International Journal of Health Sciences and Research

[Link] ISSN: 2249-9571

Original Research Article

Comparison of Bilateral Approach versus Mirror

Therapy on Hand Function in Post-Operative Wrist
Complex Injuries
Yogita A. Pawar1, Pranjali M. Gosavi2
1
Intern, Faculty of Physiotherapy, Krishna Institute of Medical Sciences Deemed To Be University,
Karad, Maharashtra, India.
2
Assistant Professor, Faculty of Physiotherapy, Krishna Institute of Medical Sciences Deemed To Be
University, Karad, Maharashtra, India.
Corresponding Author: Pranjali M. Gosavi

ABSTRACT

Background: The hand is an important functional unit of the upper limb without which the whole of the
upper limb become almost useless. Injuries to hand affect hand function which limits the activities of daily
living. Hence, early rehabilitation should be provided to the person suffering from hand injuries.
Objective: To determine the effect of bilateral approach on wrist and fingers range of motion and pain
status. To determine the effect of mirror therapy on wrist and fingers range of motion and pain status. To
compare the effect of bilateral approach versus mirror therapy on wrist and fingers range of motion and
pain status.
Materials and Methods: Total 40 subjects were selected aged between 30 to 40 years according inclusion
and exclusion criteria. Prior consent was taken. They were divided into two groups: group A and group B.
Group A received bilateral approach and group B received mirror therapy. Pre assessment was taken for
pain status, disabilities of wrist and hand function, mobility of wrist and hand prior to the treatment. These
subjects were treated for 5 days per week for 3 weeks. After 3 weeks the post treatment assessment was
taken. The outcome measures were visual analogue scale, range of motion, Michigan hand outcome
questionnaire.
Conclusion: The study concluded that there was no significant difference between bilateral approach and
mirror therapy. Both the treatment methods showed significant improvement equally on pain status,
disabilities of wrist and hand function, mobility of wrist and hand in post operative wrist complex injuries.

Key words: wrist, hand function, bilateral approach, mirror therapy, fractures, motor control, pain status.

INTRODUCTION Movements take place at wrist are flexion,

Upper limb is useless without hand extension, abduction (radial deviation),
as it is an important functional unit. [1] Wrist adduction (ulnar deviation). Wrist joint is
joint is formed between lower end of radius also called as radiocarpal joint. [2] Joints of
and articular disc of inferior radioulnar joint hand are carpometacapral, intercarpal and
proximally and three lateral bones of upper intermetacarpal joints. First carpometacarpal
row of carpal-scaphoid, lunate and triquetral joint is synovial type of joint of saddle
distally. It is a synovial type of joint of variety. Movements occur at it are flexion,
ellipsoid variety. Bones at wrist are Hamet, extension, abduction, adduction and
Pisiform, Triquetral, Capitate, Lunate, opposition. Metacarpophalangeal joints
Trapezoid, Trapezium, Scaphoid. movements are flexion, extension,

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Yogita A. Pawar [Link]. Comparison of Bilateral Approach versus Mirror Therapy on Hand Function in Post-
Operative Wrist Complex Injuries

