioids receptors activated to produce analgesia with high or low frequency TENS. The release of endogenous opioids in the spinal cord in response to TENs stimulation could result from activation of local circuits within the spinal cord or from activation of descending inhibitory pathways. Serrano Tendero et al (20) also proposed that the anti–spastic effect elicited by high frequency transcutaneous electrical nerve stimulation is mediated by endogenous opioid interacting with the opiate receptors, most probably dynorphin, in the central nervous system. In addition, Vollar et al (21) stated that the application of sensory amplitude electrical stimulation (SES) (stimulation to sensory threshold without motor contraction) over the hand could increase blood flow in the areas of the primary and secondary motor cortices as well as the primary sensory cortex. Moreover, Joodaki et al (20) investigated the effects of electrical nerve stimulation on alpha motor neuron excitability. The results showed reduction of the amplitude of h- reflex and F-wave, H/M and F/M ratio demonstrated reduction of spasticity. Tinazzi et al (27) stated that the effects of TENS on motor excitability may explain the effectiveness of TENS in the treatment of spasticity and dystonia. Golaszewskia et al (23) also indicated that the mechanism of improvement via whole hand mesh- glove stimulation was due to its neuromodulatory effect on motor cortical pathways and motor cortical excitability. The increased motor cortical excitability lasting at least one hour leads to an extension of neural activities. Both the strength of the corticospinal projections and the inhibitory and facilitatory intracortical mechanism are involved. Synaptic modifications such as long-term potentiation mechanisms may underlie this stimulation induced cortical plasticity changes. In this study, the sensory electrical stimulation group showed significant improvement of manual muscle strength of finger flexors, finger extensors and wrist extensors whereas control group showed significant improvement in the strength of finger flexors and finger extensors only. These results agreed with Satheeskumar et al (24) who found that combining electrically induced sensory inputs through transcutaneous electrical nerve stimulation (TENS) with task training in a home-based program would augment voluntary motor output in chronic stroke survivors better than either task training alone or no task training. The improvement of strength of wrist extensors in sensory electrical stimulation group can be explained in view of Ridding et al (28) who found that modifications in the human motor cortex organization and increase in the motor cortical excitability were detected after afferent input from electrical stimulation of the peripheral nerves. Peripheral nerve stimulation, which activates group Ia large muscle afferents, group Ib afferents from Golgi organs, group II afferents from slow and rapidly adapting skin afferents and cutaneous afferent fibers, elects an increase in the motor cortical excitability of body part representations that control the stimulated body part and results in reorganization of the motor and somatosensory cortices. Within the limitations of this study, post treatment results showed a significant increase in wrist extension in sensory electrical stimulation group. These results agreed with Tinazzi et al (27) who proposed that the beneficial effects of transcutaneous electrical nerve stimulation (TENS) application over the hand may be attributed to its ability to increase sensory thresholds and reduce motor evoked potentials (MEPs) in hand muscles. These results can be explained in view of Dimitrijevic et al (29) who stated that daily mesh- glove stimulation can modify altered motor control and improve voluntary wrist extension movement in stroke patients with chronic neurological deficits. Berrtolasi et al (30) also stated that transcutaneous electrical nerve stimulation (TENS) application over the flexor compartment of the forearm reduced motor evoked potentials (MEPs) in the flexor carpi radialis (FCR) muscle and increased motor evoked potential (MEPs) in the antagonist extensor carpi radialis (ECR) muscle. Part of this effect might be via an action of afferent input on the excitability of reciprocal inhibitory connections between antagonist muscles at spinal or cortical levels. Comparing the scores of Action research Arm test post treatment in sensory electrical stimulation group revealed that there was a significant increase in action research arm test. These results agreed with Yibrahim et al (31) who evaluated the effectiveness of transcutaneous electrical nerve stimulation (TENS) and placebo (TENS) on the level of activities of daily living (ADL) of stroke patients. The results indicated that TENs appear to be an effective adjunct in the regaining of motor functions and improving ADL in hemiplegic patients. Jane and Lois (32) also indicated that electrical stimulation delivered at sensory amplitude has been reported to reduce impairment and improve arm function and enhance sensorimotor recovery following stroke. Moreover, Shamay et al (33) stated that TENS decreased hyperactive stretch reflexes and improved the performance of daily activities measured by Barthel index in stroke patients. Laufer and Elboim-Gabyzon (34) also stated that sensory stimulation via TENS may be beneficial to enhance aspects of motor recovery following a stroke, particularly when used in combination with active training. The improvement in the study group did not stop at hand functions yet it had extended to other upper limb functions as seen in Action research Arm test. This could be explained by the dynamic cortical representation described by Jones (35). It was found that there is competition among body parts for territory in sensorimotor cortex, even limited activity of the upper arm might prevent the hand from gaining more control, particularly when the territory is reduced in size because of the stroke. Deafferentation of a body part in a healthy brain enhances cortical representations of adjacent body parts, and this effect is markedly increased by voluntary activity of the adjacent part. Effectiveness of Alternating EMG-Stimulation As far as we know, there have been very few studies conducted on alternating electromyogram stimulation. Alternating EMG-stimulation involves using electromyography (EMG) signals to trigger muscle contraction followed by an active voluntarily muscle contraction to reach a pre-set EMG target level. This method helps in strengthening the muscles and improving motor control by providing muscle stimulation followed by real-time feedback. Alternating EMG-stimulation concept is grounded in” Before Task Performance” (Modeling Feedback). Modeling involves reproducing actions performed by electric stimulation. The muscle contraction taken place by the electric stimulation before the active function serves as valuable sources of information pro- vided to the patient prior to task execution, offering insight into the movement pattern and how it should be executed (36). Proprioception refers to the conscious awareness of the body and limbs and encompasses several distinct properties: passive motion sense, active motion sense, limb position sense, and sense of heaviness (37). Studies have demonstrated that providing proprioceptive guidance on hand movement with passive practice results in a notable improvement in the active reproduction of this new motor skill (38). Several studies have assessed brain activity after passive movement using Functional magnetic resonance imaging, showing that passive movements, even without motor commands, stimulate not only the primary somatosensory cortex (S1) but also the primary motor area (M1), supplementary motor area (SMA), posterior parietal cortex (PPC), and both secondary somatosensory areas (S2) (39). Alternating EMG stimulation serves as a proprioceptive training method by utilizing the passive motion sense, which is generated through passive limb movement via neuromuscular electrical stimulation from the device. This is followed by asking the patient to actively move the limb to reach the predetermined EMG target level, which serves as biofeedback for the patient. Biofeedback has the potential to boost neural plasticity by stimulating auxiliary sensory inputs, making it a promising tool for neurorehabilitation (40). In this study, experimental group 2, which received alternating EMG-stimulation, showed the highest improvement percentages in grasp (89.74%), grip (97.62%) and pinch (69.08%), suggesting that alternating EMG stimulation may provide enhanced facilitation of motor learning and neuroplasticity. The significant reduction in spasticity, particularly in the wrist, further supports the effectiveness of this intervention. These results align with Habib et al (4) who found that adding alternating electromyogram stimulation to a designed physical therapy program for hand function training improves hand function and peak muscle torque in chronic stroke patients. Experimental group 2 exhibited significant reductions in spasticity at the shoulder, elbow, and wrist, with the most noticeable improvement in wrist spasticity. This reduction in spasticity was likely due to the Neuromuscular Electrical Stimulation (NMES) provided by the device during the passive phase of the alternating EMG stimulation. NMES helps reduce spasticity by modulating spinal reflexes and altering their excitability. Additionally, it has the potential to promote neuroplasticity within spinal cord pathways, leading to adaptive changes that contribute to spasticity reduction. This process is facilitated by the reorganization of neural connections through NMES (41). The results of this study align with those of Sentandreu-Man˜o´ et al (42), who demonstrated that NMES protocols led to improvements in hand motor recovery measurements and a reduction in the modified Ashworth scale in older adults after a stroke. Bakhtiary and Fatemy (43) also discovered that a combination of the Bobath inhibitory technique and electrical stimulation may effectively reduce spasticity in stroke patients. The results of this study are consistent with those of Stein et al (44), who found that NMES, when combined with other intervention modalities, can be considered an effective treatment option for improving spasticity and range of motion in stroke patients. Comparison with Control Group The control group, which received only the physical therapy regimen without any electrical stimulation, also showed improvements in hand function, but to a lesser extent compared to the intervention groups. This highlights the added benefit of incorporating electrical stimulation techniques in rehabilitation programs for stroke patients. Clinical Implications The findings of this study have important clinical implications for the rehabilitation of chronic stroke patients. Both SES and alternating EMG-stimulation can be effectively integrated into physical therapy programs to enhance hand function and reduce spasticity. The choice of intervention may depend on the specific needs and preferences of the patient, as well as the availability of equipment and expertise. Limitations and Future Research While this study provides valuable insights, it has some limitations. Single-center design, short follow-up period and relatively small sample size may limit the generalizability of the findings. Future research should include larger, multi-center trials to confirm these results and explore the long-term effects of these interventions. Additionally, Single-center design. Future studies should explore long-term effects and neural mechanisms via neuroimaging. Conclusion Alternating EMG stimulation combined with physical therapy significantly improves hand function and reduces spasticity in chronic stroke survivors, outperforming SES in key metrics. These findings advocate personalized rehabilitation strategies incorporating electrical stimulation to optimize recovery. Abbreviations ARAT: Action Research Arm Test ADL: Activities of Daily Living EMG: Electromyogram EDC: Extensor Digitorum Communis ECR: Extensor Carpi Radialis FCR: Flexor Carpi Radialis MRC: Medical Research Council MMSE: Mini-Mental State Examination MEPs: Motor Evoked Potentials NMES: Neuromuscular Electrical Stimulation SES: Sensory Electrical Stimulation PPC: Posterior Parietal Cortex ROM: Range of Motion SMA: Supplementary Motor Area TENS: Transcutaneous Electrical Nerve Stimulation Declarations Acknowledgements: Special thanks to all our patients who participated in the research for their patience and dedication. Funding This research received no external funding. Institutional Review Board Statement: The study was reviewed and approved by by the local ethical committee of the Faculty of Physical Therapy, Cairo University (Approval No: P.T.REC/012/004916). Informed consent All authors have reviewed and approved the final manuscript and consent to its publication. 