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© 2020 EDIZIONI MINERVA MEDICA European Journal of Physical and Rehabilitation Medicine 2020 June;56(3):265-71
Online version at http://www.minervamedica.it DOI: 10.23736/S1973-9087.20.06070-0

ORIGINAL ARTICLE

Task-based mirror therapy enhances the upper limb motor

function in subacute stroke patients: a randomized control trial
Hamza Y. MADHOUN, Botao TAN *, Yali FENG, Yi ZHOU, Cuijuan ZHOU, Lehua YU

Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
*Corresponding author: Botao Tan, Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing,
400010, China. E-mail: 303518@cqmu.edu.cn

ABSTRACT
BACKGROUND: The improvement of the upper limb disability, which is mainly caused by stroke, is still one of the rehabilitation treatment
challenges. However, the effectiveness of task-based mirror therapy (TBMT) on subacute stroke with moderate and severe upper limb impair-
ment has not been deeply explored.
AIM: The purpose of this study was to investigate the effects of TBMT, in comparison to occupational therapy, in moderate and severe upper
limb impairment by analyzing the motor function and activities of daily living in subacute stroke patients.
DESIGN: A randomized controlled trial.
SETTING: Rehabilitative inpatient unit.
POPULATION: Thirty patients with moderate and severe-subacute stroke recruited from the Second Affiliated Hospital of Chongqing Medical
University have been randomly divided into two groups; the task-based mirror therapy group (N.=15) and the control group (N.=15).
METHODS: The first group received TBMT while the control group only underwent only occupational therapy without a mirror utilization. Tak-
ing into consideration that both groups received conventional therapy. The intervention time was equal for both groups consisting of 25 minutes
per day for 25 days. Fugl-Meyer Assessment (FMA), Brunnstrom Assessment (BRS), Modified Barthel Index (MBI), and Modified Ashworth
Scale (MAS) were used to assess the outcomes for this study.
RESULTS: After 25 sessions of treatment, the patients in both groups have shown-improvement in the activates of daily living, motor recovery,
and motor function. No significant differences between the two groups were observed on BRS and MBI. However, interestingly, the results of the
TBMT group were significantly better than the control group in FMA (P<0.05) and certain aspects of MAS (elbow flexion, wrist flexion, wrist
extension, and fingers extension with P<0.05).
CONCLUSIONS: This study shows that the combination of conventional rehabilitation treatment and TBMT is an effective way to improve the
functional recovery in the upper limb stroke patients.
CLINICAL REHABILITATION IMPACT: TBMT is a therapeutic technique that can be used in subacute stroke patients with moderate and
severe upper limb impairment.
(Cite this article as: Madhoun HY, Tan B, Feng Y, Zhou Y, Zhou C, Yu L. Task-based mirror therapy enhances the upper limb motor function in sub-
acute stroke patients: a randomized control trial. Eur J Phys Rehabil Med 2020;56:265-71. DOI: 10.23736/S1973-9087.20.06070-0)
Key words: Upper extremity; Stroke; Motor skills disorders; Rehabilitation.

D espite the significant progress in the rehabilitation

therapy in recent years, the effective treatment of up-
per limb impairment in stroke patients is still challenging.1
Previous studies showed that around 85% of stroke patients
have a hemiparesis in the upper and/or lower limb. Between
55% to 75% of the stroke survivors suffer from limited up-
per limb functionality. This limitation can lead to muscle
weakness, limited joint motion, spasticity, sensory loss, and
reduction in the activity of daily living.2, 3 Several rehabili-
tation treatments exist to help restore motor functions and
improve the activities of daily living in stroke patients.4 For
instance, mirror therapy (MT), which was introduced by
Ramachandran and Rogers Ramachandran in 1996, was
initially used to treat the amputees suffering phantom limb
pain.5 Since then, it has been used either solely6 or coupled
with other therapies such as electrical stimulation.7 MT
is considered as an inexpensive and convenient approach
compared to other treatments.8 MT requires to put the mir-
ror between the two limbs. The unaffected limb is posi-
tioned in front of the mirror while the affected one is hidden