abduction, adduction and opposition for first fixation and secondarily, absence of rigid
joint and flexion, extension, abduction, fixation. It takes weeks to years for fracture
adduction for second to fifth joints. It is healing. Fixation of fracture can be done by
synovial joints of ellipsoid variety. various devices like stress sharing or stress
Interphalangeal joint is a hinge type of joint. shielding device. Stress sharing devices are
Movements at second to fifth digits are cast, rods, pins, screws or wires and external
flexion and extension. [2] fixator. Stress shielding device is plates. [6]
Function of the hand occurs with the Management of fractures can be done
balance and control of forces between the according three phases: emergency care,
extrinsic and intrinsic muscles of wrist and definitive care and rehabilitation. In
hand. There are two types of grips used for emergency phase RICE method is used at
performing activities of daily living- power the site of accident. RICE stands for rest of
grip and precision grip. Power grip are the part by splinting, ice therapy to reduce
isometric functions and involve clamping an swelling, compression to reduce swelling
object with partially flexed fingers against and elevation to reduce swelling. In
the palm of the hand and with counter definitive phase fracture is been treated by
pressure from the adducted thumb like various methods like- immobilization,
cylindrical grip, spherical grip, hook grip closed reduction and percutaneous fixation,
and lateral prehension. Precision grip are open reduction and internal fixation,
isotonic functions and involve minimally invasive surgery. During
manipulations an object not in contact with rehabilitation phase joint mobilization,
the palm between opposing abducted thumb muscle re-education exercises and
and fingers like pad-to-pad, tip-to-tip, pad- functional use of the limb. [1]
to-side prehension. There is also a combined
type of grip which involves digits 1 and 2, Physiotherapy interventions for hand
sometimes 3 for performing activities like injuries:
pinch. [3] 1. Mobilization: They are passive skilled
During accidents and emergency manual therapy techniques applied to a joint
cases hand injuries are commonly seen. This and related soft tissue at varying speed and
is because during emergency and accidents amplitudes using physiological and
people try to protect them self with help of accessory motions for therapeutic purpose.
hand to resist injury. Injury to hand is a It helps to reduce pain, reduce post
potential for serious handicap so as early as traumatic stiffness and increase range of
possible medical evaluation is required even motion. [3]
for smallest hand injury. These injuries vary 2. Exercises: These strengthening exercises
from childhood to adulthood and even for are used to increase the potential tension
elderly population due to various factors which produces contractile and static
like, pattern of injury, age group and growth elements of the muscle. They are of various
mechanism. [4] Injuries to wrist and hand types- isometric exercises, isotonic
leads to reduce range of motion due to exercises and isokinetic exercises. Even
formation of edema, scar, adhesion with there are high performance strengthening
changes in connective tissue. Injuries to exercises like closed chain, open chain and
hand affect the day to day activities and it is plyometric exercises. Exercises can be
difficult to treat. [5] Injuries can be fractures, conditioning based or functional or task
tendon injury, nerve injury, dislocation, specific which increases neuromuscular
crush injury, soft tissue injury. [1] coordination, agility, strength and
[6]
Fracture healing includes endurance.
debridement, stabilization and remodeling 3. Modalities: Various modalities can be
of the fracture site. Healing occurs in two sued for the treatment that is heat, cold,
ways, either primarily, presence of rigid hydrotherapy, electrical stimulation. [6]

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Yogita A. Pawar [Link]. Comparison of Bilateral Approach versus Mirror Therapy on Hand Function in Post-
Operative Wrist Complex Injuries

4. Stretching: it can be used to lengthen the bilateral arm training for upper extremity for
muscle involved. It helps to relax the muscle stroke patients. [7,8]
and lead to reduce pain and improve Mirror therapy is non invasive
movement. Along with stretch sprays can be method of treatment. Mirror visual feedback
used like vapocoolant to reduce muscle conveyed through mirror helps in restoring
spasm. [6] the brain function. [10] Mirror therapy helps
5. Assistive devices: Various devices can be in reducing pain, correct sensory and motor
used by the patient to carry out daily system problems. [11] The concept behind
activities and for ambulation. Devices like the mirror therapy is neurophysiologic. 11 In
reacher, grapper, adjustable height beds and mirror therapy a virtual reality box is used.
toilet seats, canes, crutches, walker, etc. [6] The roof of the box is removed by placing a
Unilateral movements are done vertical mirror inside it. Two holes are made
using one side only. It is also called as in front of it through which the patient
constraint induced movement therapy. The inserts his both the arms. Thus the illusion is
affected part is involved for the treatment created by seeing the reflection of the
and to carry out the movements. The normal hand. This allows motor commands
mechanism of unilateral approach is to grow to both arms to make mirror symmetric
the new neural pathways which changes in movements. This will help to correct the
brain referred to as neuroplasticity. 7 affected arm by creating the positive visual
Alternative method can be bilateral feedback informing the brain that his
approach. Previous studies have shown affected arm is moving correctly. [12]
more effect regarding bilateral approach Previous studies were carried out on
compared to unilateral approach. [7] the effect of bilateral arm movement in
Symmetrical bilateral movements stroke patients and on mirror therapy in
repetitively performed in various ways stroke, phantom limb, complex regional
along with bilateral isokinematic training pain syndrome type 1 and 2, hand surgery
are bilateral approach. [8] The mechanism of and orthopedic hand injuries. Till date a
bilateral approach is simultaneous comparative study is not carried out. So the
[8]
movement activate neural networks and study needs to be done comparing both the
cortical excitability. [8] This allows to learn a treatment methods in post operative wrist
motor task and non rhythmic movement. [7] complex injuries.
Thus promotes neural plasticity and
facilitate movement control. [8] Benefits of MATERIALS & METHODOLOGY
bilateral approach was found that subjects Methodology:
were able to perform daily activities like Type of study- Experimental study
bathing, carrying objects easily. [7] In Study design- Pre test and Post test
everyday activities we require both the arms Sampling method- Simple random sampling
to carry out the activities like bathing, Place of study- Krishna College of
feeding, dressing, driving, toileting, carrying physiotherapy, KIMSDU, Karad
objects, cooking, shopping, getting up from Sample size- 40
the bed, using keyboard, etc. So this is the Duration of study- 6 months
reason behind performing bilateral training.
[9]
This is applicable for functional Inclusion criteria:
improvement, motor control, Age Group: 30 – 40 yrs
neurophysiologic mechanism is improved, Both males and females
reduce disability, improve coordination. [9] Post operative fractures with limited range
Thus, studies have shown effect of bilateral of motion of wrist and hand
arm training on motor control and functional Exclusion Criteria:
performance in stroke individuals, even Loss of sensation in wrist and hand
comparative study between unilateral and Nerve injuries