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Tables Table 2: Within and between group comparisons for action research arm test variables Variables Items Groups (Mean ±SD) Effect size P -value 2 Post-hoc test (post-treatment) Exp 1 (n=20) Exp 2 (n=20) Control (n=20) Pairwise groups MD P-value 3 Grasp Pre-treatment 7.65 ±2.47 7.80 ±4.58 8.25 ±3.52 0.040 0.177 Post-treatment 13.75 ±4.64 14.80 ±3.79 9.80 ±3.57 0.142 0.0001 * Exp 1 vs. Exp 2 1.05 1.000 MD (Change) 6.10 7.00 1.55 Exp 1 vs. Control 3.95 0.004 * 95% CI 1.69 – 10.51 4.59 – 9.40 -0.85 – 3.95 Exp 2 vs. Control 5.00 0.0001 * Improvement % 79.74% 89.74% 18.79% Effect size 0.281 0.226 0.014 P -value 1 0.0001 * 0.0001 * 0.204 Grip Pre-treatment 4.10 ±1.46 4.20 ±2.70 4.40 ±1.50 0.002 0.918 Post-treatment 7.25 ±2.13 8.30 ±2.69 5.40 ±1.90 0.122 0.001 * Exp 1 vs. Exp 2 1.05 0.470 MD (Change) 3.15 4.10 1.00 Exp 1 vs. Control 1.85 0.040 * 95% CI 1.69 – 4.60 2.64 – 5.55 -0.45 – 2.45 Exp 2 vs. Control 2.90 0.0001 * Improvement % 76.83% 97.62% 22.73% Effect size 0.138 0.214 0.016 P -value 1 0.0001 * 0.0001 * 0.177 Pinch Pre-treatment 6.35 ±1.43 7.60 ±5.68 6.25 ±3.94 0.037 0.117 Post-treatment 9.60 ±3.42 12.85 ±5.08 8.90 ±5.31 0.075 0.014 * Exp 1 vs. Exp 2 3.25 0.069 MD (Change) 3.25 5.25 2.65 Exp 1 vs. Control 0.70 1.000 95% CI 1.15 – 5.35 2.45 – 8.04 -0.14 – 5.44 Exp 2 vs. Control 3.95 0.018 * Improvement % 51.18% 69.08% 42.40% Effect size 0.097 0.108 0.030 P -value 1 0.001 * 0.0001 * 0.063 Gross Pre-treatment 4.35 ±2.11 4.50 ±0.88 5.35 ±1.22 0.041 0.090 Post-treatment 7.35 ±2.25 7.60 ±0.59 7.10 ±1.41 0.009 0.590 Exp 1 vs. Exp 2 0.25 1.000 MD (Change) 3.00 3.10 1.75 Exp 1 vs. Control 0.25 1.000 95% CI 2.03 – 3.96 2.13 – 4.06 0.78 – 2.71 Exp 2 vs. Control 0.50 0.917 Improvement % 68.97% 68.89% 32.71% Effect size 0.251 0.263 0.102 P -value 1 0.0001 * 0.0001 * 0.0001 * Total Pre-treatment 23.60 ±4.78 24.10 ±9.81 24.25 ±6.41 0.047 0.062 Post-treatment 38.00 ±10.03 43.55 ±10.59 31.20 ±8.02 0.155 0.0001 * Exp 1 vs. Exp 2 5.55 0.126 MD (Change) 14.40 19.45 6.95 Exp 1 vs. Control 6.80 0.040 * 95% CI 9.05 – 19.77 14.10 – 24.80 1.60 – 12.30 Exp 2 vs. Control 12.35 0.0001 * Improvement % 61.02% 80.71% 28.66% Effect size 0.312 0.313 0.055 P -value 1 0.0001 * 0.0001 * 0.011 * Exp 1: received peripheral sensory electrical stimulation program; Exp 2: received alternating EMG stimulation; Control: received program for hand functions training only. Data are expressed as mean ±standard deviation (SD) MD: Mean difference CI: confidence interval P-value: probability value * Significant (P<0.05) P-value 1 : Probability value within each group; P-value 2 : probability value among groups; P-value 3 : probability value between pairwise groups (post-hoc test) Table 3: Within and between group comparisons for modified Ashworth scale Variables Items Groups (Mean ±SD) P -value 2 Post-hoc test (Post-treatment) Exp 1 (n=20) Exp 2 (n=20) Control (n=20) Pairwise groups P-value 3 Shoulder Pre-treatment Zero 8 (40%) 6 (30%) 10 (50%) 0.783 1 8 (40%) 10 (50%) 7 (35%) 1+ 4 (20%) 4 (20%) 3 (15%) Post-treatment Exp 1 vs. Exp 2 1.000 Zero 16 (80%) 16 (80%) 11 (55%) 0.102 Exp 1 vs. Control 0.115 1 4 (20%) 4 (20%) 6 (30%) Exp 2 vs. Control 0.115 1+ 0 (0%) 0 (0%) 3 (15%) P -value 1 0.0001 * Elbow Pre-treatment Zero 16 (80%) 10 (50%) 9 (45%) 0.106 1 0 (0%) 4 (20%) 5 (25%) 1+ 4 (20%) 6 (30%) 6 (30%) Post-treatment Exp 1 vs. Exp 2 0.465 Zero 16 (80%) 14 (70%) 11 (55%) 0.053 * Exp 1 vs. Control 0.081 1 4 (20%) 6 (30%) 5 (25%) Exp 2 vs. Control 0.108 1+ 0 (0%) 0 (0%) 4 (20%) P -value 1 0.0001 * Wrist Pre-treatment Zero 9 (45%) 8 (40%) 7 (35%) 0.825 1 5 (25%) 8 (40%) 8 (40%) 1+ 6 (30%) 4 (20%) 5 (25%) Post-treatment Exp 1 vs. Exp 2 0.465 Zero 14 (70%) 16 (80%) 9 (45%) 0.014 * Exp 1 vs. Control 0.048 * 1 6 (30%) 4 (20%) 6 (30%) Exp 2 vs. Control 0.025 * 1+ 0 (0%) 0 (0%) 5 (25%) P -value 1 0.0001 * Exp 1: received peripheral sensory electrical stimulation program; Exp 2: received alternating EMG stimulation; Control: received program for hand functions training only Data are expressed as number (percentage)) P-value: probability value * Significant (P<0.05) P-value 1 : Probability value within each group; P-value 2 : probability value among groups; P-value 3 : probability value between pairwise groups (post-hoc test) Table 4: Within and between group comparisons for muscle power Variables Items Groups (Mean ±SD) Effect size P -value 2 Post-hoc test (Post-treatment) Exp 1 (n=20) Exp 2 (n=20) Control (n=20) Pairwise groups MD P-value 3 Finger Flexors Pre-treatment 1.90 ±0.96 1.90 ±0.64 2.05 ±0.75 0.236 0.814 Post-treatment 2.60 ±0.99 2.95 ±0.60 2.40 ±0.50 0.066 0.024 * Exp 1 vs. Exp 2 0.35 0.021 * MD (Change) 0.70 1.05 0.35 Exp 1 vs. Control 0.20 1.000 95% CI 0.16 – 1.23 0.51 – 1.58 -0.18 – 0.88 Exp 2 vs. Control 0.55 0.013 * Improvement % 36.84% 55.26% 17.07% Effect size 0.056 0.117 0.015 P -value 1 0.011 * 0.0001 * 0.197 Finger Extensors Pre-treatment 1.85 ±0.98 2.05 ±0.75 2.00 ±0.64 0.006 0.711 Post-treatment 2.05 ±0.65 2.90 ±0.94 2.00 ±0.64 0.095 0.003 * Exp 1 vs. Exp 2 0.85 0.001 * MD (Change) 0.20 0.85 0.00 Exp 1 vs. Control 0.05 1.000 95% CI -0.29 – 0.69 -0.34 – 0.64 -0.49 – 0.49 Exp 2 vs. Control 0.90 0.001 * Improvement % 10.81% 41.46% 0.00% Effect size 0.006 0.003 0.00 P -value 1 0.429 0.552 1.000 Finger adductors Pre-treatment 1.85 ±0.98 2.40 ±0.82 2.25 ±0.85 0.029 0.183 Post-treatment 1.95 ±0.91 2.85 ±0.82 2.30 ±0.75 0.072 0.015 * Exp 1 vs. Exp 2 0.90 0.012 * MD (Change) 0.10 0.45 0.05 Exp 1 vs. Control 0.35 0.766 95% CI -0.50 – 0.70 -0.15 – 1.05 -0.55 – 0.65 Exp 2 vs. Control 0.55 0.225 Improvement % 5.41% 18.75% 2.22% Effect size 0.001 0.019 0.00 P -value 1 0.744 0.144 0.871 Finger abductors Pre-treatment 1.90 ±0.91 2.05 ±0.82 1.95 ±0.75 0.002 0.868 Post-treatment 1.95 ±0.88 2.65 ±0.92 1.95 ±0.75 0.065 0.022 * Exp 1 vs. Exp 2 0.70 0.049 * MD (Change) 0.05 0.60 0.00 Exp 1 vs. Control 0.00 1.000 95% CI -0.51 – 0.61 0.03 – 1.16 -0.56 – 0.56 Exp 2 vs. Control 0.70 0.049 * Improvement % 2.63% 29.27% 0.00% Effect size 0.00 0.037 0.00 P -value 1 0.862 0.039 * 1.000 Wrist flexors Pre-treatment 2.30 ±0.80 2.15 ±0.93 2.20 ±0.69 0.003 0.822 Post-treatment 2.85 ±0.83 2.95 ±0.78 2.30 ±0.57 0.068 0.019 * Exp 1 vs. Exp 2 0.10 1.000 MD (Change) 0.55 0.80 0.10 Exp 1 vs. Control 0.55 0.078 95% CI 0.06 – 1.03 0.31 – 1.28 -0.38 – 0.58 Exp 2 vs. Control 0.65 0.026 * Improvement % 23.91% 37.21% 4.55% Effect size 0.043 0.086 0.001 P -value 1 0.026 * 0.001 * 0.682 Wrist extensors Pre-treatment 2.10 ±0.71 2.20 ±0.76 2.15 ±0.67 0.002 0.914 Post-treatment 2.20 ±0.76 2.75 ±0.85 2.15 ±0.67 0.066 0.021 * Exp 1 vs. Exp 2 0.55 0.028 * MD (Change) 0.10 0.55 0.00 Exp 1 vs. Control 0.05 1.000 95% CI -0.36 – 0.56 0.08 – 1.01 -0.46 – 0.46 Exp 2 vs. Control 0.60 0.036 * Improvement % 4.76% 25.00% 0.00% Effect size 0.002 0.046 0.00 P -value 1 0.671 0.021 * 1.000 Exp 1: received peripheral sensory electrical stimulation program; Exp 2: received alternating EMG stimulation; Control: received program for hand functions training only Data are expressed as mean ±standard deviation (SD) MD: Mean difference CI: confidence interval P-value: probability value * Significant (P<0.05) P-value 1 : Probability value within each group; P-value 2 : probability value among groups; P-value 3 : probability value between pairwise groups (post-hoc test) Additional Declarations There is NO Competing Interest. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7836628","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":535830259,"identity":"a8f5eb2a-8394-4efa-922b-804a3bc16f2b","order_by":0,"name":"abd el-hamied el-Sherbini","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-7117-6976","institution":"Beni suef university","correspondingAuthor":true,"prefix":"","firstName":"abd","middleName":"el-hamied","lastName":"el-Sherbini","suffix":""},{"id":535830260,"identity":"3f9e7021-f9fe-43e3-8179-5399b292a50f","order_by":1,"name":"Dany Alphonse Habib","email":"","orcid":"","institution":"Faculty of Physical Therapy/ Suez University","correspondingAuthor":false,"prefix":"","firstName":"Dany","middleName":"Alphonse","lastName":"Habib","suffix":""},{"id":535830261,"identity":"e3ce1ece-1fc4-42d9-bb72-9680080f8d41","order_by":2,"name":"Ahmed Ashraf","email":"","orcid":"","institution":"Neurosciences Division, Semmelweis University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Ashraf","suffix":""},{"id":535830262,"identity":"0a5f0676-52b9-4bdd-8d19-2742b39fdc4d","order_by":3,"name":"Mohammed Emam","email":"","orcid":"","institution":"Faculty of Physical Therapy, Kafrelsheikh University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Emam","suffix":""},{"id":535830263,"identity":"1e80e21c-5736-470d-8812-49c6917c9c6a","order_by":4,"name":"Reham Ahmed","email":"","orcid":"","institution":"Faculty of Physical Therapy/ Beni-Suef University","correspondingAuthor":false,"prefix":"","firstName":"Reham","middleName":"","lastName":"Ahmed","suffix":""}],"badges":[],"createdAt":"2025-10-11 16:55:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7836628/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7836628/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95797627,"identity":"25f0b6ad-cc16-455c-8b88-c2f9487c9ae6","added_by":"auto","created_at":"2025-11-13 08:08:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1327577,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7836628/v1/cef8303f-ae84-46d2-983f-e569c681c355.pdf"},{"id":95603499,"identity":"7d994a1b-be03-47fb-a53b-5ebc894fce39","added_by":"auto","created_at":"2025-11-11 06:25:15","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22990,"visible":true,"origin":"","legend":"","description":"","filename":"Rawdataver.2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7836628/v1/f9006eb4356abe92f52142f7.xlsx"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e Competing Interest.","formattedTitle":"Efficacy of Sensory Electrical Stimulation Versus Alternating Electromyography (EMG) on the Functional Recovery of the Hand in Chronic Stroke Survivors: Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke is the most common reason for morbidity and mortality on a global scale; it occurs suddenly as a loss of brain function following disturbance or disruption in cerebral circulation (1; 2; 3; 4; 5; 6). Upper limb paresis is the most common physical disability among stroke survivors. An estimated 70% of all stroke survivors present with this condition (7). Restoration of upper limb functionality becomes essential in stroke rehabilitation as it opens independence in Activities of Daily Living (ADL) (8; 9). Weakness and loss of dexterity are consistently major contributors to post-stroke disability (10; 11; 12). Sensory Electrical Stimulation (SES) is a new aspect of treatment in propelling hand motor recovery (13). It is the delivery of a series of pulses of electrical discharge to the skin over peripheral nerves at regular intervals (14). A single session of SES applied on a paretic hand has been shown to slightly increase strength and induce cortical plasticity concerning the motor behavior of chronic and subacute stroke patients (15; 16). Although the effects of single-session SES studies, with few exceptions set by intensity, seem to indicate stronger stimulation intensities as giving more important effects at the end of the session, this seems to be consensus (17). However, despite numerous investigations into the repeated sessions of other forms of somatosensory or sensorimotor stimulation, there is still debate about the clinical effectiveness of several of these techniques, although some research showed possible advantages from, among others, neuromuscular stimulation, cutaneous stimulation, combined neuromuscular/cutaneous stimulation, constant- frequency TENS, and acupuncture; while others did not confirm these findings (11; 18). Neuromuscular Electrical Stimulation (NMES) is often applied in stroke rehabilitation for of motor impairments, either through facilitation or direct stimulation of voluntary movements (19; 20). Thus, NMES effectively reduces compensatory movements, directing electrical current to specific muscles and eliciting repetitive sensorimotor experiences (21). Scientific evidence demonstrates that NMES targeting specific muscles, when done precisely, enhances motor performance, improves sensory feedback, and promotes muscle strength in a stroke patient [8, 28]. Other studies indicate that NMES reduces the spasticity of muscles, augments excitability in the corticospinal pathways, and develops neuroplasticity [29]. In the chronic phase of stroke recovery, repetitive, intensive, and goal-directed physical training is the core of restoration of motor activity (22; 5; 23; 24).