Vol. 56 - No. 3 European Journal of Physical and Rehabilitation Medicine 265

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MADHOUN TBMT AND UPPER LIMB MOTOR FUNCTION
behind. In such setup, the patient will observe the reflection
of the unaffected limb on the mirror with the sensation that
the affected limb is actually moving.9
However, the exact mechanism of MT is still not fully
clear.10 The basic concept of MT depends on visual illu-
sion by using visual feedback from the reflection of the un-
affected part in mirror.11 Besides, MT could stimulate the
primary motor, sensorimotor, and premotor cortex and/or
mirror neurons, which is known to enhance motor recov-
ery of the upper limb in stroke patients.3, 10, 11 It was shown
in a precedent study, using functional MRI analysis, that
the activation of human mirror neurons with functional
movement is higher than normal movement.12 Recent pa-
pers have discussed the role of MT in improving motor
function in chronic cases when the impairment is mild,
moderate, or severe.8, 13, 14 As well as, MT was reported to
improve unilateral neglect,15 motor recovery, and regain
the activates of daily living of subacute stroke patients.2, 16
On the other hand, some studies have shown limited motor
improvement when applying MT in acute stage.17, 18
To the best of our knowledge, only one study described
the effects of MT-in subacute stroke patients with severe
upper limb function impairments, which showed a limited
motor improvement.19 Hence, this present study aims to
investigate the effectiveness of task-based mirror therapy
(TBMT) on subacute stroke patients with moderate and
severe upper limb impairment by analyzing the upper limb
motor function improvement and activities of daily living.
We hypothesized that TBMT would improve motor recov-
ery, the activities of daily life, and upper limb function
compared to occupational therapy. We also hypothesized
that TBMT could reduce spasticity.
Materials and methods
Study design
The work was conducted as a single-blinded randomized
controlled trial. A total of 30 participants were randomly
separated into the TBMT group (N.=15) and the control
group (N.=15) using random generator software. All sub-
jects received 25 treatment sessions, 7 days per week. Each
patient was assessed twice, once prior to the intervention
and once after it.
Participants and setting
Stroke patients who were participating in this work suffered
from upper limb hemiparesis. They were hospitalized at
the Rehabilitation Medicine and Physical Therapy Depart-
266 European Journal of Physical and Rehabilitation Medicine June 2020
Enrollment Assessed for eligibility (N.=59)
Excluded (N.=24)
- Not meeting inclusion criteria
(N.=20)
- Declined to participate (N.=4)
Randomized (N.=35)
Allocation
Allocated to Task-Based Mirror Allocated to Control group
Therapy (N.=18) (N.=17)
- Received allocated intervention - Received allocated intervention
(N.=18) (N.=17)
- Did not received allocated - Did not received allocated
intervention (N.=0) intervention (N.=0)
Follow-up
Lost to follow-up (N.=0) Lost to follow-up (N.=0)
- Discontinued intervention (N.=3) - Discontinued intervention (N.=2)
Analysis
Analyzed (N.=15) Analyzed (N.=15)
- Excluded from analysis (N.=0) - Excluded from analysis (N.=0)
Figure 1.—Flow diagram for the study.
ment at Second Affiliated Hospital of Chongqing Medical
University. The criteria to select the participating patients
were 1) diagnosed with the first stroke at the age between
20 and 85; 2) had a stroke in less than 6 month; 3) had a
Brunnstrom stage20 for upper limb functional from 1 to 3;
4) showed a good cognitive condition (with score 24 points
or more of Montreal Cognitive Assessment);21 and 5) had
a poor and limited upper limb function (the score for Fugl-
Meyer Assessment (FMA) for upper limb below 47).22 Pa-
tients with any of the following criteria were excluded 1)
visual problem; 2) aphasia; 3) unilateral neglect; 4) mus-
culoskeletal disease; and 5) participating in another study.
After the initial screening, 39 stroke patients with hemi-
paresis were eligible to be part of this study. However, 4 of
them chose not to participate. Furthermore, 3 patients were
discharged from TBMT while another 2 were transferred
to the intensive care unit from the control group. Eventu-
ally, the final number of participants was 30 (Figure 1).
Ethical consideration