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Yogita A. Pawar [Link]. Comparison of Bilateral Approach versus Mirror Therapy on Hand Function in Post-
Operative Wrist Complex Injuries

Materials Used: mirror therapy. Group A: paraffin wax bath,

Paraffin wax bath mobilization and free exercises, towel
Mirror box exercises, exercises with ball, rubber band
Towels exercises, in bilateral pattern. Group B:
Rubber bands mobilization and free exercises, towel
Ball exercises, exercises with ball, rubber band
Goniometer exercises, in front of mirror box. These
Outcome measures: subjects were treated for 5 days per week
Active range of motion. for 3 weeks. After 3 weeks the post
Visual analogue scale. treatment assessment for pain status,
Michigan hand outcome questionnaire. disabilities of wrist and hand function,
Active range of motion: To measure mobility of wrist and hand was taken with
baseline limitations of motion, to decide the help of assessment tools (visual
appropriate therapeutic interventions and to analogue scale, range of motion, Michigan
document the effectiveness of these hand outcome questionnaire). The
interventions physical therapists generally interpretation of the study was done on the
makes use of goniometric measurements. basis of comparing pre test and post test
Visual analogue scale: A Visual Analogue assessment of Range of motion, Visual
Scale is a measurement instrument that tries analogue scale, Michigan hand outcome
to measure a characteristic or attitude that is questionnaire. Thus statistical analysis was
believed to range across a continuum of done.
values and cannot easily be directly Statistical Analysis
measured. For example, the amount of pain Data of all outcome measures was measured
that a patient feels ranges across a as pre treatment & post treatment values.
continuum from none to an extreme amount Mean & standard deviation was calculated
of pain. for each outcome measure.
Michigan hand outcomes questionnaire:
This outcome questionnaire capable of Within the Group Comparison:
measuring health state dominance important Within group comparison was done by
to patient with hand disorder .it includes applying „Paired t-test‟ to pre and post
over all hand function, activities of daily treatment values of same group for all
living, pain work performance, aesthetics outcome measures.
and patients satisfaction with hand Between the Group Comparison:
functions. Between groups comparison was done by
Procedure: applying „unpaired t test‟.
The subjects were selected according Group I: bilateral approach
to the inclusion and exclusion criteria using Group II: mirror therapy
simple random sampling. They were divided
into two groups: group A and group B. RESULT
Informed consent was taken from the AGE DISTRIBUTION:
subjects. Subjects were assessed for pain Table No. 1: Age distribution
Sr No AGE TOTAL
status, disabilities of wrist and hand 1 30-33 15
function, mobility of wrist and hand prior to 2 34-36 13
3 37-40 12
the treatment for which visual analog scale,
Michigan hand outcome questionnaire and
GENDER DISTRIBUTION:
range of motion respectively was used. Table No. 2: Gender distribution
Subjects were explained about the Sr No GENDER TOTAL
1 Male 19
procedure of the study. Group A received 2 Female 21
bilateral approach and Group B received

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Yogita A. Pawar [Link]. Comparison of Bilateral Approach versus Mirror Therapy on Hand Function in Post-
Operative Wrist Complex Injuries

DATA ANALYSIS
WITHIN THE GROUP COMPARISON:
Group A:
Table No. 3: baseline parameters in group A
Sr No PARAMETERS PRE POST t value p value INFERENCE
1 Visual Analog Scale 6.05±1.76 2.35±1.309 12.711 <0.0001 Significant
2 Wrist Flexion 51.85±11.69 70.5±6.065 9.269 <0.0001 Significant
3 Wrist Extension 52.3±8.909 68.5±6.048 13.167 <0.0001 Significant
4 Wrist Ulnar Deviation 23.95±5.42 34.85±3.46 7.421 <0.0001 Significant
5 Wrist Radial Deviation 12±2.34 18.5±2.43 10.98 <0.0001 Significant
6 Fingers Flexion 29.75±28.82 35.25±32.88 2.299 0.0421 Significant
7 Fingers Extension 15.75±14.44 20.15±18.18 5.14 0.0003 Significant
8 Michigan Hand Outcome Questionnaire 115.3±11.49 130.9±12.22 11.203 <0.0001 Significant