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim of the study: \u003c/strong\u003eThis study aimed to compare the effectiveness of sensory amplitude electrical stimulation and alternating EMG-stimulation in improving hand function in patients with chronic stroke.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design: \u003c/strong\u003eThe study is a randomized controlled clinical trial which was conducted in the Faculty of Physical Therapy, Cairo University. It was registered in ClinicalTrials.gov (ID: P.T.REC/012/004916) and it received ethical approval by the local ethical committee of the Faculty of Physical Therapy, Cairo University (Approval No: P.T.REC/012/004916).\u0026rdquo; The participants were informed about the purpose and procedures of study completely, and written informed consent was requested before their entrant. \u003cstrong\u003eSubjects: \u003c/strong\u003eSixty chronic stroke patients (42 Males and 18 Females) were recruited from outpatient clinics of neurology and internal medicine in Kasr Al-Aini Hospitals and outpatient clinic, Faculty of physical therapy, Cairo University. The inclusion criteria were :chronic stroke patients aged between 45-65, with a stroke duration of 6-18 months, spasticity of the upper extremity of not more than 1+ according to the modified Ashworth Scale (MAS), the mini-mental state examination score (MMSE) of the patients was 24 and the ability to open and hold at least one block with the Box and Block Test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe exclusion criteria are: \u003c/strong\u003eNon-stroke patients, unstable underlying conditions that are associated with cardiac dysfunction, end-stage renal failure, or poorly controlled diabetes, and long-term use of the medications that can induce motor or sensory excitability, contractures, limitation of movement of the wrist joints, previously diagnosed musculoskeletal diseases that drastically affect physical movement, and having been injected with Botulinum Toxin into the hand muscles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization: \u003c/strong\u003ePatients were randomized into three equal groups (n=20 per group) using an online random number generator at the initial visit. Experimental group 1 received peripheral sensory electrical stimulation along with a standard physical therapy regimen. Experimental group 2 received the standard program of physical therapy using the regular EMG stimulation, which was interchanged. The control group received standard physical therapy. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures: \u003c/strong\u003eMeasurements were taken from all participants at baseline and after the 3-month intervention.\u003c/p\u003e\n\u003ch2\u003eInstrumentation for treatment:\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eSensory electrical stimulation: \u003c/strong\u003eA TENS device (Elettronica Pagani Roland ET 20, made in Italy) was used to deliver electrical stimulation through skin electrodes for pain management. The device could be adjusted for different frequencies (starting at 50 Hz) and intensity levels from sensory to motor stimulation. Sensory intensity is when the patient experiences a strong yet comfortable sensation without triggering muscle contraction [13].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMyoTrac Infiniti device: \u003c/strong\u003eA T9800 device (Thought Technology Ltd., Canada) uses surface EMG electrodes to detect muscle activity and automatically trigger electrical stimulation when the EMG reaches a preset threshold. This system helps patients promote voluntary muscle activation by stimulating target muscles and providing EMG feedback, allowing patients to practice replicating movements until they reach the desired muscle activation level(4; 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesigned physical therapy program for all groups: \u003c/strong\u003eEvery therapeutic session included a standard program which began at passive range of motion (ROM) of the affected limb and continued with specific stretching of wrist joint and flexor finger muscles. Each subject received a personalized training program aimed at hand functions and a special home-based conditioning task. Experimental group 1 patients were simultaneously exposed to electrical sensory stimulation and the same physical therapy program that encourages hand use.\u003c/p\u003e\n\u003cp\u003eThree pairs of surface adhesive electrodes (20 mm diameter) acted as the anode were then positioned on the distal forearm to elicit the stimuli via the median nerve, the ulnar nerve, and the radial nerve while proximally placed electrodes acted as the cathode. This electric stimulation protocol used 5 consecutive 1ms square pulses at 10 Hz frequency with 50% duty cycle (500ms on/off). Stimulation intensity was set just below motor threshold trying to avoid muscle contractions, producing a tickling/mild tingling sensation. Electrodes were placed on the wrist with 20mm separation (anode dorsal, cathode ventral). Treatment consisted of 30-minute sessions every three days for 12 weeks.\u003c/p\u003e\n\u003cp\u003eExperimental group 2 received electrical muscle stimula-tion through alternating electromyography besides physical therapy protocols aimed at restoration of hand functions. The use of electromyography made it easy to accurately identify the level of stimulation of each patient and the output level of electricity is automatically adjusted to the target stimulation level during the treatment session.\u003c/p\u003e\n\u003cp\u003eSince the MyoTrac Infiniti system was used in the working phase to stimulate the target muscle contraction through electrical stimuli applied. The subjects performed voluntary muscle contractions followed by hand function training. The paralyzed Extensor Digitorum Communis (EDC) was the target muscle. Electrodes were positioned on the dorsal surface of paretic forearm: active electrode near the muscle belly (3/4 distance between olecranon and ulnar styloid), second electrode 1 inch distal for additional stimulation, and ground electrode at was placed at least 3 inches away. This setup allowed simultaneous EMG recording and targeted stimulation. Stimulation parameters were adjusted to allow full joint movement without causing discomfort. The waveform was biphasic, the pulse length was 300 \u0026micro;s, the frequency of the participant in the choice (20 to 40 Hz), the duty cycle alternated each 5 s of stimulating with 20 s of rest.\u003c/p\u003e\n\u003cp\u003eThe duration of treatment session was 30 minutes and was performed three times per week during a tone of twelve weeks. An equal amount of time was distributed on the various learning activities, and the rest period of 60 seconds was provided among all the activities [12]. The control group was exposed to the standardized physical therapy regimen apart from which electrodes were used as a dummy treatment.\u003c/p\u003e\n\u003cp\u003eThe physical therapy program for hand function improvement consisted of progressively difficult tasks. Patients weekly advanced based on performance - moving to the next level once they were able to complete the current task successfully within 6 attempts and 60 seconds. Function activities included grasping, gripping, pinching, button- pressing, and finger-spreading exercises using rubber bands as assistive tools. Home Program: The physiotherapist also provided the participants with instructions to practice the performance of functional tasks using the hemiplegic arm 2 times in 30 minutes per day. Picked up bath sponge, small juice can and poured into glass, cup, picked up and held a 4- oz juice jar with one hand as the other unscrewed the lid, and picked up and released a 2.5-cm block (cube) and a 7.5-cm diameter ball.\u003c/p\u003e\n\u003ch2\u003eData analysis:\u003c/h2\u003e\n\u003cp\u003eBox and whisker plot were used to identify outliers, which were removed, and subsequently, it was analyzed that the data are normally distributed using the Shapiro-Wilk test, and the P -value was greater than 0.05. The test of homogeneity of variance by Levene also determined that the results supported the presence of homogeneity of variance (P\u0026iquest;0.05). As a result, parametric statistics procedures were applied. The statistical analysis was made with the help of the statistical SPSS Package program version 25 under Windows (SPSS, Inc., Chicago, IL). The measures of quantitative variables, which include clinical general characteristics, Action Research Arm Test and muscle power are presented in mean +/- standard deviation.\u003c/p\u003e\n\u003cp\u003eA priori sample size estimation was performed using \u003cem\u003eG*Power \u003c/em\u003e(version 3.1.9.4) for a MANOVA design (special effects and interactions) with Pillai\u0026rsquo;s trace and the O\u0026rsquo;Brien\u0026ndash; Shieh algorithm. The analysis was based on an assumed effect size of \u003cem\u003ef \u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e(\u003cem\u003eV \u003c/em\u003e) = 0\u003cem\u003e.\u003c/em\u003e199, an alpha level of 0\u003cem\u003e.\u003c/em\u003e05, desired statistical power of 0\u003cem\u003e.\u003c/em\u003e80, three groups, two predictors, and nine response variables. Results indicated a required total sample size of 59 participants (approximately 20 per group). Qualitative attribute includes gender, affected size, handedness, and modified Ashworth scale, which is displayed as a frequency (percentage) and compared between three groups using Chi-square test. The comparison of the clinical general characteristics of patients was conducted with one-way analysis of variance (ANOVA test). The mixed-design MANOVA was 3 (Experimental group 1, Experimental group 2 and control group) by 2 (pre-treatment, post-treatment). Under the between subjects, and within- subjects factors are group and measuring period respectively. Action Research Arm Test and muscle power were the Dependent variables. To present a pair-wise comparison among and between the significant variables that were statistically significant as established by the MANOVA, Bonferroni test was used. All the tests were significant with the level of analysis set at 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eGeneral and clinical features of the patients are provided in Table \u003ca href=\"#_bookmark1\"\u003e1\u003c/a\u003e. which presents the mean values of the data for all groups and proves that there are no significant differences (P\u003cem\u003e\u0026gt;\u003c/em\u003e0.05) of the demographic variables under analysis across these groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eClinical general characteristics of patients among groups\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"317\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp 1 (n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp\u0026nbsp;2 (n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuantitative variables\u0026nbsp;\u003c/strong\u003e(Mean \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003eSD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eAge (year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e53\u003cem\u003e.\u003c/em\u003e70 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e5\u003cem\u003e.\u003c/em\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e57\u003cem\u003e.\u003c/em\u003e25 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e3\u003cem\u003e.\u003c/em\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e57\u003cem\u003e.\u003c/em\u003e90 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e4\u003cem\u003e.\u003c/em\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e0.161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eDuration\u0026nbsp;of\u0026nbsp;Illness (month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e9\u003cem\u003e.