This study received approval from the Ethics Committee
of the Second Affiliated Hospital of Chongqing Medical
University, and all the patients were given written in-
formed consent form prior to the treatment.
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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
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TBMT AND UPPER LIMB MOTOR FUNCTION MADHOUN
Sample size calculation
The sample size was determined by using G power v.
3.1. A minimal sample size of 30 patients (15 per group)
was required for this trial to detect effect size d=0.95 for
change in the FMA score 9 Point.22 The parameters used in
this calculation were: alpha=0.05 and power =0.8.
Procedure
A total of 30 patients were randomized to the TBMT group
(N.=15) or control group (N.=15).
TBMT group
The size of the mirror box was 35x40x20 cm, which al-
lowed a good vision for the patients. The patients were
seated near the mirror, which is diagonally located along
the body level between the two limbs. The unaffected limb
is positioned at the anterior side of the mirror while the
affected limb was hidden all the time (Figure 2A). As a re-
sult, the patients can observe the healthy limb reflection on
the mirror, creating a perception that the affected limb is
moving. The activities performed by the patients included:
elbow flexion, extension, ulnar and radial deviation, flex-
ion and extension of the wrist, flexion and extension for the
fingers, abduction, and adduction for all the fingers. These
activities were conducted using various objects such as a
spongy ball, a bottle of water, a duster, chopstick, a cup,
cubes, wooden blocks, and so forth (Figure 2A).
Prior to TBMT treatment, the patients were asked to
remove any accessories around the unaffected limb like
a watch or a ring to facilitate the illusion. The sessions
focused on the unaffected upper limb, elbow, wrist, and
fingers, meanwhile no voluntary movements were allowed
using the affected limb.
A B
Figure 2.—TBMT and conventional occupation therapy. A) Patients are
performing Task-Based mirror therapy; B) patients performing conven-
tional occupation therapy treatment.
Vol. 56 - No. 3 European Journal of Physical and Rehabilitation Medicine 267
The TBMT group underwent 25 minutes of functional
task with the mirror every day in addition to conventional
therapy if needed, such as manual therapy and acupunc-
ture. The sessions were done under the supervision of the
occupational therapist in the occupational therapy room
in Rehabilitation Medicine and Physical Therapy Depart-
ment.
Control group
The control group received occupational therapy without a
mirror for 25 minutes in addition to conventional therapy
if the patients required. Similarly, the sessions were done
under the supervision of the occupational therapist in the
occupational therapy room in Rehabilitation Medicine and
Physical Therapy Department (Figure 2B).
Outcome measurement
Prior to the treatment session, all patients were assessed
with the following measures: FMA (upper limb) and
Brunnstrom Assessment (BRS), to evaluate the motor
recovery and motor function. A Modified Barthel Index
(MBI) to assess the activities of daily living. Modified
Ashworth Scale (MAS) was used to evaluate the spasticity
after stroke. Finally, once the 25 sessions were completed,
the same measurements were done again to evaluate the
improvement.
FMA
FMA is a crucial measurement to assess the motor func-
tion in the shoulder, wrist, forearm, hand, and fingers after
stroke. In this work, upper limb items were only consid-
ered. The maximum index for upper limb is 66 split into 36
for upper arm and 30 for hand and wrist. Each component
can attain a score of 0 to 2 such that 0, 1, 2 correspond
to no perform, partial perform, and complete perform, re-
spectively.22
BRS
BRS categorizes the motor recovery performance of the
upper limb, consisting of the arm and hand, into differ-
ent 6 stages. These stages are: stage (1), flaccidity; stage
(2), a little or no active movement; stage (3), movements
through the synergy, no voluntary movement; stage (4),
some movements out of synergy; stage (5), complex
movement out of the synergy with voluntary move-
ments; stage (6), synergy disappears and near normal.
The better the motor recovery is, the higher is the stage
allocated.20
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MADHOUN TBMT AND UPPER LIMB MOTOR FUNCTION