Group B:
Table No. 4: baseline parameters in group B
Sr No PARAMETERS PRE POST t value p value INFERENCE
1 Visual Analog Scale 6.5±1.433 2.75±1.517 15.674 <0.0001 Significant
2 Wrist Flexion 60.55±9.12 69.05±5.54 5.82 <0.0001 Significant
3 Wrist Extension 53.55±8.29 70.15±6.23 11.44 <0.0001 Significant
4 Wrist Ulnar Deviation 24.6±5.34 34.3±3.48 6.425 <0.0001 Significant
5 Wrist Radial Deviation 11.25±2.48 18.95±2.18 11.71 <0.0001 Significant
6 Fingers Flexion 23.35±26.08 29.8±32.56 2.704 0.014 Significant
7 Fingers Extension 13.2±14.24 17.75±19.17 3.56 0.0021 Significant
8 Michigan Hand Outcome Questionnaire 116.45±10.51 131.15±11.20 9.316 <0.0001 Significant

BETWEEN THE GROUP COMPARISON:

Table No. 5: baseline parameters comparison between both the groups
Sr No PARAMETERS GROUP A GROUP B t value p value REMARKS
1 Visual Analog Scale 2.35±1.309 2.75±1.517 0.8927 0.3777 Not Significant
2 Wrist Flexion 70.5±6.065 69.05±5.549 0.788 0.4351 Not Significant
3 Wrist Extension 68.5±6.048 70.15±6.235 0.8495 0.4009 Not Significant
4 Wrist Ulnar Deviation 34.85±3.46 34.3±3.48 0.5006 0.619 Not Significant
5 Wrist Radial Deviation 18.5±2.439 18.95±2.188 0.614 0.542 Not Significant
6 Fingers Flexion 35.25±32.88 29.8±32.56 0.5266 0.6015 Not Significant
7 Fingers Extension 20.15±18.18 17.75±19.17 0.406 0.686 Not Significant
8 Michigan Hand Outcome Questionnaire 130.9±12.22 131.15±11.207 0.067 0.9466 Not Significant

DISCUSSION
This study “Comparison of bilateral
approach versus mirror therapy on hand
function in post operative wrist complex
injuries” was conducted to compare the two
treatments that is bilateral approach and
mirror therapy and find out which one
improves functional mobility of wrist and
hand and reduces pain. As hand is an
important functional unit of the upper limb
without which the whole of the upper limb
become almost useless. Injuries to hand
affect hand function which limits the
Fig No. 1: baseline parameters comparison between both the activities of daily living. Hence, early
groups
rehabilitation should be provided to the
Above table and graph shows pre and post person suffering from hand injuries.
comparison between the groups. Post Previous study “Effect of mirror
treatment there was not significant therapy on hand function in patients with
improvement noted in both the groups. hand orthopedic injuries: a randomized
controlled trial” by H. R. Rostami, A. Arefi
and S. Tabatabaei was to see the effect of

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Yogita A. Pawar [Link]. Comparison of Bilateral Approach versus Mirror Therapy on Hand Function in Post-
Operative Wrist Complex Injuries