\u003c/em\u003e50 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e2\u003cem\u003e.\u003c/em\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e10\u003cem\u003e.\u003c/em\u003e30 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e2\u003cem\u003e.\u003c/em\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e10\u003cem\u003e.\u003c/em\u003e60 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e2\u003cem\u003e.\u003c/em\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e0.195\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eStroke\u0026nbsp;impairment\u0026nbsp;assessment\u0026nbsp;(Touch)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e3\u003cem\u003e.\u003c/em\u003e00 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e3\u003cem\u003e.\u003c/em\u003e00 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e3\u003cem\u003e.\u003c/em\u003e00 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eStroke\u0026nbsp;impairment\u0026nbsp;assessment\u0026nbsp;(Position)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e3\u003cem\u003e.\u003c/em\u003e00 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e3\u003cem\u003e.\u003c/em\u003e00 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e3\u003cem\u003e.\u003c/em\u003e00 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eMini-mental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e27\u003cem\u003e.\u003c/em\u003e40 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e27\u003cem\u003e.\u003c/em\u003e40 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e1\u003cem\u003e.\u003c/em\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e27\u003cem\u003e.\u003c/em\u003e25 \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003e0\u003cem\u003e.\u003c/em\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e0.874\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualitative\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003evariables\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(Number\u0026nbsp;(%))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eGender\u0026nbsp;(males\u0026nbsp;: females)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e12\u0026nbsp;(60%)\u0026nbsp;:\u0026nbsp;8 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e14\u0026nbsp;(70%)\u0026nbsp;:\u0026nbsp;6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e16\u0026nbsp;(80%)\u0026nbsp;:\u0026nbsp;4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e0.386\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eAffected\u0026nbsp;side\u0026nbsp;(Right\u0026nbsp;: Left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e16\u0026nbsp;(80%)\u0026nbsp;:\u0026nbsp;4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e13\u0026nbsp;(65%)\u0026nbsp;:\u0026nbsp;7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e16\u0026nbsp;(80%)\u0026nbsp;:\u0026nbsp;4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e0.449\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9621%;\"\u003e\n \u003cp\u003eHandedness\u0026nbsp;(Right\u0026nbsp;: Left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e18\u0026nbsp;(90%)\u0026nbsp;:\u0026nbsp;2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e18\u0026nbsp;(90%)\u0026nbsp;:\u0026nbsp;2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2965%;\"\u003e\n \u003cp\u003e19\u0026nbsp;(95%)\u0026nbsp;:\u0026nbsp;1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.14826%;\"\u003e\n \u003cp\u003e0.804\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExp\u0026nbsp;1\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003ereceived peripheral sensory electrical stimulation program; Exp 2\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003ereceived alternating EMG stimulation; control:received program for hand functions training only. Quantitative data are expressed as mean \u003cem\u003e\u0026plusmn;\u0026nbsp;\u003c/em\u003estandard deviation (SD) and compared statistically by ANOVA test. Qualitative data are expressed as number (percentage) and compared statistically by Chi-square test. P-value \u0026gt; 0.05: non-significant.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;1. \u003cstrong\u003eAction Research Arm Test Results\u0026nbsp;\u003c/strong\u003eTable (2) presents the mean values of Action Research Arm Test scores across three groups. (Supp 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGrasp Subscale:\u0026nbsp;\u003c/strong\u003eANOVA revealed no significant base- line differences between groups (P=0.177), but significant post-treatment differences emerged (P=0.0001). Post-hoc LSD testing showed significant differences between experimental group 1 and control group (P=0.004) and between experimental group 2 and control group (P=0.0001), while both experimental groups did not differ significantly (P=1.000). The mean differences indicated improvement per- centages of 79.74%, 89.74%, and 18.79% for experimental group 1, 2, and control group respectively, with experimental group 2 demonstrating the highest post-treatment performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGrip Subscale:\u0026nbsp;\u003c/strong\u003eANOVA showed no significant baseline differences between groups (P=0.918), but significant post- treatment differences (P=0.001). Post-hoc LSD analysis revealed significant differences between experimental group 1 and control (P=0.040) and between experimental group 2 and control (P=0.0001), with no significant difference between both experimental groups (P=0.470). Mean differences showed improvement percentages of 76.83% in experimental group 1, 97.62% in experimental group 2, and 22.73% in control group. experimental group 2 achieved the highest ARAT grip subscale scores post-intervention, with large effect sizes compared to both experimental group 1 (0.57) and control (1.60).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePinch Subscale:\u0026nbsp;\u003c/strong\u003eANOVA indicated no significant baseline differences (P=0.117), but significant post-treatment differences (P=0.014). Post-hoc LSD testing showed a significant difference only between experimental group 2 and control (P=0.018), while differences between experimental groups (P=0.069) and between experimental group 1 and control (P=1.000) were not significant. Mean differences revealed significant improvements in all three groups (P \u0026iexcl; 0.05), with experimental group 2 showing the best post-treatment performance in the pinch subscale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGross Subscale:\u0026nbsp;\u003c/strong\u003eANOVA showed no significant differences at baseline (P=0.090) or post-treatment (P=0.590). Mean differences indicated improvement percentages of 68.97%, 68.89%, and 32.71% for experimental group 1, 2 and control respectively, with experimental group 1 recording the highest post-treatment results in the gross subscale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;ARAT\u0026nbsp;Score:\u0026nbsp;\u003c/strong\u003eANOVA revealed no significant base- line differences (P=0.062), but significant post-treatment differences between groups (P=0.0001). Post-hoc LSD testing showed significant differences between experimental group 2 and control (P=0.0001) and between experimental group 1 and control (P=0.040), with no significant difference experimental groups (P=0.126). Mean differences demonstrated significant improvements in all groups (P=0.0001), with experimental group 2 achieving the highest total ARAT score post-treatment.\u003c/p\u003e\n\u003ch2\u003e2. Modified Ashworth Scale Results\u003c/h2\u003e\n\u003cp\u003eTable (3) presents the mean values of Modified Ashworth Scale scores across three groups. (Supp 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShoulder:\u0026nbsp;\u003c/strong\u003eANOVA revealed no significant baseline differences (P=0.783) and no significant post-treatment differences (P=0.102) among the three groups. Mean differences indicated that experimental group 2 and control achieved the highest post-treatment Modified Ashworth Scale scores for shoulder spasticity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eElbow:\u0026nbsp;\u003c/strong\u003eANOVA showed no significant baseline differences (P=0.106) or post-treatment (P=0.053). Mean differences showed that experimental group 1 recorded the highest post-treatment Modified Ashworth Scale scores for elbow spasticity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWrist:\u0026nbsp;\u003c/strong\u003eANOVA\u0026nbsp;indicated\u0026nbsp;no\u0026nbsp;significant\u0026nbsp;baseline\u0026nbsp;differences\u0026nbsp;(P=0.825), but significant post-treatment differences (P=0.014). Post-hoc LSD testing showed significant differences between experimental group 1 vs control (P=0.048) and between experimental group 2 vs control (P=0.025), while no significant difference was found between experimental group 1 vs experimental group 2 (P=0.465). Mean differences revealed that experimental group 2 achieved the highest post-treatment Modified Ashworth Scale scores for wrist spasticity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Muscle Power Results\u0026nbsp;\u003c/strong\u003eTable (4) presents the mean values of muscle power measurements across three groups for finger flexors, finger extensors, finger adductors, finger abductors, wrist flexors, and wrist extensors. (Supp 3) \u003cstrong\u003eFinger Flexors:\u0026nbsp;\u003c/strong\u003eANOVA\u0026nbsp;revealed\u0026nbsp;no\u0026nbsp;significant\u0026nbsp;baseline differences (P=0.814), but significant post-treatment differences\u0026nbsp;(P=0.024).\u0026nbsp;Post-hoc\u0026nbsp;LSD\u0026nbsp;testing\u0026nbsp;showed\u0026nbsp;significant differences\u0026nbsp;between\u0026nbsp;experimental\u0026nbsp;group\u0026nbsp;1\u0026nbsp;and\u0026nbsp;experimental group\u0026nbsp;2\u0026nbsp;(P=0.021)\u0026nbsp;and\u0026nbsp;between\u0026nbsp;experimental\u0026nbsp;group\u0026nbsp;2\u0026nbsp;vs control\u0026nbsp;(P=0.013),\u0026nbsp;with\u0026nbsp;no\u0026nbsp;significant\u0026nbsp;difference\u0026nbsp;between experimental group 1 vs control (P=1.000). Mean differences\u0026nbsp;indicated\u0026nbsp;improvement\u0026nbsp;percentages\u0026nbsp;of\u0026nbsp;36.84%,\u0026nbsp;55.26%,\u0026nbsp;and 17.07%\u0026nbsp;for\u0026nbsp;experimental\u0026nbsp;group\u0026nbsp;1,\u0026nbsp;2,\u0026nbsp;and\u0026nbsp;control\u0026nbsp;respectively,\u0026nbsp;with\u0026nbsp;experimental\u0026nbsp;group\u0026nbsp;2\u0026nbsp;achieving\u0026nbsp;the\u0026nbsp;highest\u0026nbsp;post- treatment finger flexor muscle power.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinger Extensors:\u0026nbsp;\u003c/strong\u003eANOVA showed no significant baseline differences (P=0.711), but significant post-treatment differences (P=0.003). Post-hoc LSD analysis revealed significant differences between experimental group 1 and experimental group 2 (P=0.001) and between experimental group 2 and control (P=0.001), with no significant difference between experimental group 1 and control (P=1.000). Mean differences demonstrated improvement percentages of 10.81%, 41.46%, and 0.00% for experimental group 1, 2, and control respectively, with experimental group 2 recording the highest post-treatment finger extensor muscle power.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinger Adductors:\u0026nbsp;\u003c/strong\u003eANOVA indicated no significant base- line differences (P=0.711), but significant post-treatment differences (P=0.003). Post-hoc LSD testing showed significant differences only between experimental group 1 and experimental group 2 (P=0.012), while no significant differences were found between experimental group 1 and control (P=0.766) or experimental group 2 and control (P=0.225). Mean differences revealed improvement percent- ages of 5.41%, 18.75%, and 2.22% for experimental group 1, 2, and control respectively, with experimental group 2 achieving the highest post-treatment finger adductor muscle power.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinger Abductors:\u0026nbsp;\u003c/strong\u003eANOVA showed no significant baseline differences (P=0.868), but significant post-treatment differences (P=0.022). Post-hoc LSD analysis revealed significant differences between groups experimental group 1 and experimental group 2 (P=0.049) and between experimental group 2 and control (P=0.049), with no significant difference between experimental group 1 and control (P=1.000). Mean differences indicated improvement percentages of 2.63%, 29.27%, and 0.00% for experimental group 1, 2, and control respectively, with experimental group 2 recording the highest post-treatment finger abductor muscle power.