Modified Barthel Index BRS

The Barthel Index is used to measure the activities of daily In the TBMT group, the mean score for the upper limb
living. The maximum score is 100 which consisting of 10 of BRS before treatment was 2.53±0.51 and after treat-
items associated with different activities including (1) per- ment 3.33±0.48 with P=0.001 but in the control group
sonal hygiene, (2) bathing self, (3) feeding, (4) toilet, (5) was 2.33±0.90 before the therapy and 3.00±0.75 after
stair climbing, (6) dressing, (7) bowel control, (8) bladder therapy with P=0.002. Furthermore, the hand score of
control, (9) ambulation, (10) transfers. Once again, a high- Brunnstrom stage in the TBMT group was 2.67±0.48
er score corresponds to better activates of daily living.23 before the therapy and 3.40±0.50 after 25 days with
P=0.001, but in another group, the mean score was
MAS 2.33±0.72 before and 2.93±1.03 after therapy with
P=0.003 (Table II). The Brunnstrom stage had no sig-
MAS was used to assess the spasticity, in which the score
nificant difference between both groups. The degree
is ranging from 0 to 4. In this scale, 4 represents the high-
of recovery was almost the same between the groups
est spasticity and muscle tone.24
0.80±0.56 TBMT and 0.66±0.48 CT with P=0.529 in the
Statistical analysis upper limb and 0.73±0.45 TBMT and 0.60±0.50 CT with
P=0.446 in the hand (Table III).
The statistical analysis was performed using SPSS ver. 23
for Macintosh. The results are shown as mean and standard The MBI
deviation (M±SD). All the data underwent a test of nor- MBI showed a significant increase in both group function.
mality of the distribution using the Kolmogorov-Smirnov Increase from 54.53±23.75 to 72.27±16.58 in the TBMT
Test. An independent sample t-test or Chi-squared test was
used to compare the general characteristics between both Table II.—The outcome measures results for pre and post-inter-
groups. An independent sample t-test or Mann-Whitney U vention within and between groups.
was used to compare the significant level between groups. Outcome measure TBMT CT P value
A paired sample t-test or Wilcoxon signed-rank test was Brunnstrom Upper limb Pre 2.53±0.51 2.33±0.90 0.762
used to determine the significant level of the differences Post 3.33±0.48 3.00±0.75 0.199
before and after treatment measurements of the individual P value 0.001 0.002
Brunnstrom Hand Pre 2.67±0.48 2.33±0.72 0.193
groups. For all values obtained 0.05 was set as threshold or Post 3.40±0.50 2.93±1.03 0.229
for statistical significance. P value 0.001 0.003
MBI Pre 54.53±23.75 57.40±20.10 0.724
Post 72.27±16.58 70.13±19.25 0.748
Results P value <0.000 <0.000
Fugl-Meyer Assessment Pre 19.33±7.62 20.60±12.07 0.901
There were no significant differences between the TBMT Post 31.40±8.19 27.07±12.49 0.271
and the control group for the general characteristics (Table I). P value <0.000 0.001
*Values presented as mean±standard deviation. Significance difference at P≤0.05
TBMT: Task-Based Mirror therapy; CT: control group; MBI: Modified Barthel
Table I.—The general characteristics of the subjects. Index; FMA: Fugl-Meyer Assessment.

TBMT
Characteristic CT (N.=15) P value
(N.=15)
Table III.—The elevation of motor function and activities of daily
Mean (age) 49.33±10.43 53.93±8.76 0.202 living.
Gender, N. (%) Male 11 (73.3%) 9 (60%) 0.439
Female 4 (26.7%) 6 (40%) Variable TBMT CT P value
Type of stroke, N. (%) Hemorrhage 10 (66.7%) 11 (73.3%) 0.690 BRS Upper limb (Δ) 0.80±0.56 0.66±0.48 0.529
Ischemia 5 (33.3%) 4 (26.7%) BRS Hand (Δ) 0.73±0.45 0.60±0.50 0.446
Side of paresis, N. (%) Right 6 (40%) 5 (33.3%) 0.705 MBI (Δ) 17.73±9.83 12.73±7.17 0.084
Left 9 (60%) 10 (66.7%) FMA (Δ) 12.06±5.84 6.46±3.92 0.005
Mean stroke duration (month) 4.13±1.84 3.60±1.76 0.425
*Values are presented as mean±standard deviation. Significance difference
*Values are presented as the number of patients (N) or mean±standard deviation. at P≤0.05. TBMT: Task-based mirror therapy group; CT: control group; BRS:
Significance difference at P≤0.05. Brunnstrom Assessment; MBI: Modified Barthel Index; FMA: Fugl-Meyer
TBMT: task-based mirror therapy; CT: control group. Assessment.