mirror therapy in restoring hand function in One group received bilateral approach and
patients with active range of motion another group received mirror therapy. Pre
impairments followed orthopaedic injuries. assessment was taken for pain status,
The post test baseline TAM, DASH was disabilities of wrist and hand function,
significant improvement in both the groups mobility of wrist and hand prior intervening
(p=0.001). The study “Comparison of with the treatment. The interventions were
bilateral approach and unilateral training for carried out for 5 days per week for 3 weeks.
upper extremity hemiparesis in stroke” by The outcome measures for this study
Mary E. S, Gwyn N. L and Daniel M. C was were Visual analog scale, range of motion,
done to efficacy comparing two groups Michigan hand outcome questionnaire.
using various tasks performed in chronic After 3 weeks post assessment was taken.
stroke survivors with moderate upper The results of this study indicate that
extremity impairments. Thus concluded that bilateral approach and mirror therapy both
both unilateral and bilateral training are are effective in treatment of post operative
efficacious for moderately impaired chronic wrist complex. This was confirmed using
stroke survivors and bilateral training may statistical analysis by using „Paired t- test‟
be more advantageous for proximal arm for within group comparison and „Unpaired
functioning. t- test‟ for between the group comparisons.
Previous studies are carried out to Within the group comparison: Group
see the effect of mirror therapy on hand A:pre and post training there was significant
function in patients with hand orthopaedic improvement noted with bilateral approach
injuries but not with bilateral approach. So in visual analog scale (p=<0.0001), wrist
the study need to be done to compare flexion (p=<0.0001), wrist extension
between bilateral approach and mirror (p=<0.0001), wrist ulnar deviation
therapy in post operative wrist complex (p=<0.0001), writs radial deviation
injuries in order to maximize improvement (p=<0.0001), fingers flexion (p=0.0421),
along with reducing treatment period. fingers extension (p=0.0003), Michigan
The aim of the study is to find out hand outcome questionnaire (p=<0.0001).
the effect of bilateral approach versus mirror Group B: pre and post training there was
therapy on hand function in post operative significant improvement noted with bilateral
wrist complex injuries. The objectives were approach in visual analog scale
To determine the effect of bilateral approach (p=<0.0001), wrist flexion (p=<0.0001),
on wrist and fingers range of motion and wrist extension (p=<0.0001), wrist ulnar
pain status, To determine the effect of deviation (p=<0.0001), writs radial
mirror therapy on wrist and fingers range of deviation (p=<0.0001), fingers flexion
motion and pain status and To compare the (p=0.014), fingers extension (p=0.0021),
effect of bilateral approach versus mirror Michigan hand outcome questionnaire
therapy on wrist and fingers range of motion (p=<0.0001).
and pain status. Between the group comparison: Post
The study was conducted with 40 training there was not significant difference
subjects. Subjects were selected according between outcome variables in visual analog
to the inclusion and exclusion criteria. scale (p=0.3777), wrist flexion (p=0.4351),
Inclusion criteria were age Group between wrist extension (p=0.4009), wrist ulnar
30-40 yrs, both males and females and post deviation (p=0.619), writs radial deviation
operative fractures with limited range of (p=0.542), fingers flexion (p=0.6015),
motion of wrist and hand. Exclusion criteria fingers extension (p=0.686), Michigan hand
were Loss of sensation in wrist and hand outcome questionnaire (p=0.9466).
and Nerve injuries. The reason behind the improvement
The subjects were divided into two is due to decreased fear and anxiety of using
groups. Prior consent was taken from them. the affected limb as mirror therapy as well

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Yogita A. Pawar [Link]. Comparison of Bilateral Approach versus Mirror Therapy on Hand Function in Post-
Operative Wrist Complex Injuries

as bilateral approach helped them to patients with hand orthopaedic injuires: a

overcome fear and anxiety and movement randomized controlled trial; Disability and
increased and pain reduced. Among few rehabilitation; 2013 sep 1;35(19): 1647-51.
participants there may not be major changes 5. Jindal R, Jindal N, Dass A; Prevalence of
hand fractures: a clinical study; international
due to lack of regularity, no information
journal of contemporary medical research;
about the necessity of rehabilitation after the 2016; 3: 3245-7.
surgery. The study was limited to a small 6. S. Hoppenfeld, V. L. Murthy; Treatment
geographic area and duration was short and and rehabilitation of fractures; Lippincott
limited. Suggestions for the study given can Williams & Wilkins; 2000.
be that a future study with large sample size 7. Keh-chung Lin, Yi-an Chen, Chia-ling
and with other joint complex can be done. Chen, et al. The Effects of Bilateral Arm
Training on Motor Control and Functional
CONCLUSION Performance in Chronic Stroke: a
The study concluded that there was randomized controlled study;
no significant difference between bilateral Neurorehabilitation and Neural Repair;
2010 jan; 24(1); 42-51.
approach and mirror therapy. Both the
8. Mary Ellen Stoykov, Gwyn N. Lewis,
treatment methods showed significant
Daniel M. Corcos; Comparison of Bilateral
improvement equally on pain status, and Unilateral Training for Upper Extremity
disabilities of wrist and hand function, Hemiparesis in Stroke; Neurorehabilitation
mobility of wrist and hand in post operative and Neural Repair; 2009 nov; 23(9): 945-
wrist complex injuries. 53.
9. Waller SM, Jill Whitall; Bilateral arm
ACKNOWLEDGEMENT training: Why and who benefits?
We acknowledge the guidance and support from NeuroRehabilitation; 2008 jan 1;23(1): 29–
faculty of physiotherapy. 41.
10. Ramchandran VS and Eric L. Altschuler;
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How to cite this article: Pawar YA, Gosavi PM. Comparison of bilateral approach versus mirror
therapy on hand function in post-operative wrist complex injuries. Int J Health Sci Res. 2019;
9(7):183-189.

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