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWrist Flexors:\u0026nbsp;\u003c/strong\u003eANOVA revealed no significant baseline differences (P=0.822), but significant post-treatment differences (P=0.019). Post-hoc LSD testing showed significant differences only between experimental group 2 and control (P=0.026), while no significant differences were found between experimental group 1 and experimental group 2 (P=1.000) or experimental group 1 and control (P=0.078). Mean differences demonstrated improvement percentages of 23.91%, 37.21%, and 4.55% for experimental group 1, 2, and control respectively, with experimental group 2 achieving the highest post-treatment wrist flexor muscle power.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWrist\u0026nbsp;Extensors:\u0026nbsp;\u003c/strong\u003eANOVA indicated no significant baseline differences (P=0.914), but significant post-treatment differences (P=0.021). Post-hoc LSD analysis revealed significant differences experimental group 1 and experimental group 2 (P=0.028) and between experimental group 2 and control (P=0.036), with no significant difference between experimental group 1 and control (P=1.000). Mean differences showed improvement percentages of 4.76%, 25.00%, and 0.00% for experimental group 1, 2, and control respectively, with experimental group 2 recording the highest post- treatment wrist extensor muscle power.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that the integration of either Sensory Electrical Stimulation (SES) or Alternating Electromyogram (EMG) stimulation into a standardized physical therapy program significantly enhanced hand function, reduced spasticity, and improved muscle power in chronic stroke survivors when compared to physical therapy alone. A notable finding was the general superiority of Alternating EMG stimulation (experimental group 2) across several key metrics. This included more pronounced improvements in fine motor control, as evidenced by the grasp, grip, and pinch subscales of the Action Research Arm Test (ARAT), and a higher overall ARAT total score.\u003c/p\u003e\n\u003cp\u003eFurthermore, experimental group 2 exhibited a significant reduction in wrist spasticity and greater improvements in muscle power across most assessed finger and wrist muscles. Conversely, SES (experimental group 1) demonstrated a better outcome in the Gross ARAT subscale, suggesting a differential impact on broader motor movements (1). The nuanced finding that while Alternating EMG stimulation generally outperformed SES, SES showed superior results in the Gross ARAT subscale, suggests that these two modalities might target distinct aspects of motor recovery (e.g., fine motor control versus gross motor movements).\u003c/p\u003e\n\u003cp\u003eThis is a critical observation that moves beyond a simple” better/worse” comparison to a more sophisticated understanding of how each intervention contributes to the rehabilitation process, potentially informing more tailored treatment approaches.\u003c/p\u003e\n\u003ch2\u003eEffectiveness of Sensory Electrical Stimulation (SES)\u003c/h2\u003e\n\u003cp\u003eSensory electrical stimulation has been shown to enhance both sensory and motor functions in stroke patients. The mechanism involves delivering electrical currents through electrodes placed on the skin, which stimulate sensory nerves without necessarily causing overt muscle contractions. This continuous sensory input is believed to modulate the excitability of the motor cortex, thereby improving sensory discrimination and motor performance. This is achieved by enhancing the neural plasticity of the sensory cortex and regulating motor plasticity and recovery\u003c/p\u003e\n\u003cp\u003e(12). It also increases sensorimotor cortex activity and connectivity, which is crucial for enhancing motor skill acquisition and consolidation, as observed through changes in visuomotor task performance and cortical adaptations using electroencephalography (12). Activation of sensory afferent inputs, particularly when combined with stimulation of specific motor areas, appears to be an efficient means of promoting plastic changes at both cortical and spinal levels (13).\u003c/p\u003e\n\u003cp\u003eIn this study, experimental group 1, which received Sensory electrical stimulation, showed significant improvements in hand function as measured by the Action Research Arm Test (ARAT) and the Modified Ashworth Scale. The improvements in grasp, grip, pinch, and gross motor functions were substantial, indicating that SES can effectively enhance hand function in chronic stroke patients. These findings are consistent with Ikuno et al (25) who recommended Peripheral sensory nerve stimulation for clinical use to improve the outcomes of task-oriented training in patients with subacute stroke. Wu et al (26) also concluded\u003c/p\u003e\n\u003cp\u003ethat electric sensory stimulation in combination with training protocols may enhance the benefit of customary neuro rehabilitative treatments and possibly motor learning. The result of this study was inconsistent with Ghaziani et al (14) who stated that Sensory electrical stimulation prior to arm training was equally beneficial as arm training alone.\u003c/p\u003e\n\u003cp\u003eThe improvement of upper limb muscles spasticity in sensory electrical stimulation post treatment is in accordance with Moon et al (15) who found that repeated applications of TENS can reduce spasticity and improve voluntary functions in hemiparetic patients. The results also agreed with Peurala et al (16) who investigated whether cutaneous electrical stimulation using a flexible mesh glove has a role in the enhancement of sensorimotor function in chronic stroke. They concluded that cutaneous stimulation had positive effects on voluntary motor performance, limb sensation and spasticity in chronic stroke patients.\u003c/p\u003e\n\u003cp\u003eIn the current study, the improvement in the muscle tone did not target the hand and wrist muscles yet it had extended to whole upper limb muscles (elbow flexors and shoulder flexors). These findings agreed with Dimitrijevic and Soroker\u003c/p\u003e\n\u003cp\u003e(17) who examined the effects of whole – hand afferent electrical stimulation via a wired mesh- glove upon the residual motor control of the upper extremity. The results indicated beneficial effects in the form of reduction in muscle hypertonia and facilitation of isolated hand movements.\u003c/p\u003e\n\u003cp\u003eThe anti-spastic and analgesic effects of transcutaneous electrical nerve stimulation (TENS) can be explained in view of in et al (18) who stated that at the spinal level, there are different opioids released with different stimulation frequencies and thus possibly different opioids receptors activated to produce analgesia with high or low frequency TENS. The release of endogenous opioids in the spinal cord in response to TENs stimulation could result from activation of local circuits within the spinal cord or from activation of descending inhibitory pathways. Serrano Tendero et al\u003c/p\u003e\n\u003cp\u003e(20) also proposed that the anti–spastic effect elicited by high frequency transcutaneous electrical nerve stimulation is mediated by endogenous opioid interacting with the opiate receptors, most probably dynorphin, in the central nervous system. In addition, Vollar et al (21) stated that the application of sensory amplitude electrical stimulation (SES) (stimulation to sensory threshold without motor contraction) over the hand could increase blood flow in the areas of the primary and secondary motor cortices as well as the primary sensory cortex.\u003c/p\u003e\n\u003cp\u003eMoreover, Joodaki et al (20) investigated the effects of electrical nerve stimulation on alpha motor neuron excitability. The results showed reduction of the amplitude of h- reflex and F-wave, H/M and F/M ratio demonstrated reduction of spasticity. Tinazzi et al (27) stated that the effects of TENS on motor excitability may explain the effectiveness of TENS in the treatment of spasticity and dystonia. Golaszewskia et al (23) also indicated that the mechanism of improvement via whole hand mesh- glove stimulation was due to its neuromodulatory effect on motor cortical pathways and motor cortical excitability. The increased motor cortical excitability lasting at least one hour leads to an extension of neural activities. Both the strength of the corticospinal projections and the inhibitory and facilitatory intracortical mechanism are involved. Synaptic\u003c/p\u003e\n\u003cp\u003emodifications such as long-term potentiation mechanisms may underlie this stimulation induced cortical plasticity changes.\u003c/p\u003e\n\u003cp\u003eIn this study, the sensory electrical stimulation group showed significant improvement of manual muscle strength of finger flexors, finger extensors and wrist extensors whereas control group showed significant improvement in the strength of finger flexors and finger extensors only. These results agreed with Satheeskumar et al (24) who found that combining electrically induced sensory inputs through transcutaneous electrical nerve stimulation (TENS) with task training in a home-based program would augment voluntary motor output in chronic stroke survivors better than either task training alone or no task training.\u003c/p\u003e\n\u003cp\u003eThe improvement of strength of wrist extensors in sensory electrical stimulation group can be explained in view of Ridding et al (28) who found that modifications in the human motor cortex organization and increase in the motor cortical excitability were detected after afferent input from electrical stimulation of the peripheral nerves. Peripheral nerve stimulation, which activates group Ia large muscle afferents, group Ib afferents from Golgi organs, group II afferents from slow and rapidly adapting skin afferents and cutaneous afferent fibers, elects an increase in the motor cortical excitability of body part representations that control the stimulated body part and results in reorganization of the motor and somatosensory cortices.\u003c/p\u003e\n\u003cp\u003eWithin the limitations of this study, post treatment results showed a significant increase in wrist extension in sensory electrical stimulation group. These results agreed with Tinazzi et al (27) who proposed that the beneficial effects of transcutaneous electrical nerve stimulation (TENS) application over the hand may be attributed to its ability to increase sensory thresholds and reduce motor evoked potentials (MEPs) in hand muscles.\u003c/p\u003e\n\u003cp\u003eThese results can be explained in view of Dimitrijevic et al (29) who stated that daily mesh- glove stimulation can modify altered motor control and improve voluntary wrist extension movement in stroke patients with chronic neurological deficits. Berrtolasi et al (30) also stated that transcutaneous electrical nerve stimulation (TENS) application over the flexor compartment of the forearm reduced motor evoked potentials (MEPs) in the flexor carpi radialis (FCR) muscle and increased motor evoked potential (MEPs) in the antagonist extensor carpi radialis (ECR) muscle. Part of this effect might be via an action of afferent input on the excitability of reciprocal inhibitory connections between antagonist muscles at spinal or cortical levels.\u003c/p\u003e\n\u003cp\u003eComparing the scores of Action research Arm test post treatment in sensory electrical stimulation group revealed that there was a significant increase in action research arm test. These results agreed with Yibrahim et al (31) who evaluated the effectiveness of transcutaneous electrical nerve stimulation (TENS) and placebo (TENS) on the level of activities of daily living (ADL) of stroke patients. The results indicated that TENs appear to be an effective adjunct in the regaining of motor functions and improving ADL in hemiplegic patients.\u003c/p\u003e\n\u003cp\u003eJane and Lois (32) also indicated that electrical stimulation delivered at sensory amplitude has been reported to reduce impairment and improve arm function and enhance\u003c/p\u003e\n\u003cp\u003esensorimotor recovery following stroke. Moreover, Shamay et al (33) stated that TENS decreased hyperactive stretch reflexes and improved the performance of daily activities measured by Barthel index in stroke patients. Laufer and Elboim-Gabyzon (34) also stated that sensory stimulation via TENS may be beneficial to enhance aspects of motor recovery following a stroke, particularly when used in combination with active training.