268 European Journal of Physical and Rehabilitation Medicine June 2020

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access

cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

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TBMT AND UPPER LIMB MOTOR FUNCTION MADHOUN

group with P<0.001 and from 57.40±20.10 to 70.13±19.25
in the control group P<0.001. Nonetheless, there was no
significant difference observed when comparing both
group (Table II). Similarly, both groups had nearly equal
degrees of recovery 17.73 ±9.83 and 12.73 ±7.17 in TBMT
and CT, respectively with P=0.084 (Table III).
The FMA
The patients had a better FMA Score after treatment. This
observation was evident for both group (19.33±7.62 to
31.40±8.19 with P<0.001 in the TBMT group and from
20.60±12.07 to 27.07±12.49 in the control group with
P=0.001) (Table II). Furthermore, the degree of recov-
ery (more than 9 points) was greater in the TBMT group
(12.06±5.84) than CT group (6.46±3.92) with P=0.005
(Table III).
MAS
For the MAS, when comparing the results between pre-
treatment and post-treatment, it was realized that only in
elbow flexion (P=0.016), wrist flexion (P=0.034), wrist ex-
tension (P=0.002) and fingers extension group (P=0.034) a
statistical significance existed in the TBMT. On the other
hand, there was no statistical significance for the other
movement and the control group (Table IV).
Discussion
The MT technique gives the patients visual illusion
through visual feedback that the affected limb is mov-
ing.25 This method activates the premotor area, which
has a role for enhancing motor recovery after stroke.10, 13
In addition, activating the premotor area can lead to en-
hancing the primary motor area and stimulating the mo-
tor function in the upper limb. Besides, MT may activate
the right superior occipital gyrus and superior temporal
gyrus.11, 13 Previous work showed that the visual illusion
through MT activates the mirror neurons that are found in
the frontotemporal area, superior temporal gyrus,10 and
sensorimotor cortex.3
This study investigated whether TBMT combined with
conventional rehabilitation therapy affects upper limb
motor function, motor recovery, activities of daily life,
and spasticity in subacute stroke patients with moderate
and severe impairments in comparison to occupational
therapy.
Both groups, TBMT and control, had an upper limb im-
provement in motor function and activities of daily life as
per Brunnstrom Assessment, FMA, and MBI scales. Not-
ing that, out of these three assessments solely in FMA sta-
tistically significant difference between both groups was
observed. The result for the TBMT group over the control
was better with P<0.05.
This result agrees with the previous outcomes of
Mirela Cristina et al.16 study done on 33 subacute stroke
patients with mild to moderate upper limb impairment.
In that work, the patients were divided into the experi-
ment group (TBMT) and control group and were sub-
jected to 8 weeks of treatment. As discussed, the ex-
periment group demonstrated better motor recovery and
function.
In another work by Park et al.,6 TBMT was reported
as an effective treatment to enhance upper limb motor
function and self-care in comparison to sham therapy on
subacute stroke patients. Furthermore, various previous
studies have reached the same conclusion on the positive
impact of MT in treating stroke patients.2, 25, 26