\u003c/p\u003e\n\u003cp\u003eThe improvement in the study group did not stop at hand functions yet it had extended to other upper limb functions as seen in Action research Arm test. This could be explained by the dynamic cortical representation described by Jones (35). It was found that there is competition among body parts for territory in sensorimotor cortex, even limited activity of the upper arm might prevent the hand from gaining more control, particularly when the territory is reduced in size because of the stroke. Deafferentation of a body part in a healthy brain enhances cortical representations of adjacent body parts, and this effect is markedly increased by voluntary activity of the adjacent part.\u003c/p\u003e\n\u003ch2\u003eEffectiveness of Alternating EMG-Stimulation\u003c/h2\u003e\n\u003cp\u003eAs far as we know, there have been very few studies conducted on alternating electromyogram stimulation. Alternating EMG-stimulation involves using electromyography (EMG) signals to trigger muscle contraction followed by an active voluntarily muscle contraction to reach a pre-set EMG target level. This method helps in strengthening the muscles and improving motor control by providing muscle stimulation followed by real-time feedback. Alternating EMG-stimulation concept is grounded in” Before Task Performance” (Modeling Feedback). Modeling involves reproducing actions performed by electric stimulation. The muscle contraction taken place by the electric stimulation before the active function serves as valuable sources of information pro- vided to the patient prior to task execution, offering insight into the movement pattern and how it should be executed\u003c/p\u003e\n\u003cp\u003e(36). Proprioception refers to the conscious awareness of the body and limbs and encompasses several distinct properties: passive motion sense, active motion sense, limb position sense, and sense of heaviness (37).\u003c/p\u003e\n\u003cp\u003eStudies have demonstrated that providing proprioceptive guidance on hand movement with passive practice results in a notable improvement in the active reproduction of this new motor skill (38). Several studies have assessed brain activity after passive movement using Functional magnetic resonance imaging, showing that passive movements, even without motor commands, stimulate not only the primary somatosensory cortex (S1) but also the primary motor area (M1), supplementary motor area (SMA), posterior parietal cortex (PPC), and both secondary somatosensory areas (S2)\u003c/p\u003e\n\u003cp\u003e(39). Alternating EMG stimulation serves as a proprioceptive training method by utilizing the passive motion sense, which is generated through passive limb movement via neuromuscular electrical stimulation from the device. This is followed by asking the patient to actively move the limb to reach the predetermined EMG target level, which serves as biofeedback for the patient. Biofeedback has the potential to boost neural plasticity by stimulating auxiliary sensory inputs, making it a promising tool for neurorehabilitation (40).\u003c/p\u003e\n\u003cp\u003eIn this study, experimental group 2, which received alternating EMG-stimulation, showed the highest improvement percentages in grasp (89.74%), grip (97.62%) and pinch (69.08%), suggesting that alternating EMG stimulation may provide enhanced facilitation of motor learning and neuroplasticity. The significant reduction in spasticity, particularly in the wrist, further supports the effectiveness of this intervention. These results align with Habib et al (4) who found that adding alternating electromyogram stimulation to a designed physical therapy program for hand function training improves hand function and peak muscle torque in chronic stroke patients.\u003c/p\u003e\n\u003cp\u003eExperimental group 2 exhibited significant reductions in spasticity at the shoulder, elbow, and wrist, with the most noticeable improvement in wrist spasticity. This reduction in spasticity was likely due to the Neuromuscular Electrical Stimulation (NMES) provided by the device during the passive phase of the alternating EMG stimulation. NMES helps reduce spasticity by modulating spinal reflexes and altering their excitability. Additionally, it has the potential to promote neuroplasticity within spinal cord pathways, leading to adaptive changes that contribute to spasticity reduction. This process is facilitated by the reorganization of neural connections through NMES (41). The results of this study align with those of Sentandreu-Man˜o´ et al (42), who demonstrated that NMES protocols led to improvements in hand motor recovery measurements and a reduction in the modified Ashworth scale in older adults after a stroke. Bakhtiary and Fatemy (43) also discovered that a combination of the Bobath inhibitory technique and electrical stimulation may effectively reduce spasticity in stroke patients. The results of this study are consistent with those of Stein et al (44), who found that NMES, when combined with other intervention modalities, can be considered an effective treatment option for improving spasticity and range of motion in stroke patients.\u003c/p\u003e\n\u003ch2\u003eComparison with Control Group\u003c/h2\u003e\n\u003cp\u003eThe control group, which received only the physical therapy regimen without any electrical stimulation, also showed improvements in hand function, but to a lesser extent compared to the intervention groups. This highlights the added benefit of incorporating electrical stimulation techniques in rehabilitation programs for stroke patients.\u003c/p\u003e\n\u003ch2\u003eClinical Implications\u003c/h2\u003e\n\u003cp\u003eThe findings of this study have important clinical implications for the rehabilitation of chronic stroke patients. Both SES and alternating EMG-stimulation can be effectively integrated into physical therapy programs to enhance hand function and reduce spasticity. The choice of intervention may depend on the specific needs and preferences of the patient, as well as the availability of equipment and expertise.\u003c/p\u003e\n\u003ch2\u003eLimitations and Future Research\u003c/h2\u003e\n\u003cp\u003eWhile this study provides valuable insights, it has some limitations. Single-center design, short follow-up period and relatively small sample size may limit the generalizability of the findings. Future research should include larger, multi-center trials to confirm these results and explore the long-term effects of these interventions. Additionally, Single-center design. Future studies should explore long-term effects and neural mechanisms via neuroimaging.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlternating EMG stimulation combined with physical therapy significantly improves hand function and reduces spasticity in chronic stroke survivors, outperforming SES in key metrics. These findings advocate personalized rehabilitation strategies incorporating electrical stimulation to optimize recovery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eARAT:\u0026nbsp;Action\u0026nbsp;Research\u0026nbsp;Arm\u0026nbsp;Test\u0026nbsp;ADL: Activities of Daily Living EMG: Electromyogram\u003c/p\u003e\n\u003cp\u003eEDC:\u0026nbsp;Extensor\u0026nbsp;Digitorum\u0026nbsp;Communis ECR: Extensor Carpi Radialis\u003c/p\u003e\n\u003cp\u003eFCR: Flexor Carpi Radialis MRC:\u0026nbsp;Medical\u0026nbsp;Research\u0026nbsp;Council\u003c/p\u003e\n\u003cp\u003eMMSE:\u0026nbsp;Mini-Mental\u0026nbsp;State\u0026nbsp;Examination MEPs: Motor Evoked Potentials\u003c/p\u003e\n\u003cp\u003eNMES:\u0026nbsp;Neuromuscular\u0026nbsp;Electrical\u0026nbsp;Stimulation SES: Sensory Electrical Stimulation\u003c/p\u003e\n\u003cp\u003ePPC:\u0026nbsp;Posterior\u0026nbsp;Parietal\u0026nbsp;Cortex ROM: Range of Motion\u003c/p\u003e\n\u003cp\u003eSMA:\u0026nbsp;Supplementary\u0026nbsp;Motor Area\u003c/p\u003e\n\u003cp\u003eTENS: Transcutaneous Electrical Nerve Stimulation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eSpecial thanks to all our patients who participated in the research for their patience and dedication.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;research\u0026nbsp;received\u0026nbsp;no\u0026nbsp;external funding.\u003c/p\u003e\n\u003cp\u003eInstitutional Review Board Statement:\u0026nbsp;The study was reviewed and approved by by the local ethical committee of the Faculty of Physical Therapy, Cairo University (Approval No: P.T.REC/012/004916).\u003c/p\u003e\n\u003cp\u003eInformed\u0026nbsp;consent\u003c/p\u003e\n\u003cp\u003eAll\u0026nbsp;authors\u0026nbsp;have\u0026nbsp;reviewed\u0026nbsp;and\u0026nbsp;approved\u0026nbsp;the\u0026nbsp;final\u0026nbsp;manuscript and consent to its publication.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eData\u0026nbsp;is\u0026nbsp;available\u0026nbsp;upon\u0026nbsp;reasonable\u0026nbsp;request\u0026nbsp;from\u0026nbsp;the corresponding author.\u003c/p\u003e\n\u003cp\u003eConflicts\u0026nbsp;of interest\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eB. 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Bai, \u0026ldquo;Effectiveness of contralaterally controlled functional elec- trical stimulation versus neuromuscular electrical stimulation on upper limb motor functional recovery in subacute stroke patients: a randomized controlled trial,\u0026rdquo; \u003cem\u003eNeural Plasticity\u003c/em\u003e, vol. 2021, no. 1, p. 1987662, 2021.\u003c/li\u003e\n\u003cli\u003eI. A. Serrano Tendero, \u0026ldquo;Cortical mapping of the neuronal circuits modulating the muscle tone. introduction to the electrophysiological treatment of the spastic hand,\u0026rdquo; 2012.\u003c/li\u003e\n\u003cli\u003eG. Vallar, M. L. Rusconi, and B. Bernardini, \u0026ldquo;Modulation of neglect hemianesthesia by transcutaneous electrical stimulation,\u0026rdquo; \u003cem\u003eJournal of the International Neuropsychological \u003c/em\u003e\u003cem\u003eSociety\u003c/em\u003e, vol. 2, no. 5, pp. 452\u0026ndash;459, 1996.\u003c/li\u003e\n\u003cli\u003eL. Lin, W. Qing, Z. Zheng, W. Poon, S. Guo, S. Zhang, and X. Hu, \u0026ldquo;Somatosensory integration in robot-assisted motor restoration post-stroke,\u0026rdquo; \u003cem\u003eFrontiers in Aging Neuroscience\u003c/em\u003e, vol. 16, p. 1491678, 2024.\u003c/li\u003e\n\u003cli\u003eS. M. Golaszewski, J. Bergmann, M. Christova, R. Nardone, M. Kronbichler, D. Rafolt, E. Gallasch, W. Staffen, G. Ladurner, and R. Beisteiner, \u0026ldquo;Increased motor cortical excitability after whole-hand electrical stimulation: a tms study,\u0026rdquo; \u003cem\u003eClinical Neurophysiology\u003c/em\u003e, vol. 121, no. 2, pp. 248\u0026ndash;254, 2010.\u003c/li\u003e\n\u003cli\u003eD. SATHEESKUMAR, K. Dhaneshkumar, and K. Rajasenthil, \u0026ldquo;A comparative study to identify the effects of transcutaneous electrical nerve stimulation combined with sensorimotor task oriented training to improve the hand function in hemiplegic cerebral palsy children.\u0026rdquo; \u003cem\u003eJournal of Clinical \u0026amp; Diagnostic Research\u003c/em\u003e, vol. 12, no. 1, 2018.\u003c/li\u003e\n\u003cli\u003eK. Ikuno, S. Kawaguchi, S. Kitabeppu, M. Kitaura, K. Tokuhisa, S. Morimoto, A. Matsuo, and K. Shomoto, \u0026ldquo;Effects of peripheral sensory nerve stimulation plus task- oriented training on upper extremity function in patients with subacute stroke: a pilot randomized crossover trial,\u0026rdquo; \u003cem\u003eClinical rehabilitation\u003c/em\u003e, vol. 26, no. 11, pp. 999\u0026ndash;1009, 2012.\u003c/li\u003e\n\u003cli\u003eC. W. Wu, H.-J. Seo, and L. G. Cohen, \u0026ldquo;Influence of electric somatosensory stimulation on paretic-hand function in chronic stroke,\u0026rdquo; \u003cem\u003eArchives of physical medicine and rehabilitation\u003c/em\u003e, vol. 87, no. 3, pp. 351\u0026ndash;357, 2006.\u003c/li\u003e\n\u003cli\u003eM. Tinazzi, S. Farina, K. Bhatia, A. Fiaschi, G. Moretto, L. Bertolasi, S. Zarattini, and N. Smania, \u0026ldquo;Tens for the treatment of writer\u0026rsquo;s cramp dystonia: a randomized, placebo- controlled study,\u0026rdquo; \u003cem\u003eNeurology\u003c/em\u003e, vol. 64, no. 11, pp. 1946\u0026ndash;1948, 2005.\u003c/li\u003e\n\u003cli\u003eM. Ridding, B. Brouwer, T. Miles, J. Pitcher, and P. Thompson, \u0026ldquo;Changes in muscle responses to stimulation of the motor cortex induced by peripheral nerve stimulation in human subjects,\u0026rdquo; \u003cem\u003eExperimental brain research\u003c/em\u003e, vol. 131, no. 1, pp. 135\u0026ndash;143, 2000.