Table IV.—The Ashworth scale results for pre and post-intervention within and between groups.
Variable TBMT CT P value TBMT CT P value
Elbow flexion Pre 1.80±1.52 0.80±0.94 0.073 Fingers Flexion Pre 0.73±1.03 0.33±0.48 0.098
Post 0.87±0.83 0.53±0.83 0.204 Post 0.40±0.63 0.26±0.45 0.900
P value 0.016 0.200 P value 0.096 0.467
Elbow extension Pre 1.93±1.03 1.00±1.13 0.026 Fingers extension Pre 1.60±1.18 0.87±0.91 0.072
Post 1.53±0.83 0.67±0.72 0.007 Post 1.20±1.01 0.73±0.79 0.173
P value 0.063 0.267 P value 0.034 0.533
Wrist flexion Pre 1.07±0.96 0.33±0.48 0.023 Thumb flexion Pre 0.60±0.91 0.33±0.48 0.541
Post 0.67±0.90 0.20±0.41 0.098 Post 0.47±0.64 0.20±0.41 0.213
P value 0.034 0.400 P value 0.414 0.400
Wrist extension Pre 2.13±1.21 0.67±0.48 <0.000 Thumb extension Pre 0.80±0.86 0.53±0.74 0.349
Post 1.07±1.03 0.53±0.51 0.159 Post 0.67±0.81 0.40±0.63 0.309
P value 0.002 0.400 P value 0.414 0.400
*Values are presented as mean±standard deviation. Significance difference at P≤0.05.
TBMT: Task-Based Mirror therapy; CT: control group.

Vol. 56 - No. 3 European Journal of Physical and Rehabilitation Medicine 269

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
MADHOUN TBMT AND UPPER LIMB MOTOR FUNCTION
In addition, a recent report suggested that the usage of
MT can be useful when coupled with other methods such
as electrical stimulation,27 bilateral arm training,1 somato-
sensory stimulation.10
Regarding spasticity recovery, all patients showed
only minor improvement according to MAS data after
treatment except elbow flexion, wrist flexion, wrist ex-
tension, and fingers extension in the TBMT group. This
observation came in partial disagreement with previous
studies showing that MT had no significant improvement
in terms of spasticity.1, 9 This point may require further
investigation that can be a subject of future study.
As demonstrated earlier, MT can be an effective tech-
nique to treat stroke patients. In addition, to its effective-
ness, MT is a simple and affordable treatment. It is easy to
be implemented in hospitals, clinic, and in-house patients.
On the other hand, some challenges were faced in this
work. For example, some patients felt bored due to spend-
ing long times (25-minute) looking to the mirror while ex-
ercising. The usage of the mirror was cumbersome with
few patients as they suffered from blurred vision.
Limitations of this study
This study had some limitations, first, the small sample
size, which consisted of only 30 patients. Second, we did
not compare TBMT and the MT alone without a functional
task. Third, it was difficult to generalize these results to all
the subacute stroke patients due to excluding patients with
either a communication and/or cognitive problem. Finally,
the long term effects of TBMT on stroke patients were not
evaluated.
Conclusions
This study showed that TBMT, combined with the reha-
bilitation treatment on subacute stroke patients with mod-
erate and severe upper limb impairment is an effective
treatment for improving the motor function and activities
of daily life.
References
1.  Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Ben-
shamir B, Padankatti SM, David JA. Mirror therapy enhances motor
performance in the paretic upper limb after stroke: a pilot randomized
controlled trial. Arch Phys Med Rehabil 2014;95:2000–5.
2.  Lim KB, Lee HJ, Yoo J, Yun HJ, Hwang HJ. Efficacy of Mirror Thera-
py Containing Functional Tasks in Poststroke Patients. Ann Rehabil Med
2016;40:629–36.
3.  Cantero-Téllez R, Naughton N, Algar L, Valdes K. Outcome measure-
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TBMT AND UPPER LIMB MOTOR FUNCTION MADHOUN

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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Funding.—The funds provided by Chongqing Municipal Health Committee Key Projects (NO.2016ZDXM009) and Chongqing Administration of Sport
Project 2018.
Authors’ contributions.—Hamza Yassin Madhoun designed, performed the experiments, analyzed the data, and wrote the manuscript; Botao Tan designed
experiments, helped supervise the project and co-wrote the paper; Yali Feng performed the experiments and assessed the patients; Yi Zhou, Cuijuan Zhou
performed the experiments and assessed the patients; Lehua Yu conceived of the presented idea, supervised the research and findings of this work. All authors
discussed the results and contributed to the final manuscript.
History.—Article first published online: March 25, 2020. - Manuscript accepted: March 23, 2020. - Manuscript revised: February 7, 2020. - Manuscript
received: October 30, 2019.

Vol. 56 - No. 3 European Journal of Physical and Rehabilitation Medicine 271