\u003c/li\u003e\n\u003cli\u003eM. Dimitrijevic\u0026acute;, \u0026ldquo;Mesh glove electrical stimulation.\u0026rdquo; \u003cem\u003eScience \u003c/em\u003e\u003cem\u003e\u0026amp; Medicine\u003c/em\u003e, vol. 3, p. 54, 1996.\u003c/li\u003e\n\u003cli\u003eL. Bertolasi, A. Priori, M. Tinazzi, V. Bertasi, and J. C. Rothwell, \u0026ldquo;Inhibitory action of forearm flexor muscle afferents on corticospinal outputs to antagonist muscles in humans,\u0026rdquo; \u003cem\u003eThe Journal of Physiology\u003c/em\u003e, vol. 511, no. 3, pp. 947\u0026ndash; 956, 1998.\u003c/li\u003e\n\u003cli\u003eY. Tekeolu, B. Adak, and T. Go\u0026uml;ksoy, \u0026ldquo;Effect of transcutaneous electrical nerve stimulation (tens) on barthel activities of daily living (adl) index score following stroke,\u0026rdquo; \u003cem\u003eClinical rehabilitation\u003c/em\u003e, vol. 12, no. 4, pp. 277\u0026ndash;280, 1998.\u003c/li\u003e\n\u003cli\u003eJ. E. Sullivan and L. D. Hedman, \u0026ldquo;Effects of home- based sensory and motor amplitude electrical stimulation on arm dysfunction in chronic stroke,\u0026rdquo; \u003cem\u003eClinical Rehabilitation\u003c/em\u003e, vol. 21, no. 2, pp. 142\u0026ndash;150, 2007.\u003c/li\u003e\n\u003cli\u003eS. S. Ng and C. W. Hui-Chan, \u0026ldquo;Transcutaneous electrical nerve stimulation combined with task-related training improves lower limb functions in subjects with chronic stroke,\u0026rdquo; \u003cem\u003eStroke\u003c/em\u003e, vol. 38, no. 11, pp. 2953\u0026ndash;2959, 2007.\u003c/li\u003e\n\u003cli\u003eY. Laufer and M. Elboim-Gabyzon, \u0026ldquo;Does sensory transcuta- neous electrical stimulation enhance motor recovery follow- ing a stroke? a systematic review,\u0026rdquo; \u003cem\u003eNeurorehabilitation and neural repair\u003c/em\u003e, vol. 25, no. 9, pp. 799\u0026ndash;809, 2011.\u003c/li\u003e\n\u003cli\u003eT. A. Jones, \u0026ldquo;Motor compensation and its effects on neural reorganization after stroke,\u0026rdquo; \u003cem\u003eNature Reviews Neuroscience\u003c/em\u003e, vol. 18, no. 5, pp. 267\u0026ndash;280, 2017.\u003c/li\u003e\n\u003cli\u003eL. M. Muratori, E. M. Lamberg, L. Quinn, and S. V. Duff, \u0026ldquo;Applying principles of motor learning and control to upper extremity rehabilitation,\u0026rdquo; \u003cem\u003eJournal of hand therapy\u003c/em\u003e, vol. 26, no. 2, pp. 94\u0026ndash;103, 2013.\u003c/li\u003e\n\u003cli\u003eJ. E. Aman, N. Elangovan, I.-L. Yeh, and J. Konczak, \u0026ldquo;The effectiveness of proprioceptive training for improving motor function: a systematic review,\u0026rdquo; \u003cem\u003eFrontiers in human neuroscience\u003c/em\u003e, vol. 8, p. 1075, 2015.\u003c/li\u003e\n\u003cli\u003eI. A. Beets, M. Mace\u0026acute;, R. L. Meesen, K. Cuypers, O. Levin, and S. P. Swinnen, \u0026ldquo;Active versus passive training of a complex bimanual task: is prescriptive proprioceptive information sufficient for inducing motor learning?\u0026rdquo; \u003cem\u003ePloS one\u003c/em\u003e, vol. 7, no. 5, p. e37687, 2012.\u003c/li\u003e\n\u003cli\u003eH. Onishi, \u0026ldquo;Cortical excitability following passive move- ment,\u0026rdquo; \u003cem\u003ePhysical Therapy Research\u003c/em\u003e, vol. 21, no. 2, pp. 23\u0026ndash;32, 2018.\u003c/li\u003e\n\u003cli\u003eH. Huang, S. L. Wolf, and J. He, \u0026ldquo;Recent developments in biofeedback for neuromotor rehabilitation,\u0026rdquo; \u003cem\u003eJournal of neuroengineering and rehabilitation\u003c/em\u003e, vol. 3, no. 1, p. 11, 2006.\u003c/li\u003e\n\u003cli\u003eS. M. Almutairi, M. E. Khalil, N. Almutairi, S. M. Alsaadoon, D. S. Alharbi, S. D. Al Assadi, S. F. Alghamdi, S. N. Albattah, and A. M. Alenazi, \u0026ldquo;Effects of neuromuscular electrical stimulation on spasticity and walking performance among individuals with chronic stroke: a pilot randomized clinical trial,\u0026rdquo; in \u003cem\u003eHealthcare\u003c/em\u003e, vol. 11, no. 24. MDPI, 2023, p. 3137.\u003c/li\u003e\n\u003cli\u003eT. Sentandreu-Man\u0026tilde;o\u0026acute;, J. M. Toma\u0026acute;s, and J. Ricardo Salom Terra\u0026acute;dez, \u0026ldquo;A randomised clinical trial comparing 35 hz versus 50 hz frequency stimulation effects on hand motor recovery in older adults after stroke,\u0026rdquo; \u003cem\u003eScientific Reports\u003c/em\u003e, vol. 11, no. 1, p. 9131, 2021.\u003c/li\u003e\n\u003cli\u003eA. H. Bakhtiary and E. Fatemy, \u0026ldquo;Does electrical stimulation reduce spasticity after stroke? a randomized controlled study,\u0026rdquo; \u003cem\u003eClinical rehabilitation\u003c/em\u003e, vol. 22, no. 5, pp. 418\u0026ndash;425, 2008.\u003c/li\u003e\n\u003cli\u003eC. Stein, C. G. Fritsch, C. Robinson, G. Sbruzzi, and R. D. M. Plentz, \u0026ldquo;Effects of electrical stimulation in spastic muscles after stroke: systematic review and meta-analysis of randomized controlled trials,\u0026rdquo; \u003cem\u003eStroke\u003c/em\u003e, vol. 46, no. 8, pp. 2197\u0026ndash; 2205, 2015.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eWithin and between group comparisons for action research arm test variables\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eItems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\"\u003e\n \u003cp\u003eGroups (Mean ±SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003cp\u003esize\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;P\u003c/em\u003e-value\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003ePost-hoc test (post-treatment)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1\u003c/p\u003e\n \u003cp\u003e(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eExp 2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Pairwise groups \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eGrasp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e7.65 ±2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e7.80 ±4.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.25 ±3.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e13.75 ±4.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e14.80 ±3.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.80 ±3.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e6.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.004\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e1.69 – 10.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e4.59 – 9.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.85 – 3.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e79.74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e89.74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.281\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eGrip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e4.10 ±1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e4.20 ±2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.40 ±1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e7.25 ±2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e8.30 ±2.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.40 ±1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.470\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e3.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e4.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.040\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e1.69 – 4.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e2.64 – 5.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.45 – 2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e76.83%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e97.62%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003ePinch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e6.35 ±1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e7.60 ±5.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.25 ±3.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e9.60 ±3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e12.85 ±5.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.90 ±5.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.014\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e5.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e1.15 – 5.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e2.45 – 8.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.14 – 5.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.018\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e51.18%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e69.08%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eGross\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e4.35 ±2.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e4.50 ±0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.35 ±1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e7.35 ±2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e7.60 ±0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.10 ±1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e3.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e2.03 – 3.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e2.13 – 4.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.78 – 2.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e68.97%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e68.89%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e23.60 ±4.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e24.10 ±9.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.25 ±6.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e38.00 ±10.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e43.55 ±10.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.20 ±8.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e14.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e19.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.040\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e9.05 – 19.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e14.10 – 24.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.60 – 12.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e61.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e80.71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.011\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExp 1: received peripheral sensory electrical stimulation program;\u0026nbsp;Exp 2: received alternating EMG stimulation; Control: received program for hand functions training only.\u003c/p\u003e\n\u003cp\u003eData are expressed as mean ±standard deviation (SD) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;MD: Mean difference \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;CI: confidence interval \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value: probability value \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003csup\u003e*\u003c/sup\u003e Significant (P\u0026lt;0.05)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP-value\u003csup\u003e1\u003c/sup\u003e: Probability value within each group; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value\u003csup\u003e2\u003c/sup\u003e: probability value among groups; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value\u003csup\u003e3\u003c/sup\u003e: probability value between pairwise groups (post-hoc test)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003eWithin and between group comparisons for modified Ashworth scale\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eItems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eGroups (Mean ±SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;P\u003c/em\u003e-value\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePost-hoc test (Post-treatment)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1\u003c/p\u003e\n \u003cp\u003e(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Pairwise groups \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\"\u003e\n \u003cp\u003eShoulder\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eZero\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eZero\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\"\u003e\n \u003cp\u003eElbow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eZero\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.465\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eZero\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.053\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\"\u003e\n \u003cp\u003eWrist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eZero\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.465\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eZero\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.014\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.048\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.025\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExp 1: received peripheral sensory electrical stimulation program; Exp 2: received alternating EMG stimulation; Control: received program for hand functions training only\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData are expressed as number (percentage)) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value: probability value \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003csup\u003e*\u003c/sup\u003e Significant (P\u0026lt;0.05)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP-value\u003csup\u003e1\u003c/sup\u003e: Probability value within each group; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value\u003csup\u003e2\u003c/sup\u003e: probability value among groups; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; P-value\u003csup\u003e3\u003c/sup\u003e: probability value between pairwise groups (post-hoc test)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u0026nbsp;\u003c/strong\u003eWithin and between group comparisons for muscle power\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eItems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eGroups (Mean ±SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003cp\u003esize\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003ePost-hoc test (Post-treatment)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1\u003c/p\u003e\n \u003cp\u003e(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Pairwise groups \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eFinger\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFlexors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.90 ±0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.90 ±0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.05 ±0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.60 ±0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.95 ±0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.40 ±0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.024\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.021\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.16 – 1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.51 – 1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.18 – 0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.013\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.84%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.07%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.011\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eFinger\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eExtensors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.85 ±0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.05 ±0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00 ±0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.711\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.05 ±0.65\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.90 ±0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00 ±0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.29 – 0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.34 – 0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.49 – 0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.81%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.429\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eFinger\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eadductors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.85 ±0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.40 ±0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.25 ±0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.95 ±0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.85 ±0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.30 ±0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.015\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.012\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.766\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.50 – 0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.15 – 1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.55 – 0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.225\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.22%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.744\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.871\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eFinger\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eabductors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.90 ±0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.05 ±0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.95 ±0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.868\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.95 ±0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.65 ±0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.95 ±0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.022\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.049\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.51 – 0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.03 – 1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.56 – 0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.049\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.63%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.27%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.862\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.039\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eWrist\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eflexors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.30 ±0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.15 ±0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.20 ±0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.822\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.85 ±0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.95 ±0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.30 ±0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.019\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.06 – 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.31 – 1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.38 – 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.026\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.91%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.21%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.55%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.026\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003eWrist\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;extensors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.10 ±0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.20 ±0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.15 ±0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.914\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.20 ±0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.75 ±0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.15 ±0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.021\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Exp 2 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.028\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMD (Change)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 1 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.36 – 0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.08 – 1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.46 – 0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExp 2 \u003cem\u003evs.\u003c/em\u003e Control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.036\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImprovement %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.671\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.021\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExp 1: received peripheral sensory electrical stimulation program; Exp 2: received alternating EMG stimulation; Control: received program for hand functions training only\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData are expressed as mean ±standard deviation (SD) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;MD: Mean difference \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;CI: confidence interval \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value: probability value \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003csup\u003e*\u003c/sup\u003e Significant (P\u0026lt;0.05)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP-value\u003csup\u003e1\u003c/sup\u003e: Probability value within each group; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value\u003csup\u003e2\u003c/sup\u003e: probability value among groups; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;P-value\u003csup\u003e3\u003c/sup\u003e: probability value between pairwise groups (post-hoc test)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sensory electrical stimulation, Alternating electromyogram stimulation, Rehabilitation, Stroke, Hand function","lastPublishedDoi":"10.21203/rs.3.rs-7836628/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7836628/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and purpose:\u003c/strong\u003e Upper limb paresis among stroke survivors is the most common physical disability, significantly affecting their ability to perform Activities of Daily Living (ADL). Electrical stimulation is considered a promising approach to restore upper limb function. This study aimed to compare the effectiveness of Sensory Electrical Stimulation (SES) and alternating Electromyogram (EMG) Biofeedback in improving hand function in chronic stroke patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Method: \u003c/strong\u003eSixty stroke participants were randomly divided into three groups: experimental group 1 received standard physical therapy plus SES; experimental group 2 received physical therapy with alternating EMG Biofeedback; and the control group received only standard physical therapy. Over a three-month period, hand function was evaluated using the Action Research Arm Test (ARAT), muscle strength was assessed via the Medical Research Council (MRC) Scale, and spasticity was measured using the Modified Ashworth Scale.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eStatistical analysis showed significant improvements in motor function, muscle strength, and reduced spasticity in both experimental groups compared to the control group (p \u0026lt; 0.05). Notably, experimental group 2 (EMG Biofeedback) showed superior outcomes in ARAT subscales—grasp (89.74%), grip (97.62%), and pinch (69.08%)—and exhibited lower wrist spasticity (p = 0.014) than experimental group 1 (SES).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe findings suggest that both SES and EMG Biofeedback are effective when integrated into structured hand-training programs for chronic stroke rehabilitation. However, alternating EMG Biofeedback showed greater efficacy in improving hand function, increasing muscular strength, and reducing spasticity, making it a more favorable intervention for this patient population.\u003c/p\u003e\n\u003cp\u003eTrial registration: Registered at ClinicalTrials.gov on 20\u003csup\u003eth\u003c/sup\u003e February 2025 (ClinicalTrials.gov identifier: NCT06836596).\u003c/p\u003e","manuscriptTitle":"Efficacy of Sensory Electrical Stimulation Versus Alternating Electromyography (EMG) on the Functional Recovery of the Hand in Chronic Stroke Survivors: Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 06:25:11","doi":"10.21203/rs.3.rs-7836628/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f43d15a3-b41c-4086-95f2-79330c4ce922","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56971658,"name":"Health sciences/Diseases/Neurological disorders/Stroke"},{"id":56971659,"name":"Biological sciences/Neuroscience/Diseases of the nervous system/Stroke"}],"tags":[],"updatedAt":"2025-11-11T06:25:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-11 06:25:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7836628","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7836628","identity":"rs-7836628","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}