Comparative Effects of Task-specific Drawing Exercises and Fine Motor Training on Dexterity and Hand Motor Function After Stroke

Stroke is a major cause of long-term disability and frequently results in persistent impairment of upper limb function. Hand dysfunction is particularly important because recovery of precise hand and finger movements may remain incomplete even when gross upper limb movements improve. Impairments in dexterity, coordination, motor control, movement precision, and object manipulation can interfere with activities of daily living such as writing, eating, dressing, grooming, and handling everyday objects. Consequently, improving functional hand performance will remain an important component of neurological rehabilitation.

Contemporary stroke rehabilitation will emphasize repetitive, purposeful, and task-oriented practice to facilitate motor relearning and functional recovery. Task-specific interventions will involve repeated practice of meaningful movements using the affected upper limb. Task-specific drawing exercises will provide a structured form of task-oriented training that will require controlled finger movements, visuomotor coordination, movement accuracy, motor planning, and precision. The progressive nature of the drawing activities will allow the demands placed on hand control to increase throughout the intervention period.

Fine motor hand training will provide another structured rehabilitation approach based on repetitive manipulation of objects and performance of coordinated hand activities. Such activities will require controlled finger movements, grasp-and-release ability, precision, object manipulation, and coordination. The progression of activities from relatively simple to more demanding tasks will provide gradually increasing challenges to fine motor control and functional hand use.

This study will be conducted as a Randomized Controlled Trial (RCT) to compare the effectiveness of task-specific drawing exercises and fine motor hand training in individuals with subacute stroke. A total of 26 participants will be randomly allocated into two intervention groups. Group A will receive task-specific drawing exercises, while Group B will receive fine motor hand training. Before receiving their assigned intervention, both groups will receive the same baseline wrist and finger range-of-motion exercises, including wrist circles, wrist flexion and extension, finger abduction and adduction, and thumb opposition. These baseline exercises will be performed for 10 repetitions each.

Task-Specific Drawing Exercise Group Participants allocated to Group A will receive a progressively structured drawing intervention over four weeks. The intervention will be performed on alternate days, with each session lasting 30-45 minutes, and each prescribed activity will be performed for 15 repetitions.

During Week 1 (Module 1), participants will perform geometric shape drawing and shading activities. The illustrated tasks will include parallel vertical lines, horizontal lines, diagonal lines, curved and semicircular lines, concentric circular and oval patterns, spiral patterns, repeated curved patterns, and cone-like forms. Additional geometric patterns will include nested squares, nested rectangular forms, parallelogram-like patterns, and nested triangular forms. These activities will provide the initial level of drawing practice and will require participants to reproduce controlled lines, curves, repeated patterns, and geometric forms with the affected hand. The module will emphasize controlled movement, precision, and coordination while introducing repetitive drawing practice.

During Week 2 (Module 2), the drawing program will progress to combined and more recognizable forms. The illustrated activities will include a house, table, chair, bowl or cup-like form, and bicycle. These drawings will combine multiple lines and geometric components to create more complex forms. Compared with the first week's isolated geometric patterns, these activities will require greater integration of different movement directions and greater motor planning. Participants will therefore progress from relatively simple geometric patterns toward drawings requiring more coordinated and continuous hand movements.

During Week 3 (Module 3), participants will progress to irregular and natural-form drawing activities. The illustrated tasks will include different leaf forms, including a simple leaf with a central vein, a compound or multi-leaf form, and an irregular leaf with a more complex outline. These activities will introduce asymmetrical and less predictable outlines compared with the standardized geometric forms used during the earlier modules. Participants will be required to control curved and variable movements while reproducing the general structure and details of the illustrated forms.

During Week 4 (Module 4), participants will perform freehand drawing activities. The illustrated tasks will include a branching tree, a coniferous or pine-type tree, and human eyes. These activities will require greater independent control of hand movements and greater variation in line direction, curvature, proportion, and detail. The freehand module will represent the final stage of progression and will allow participants to integrate the movement control and coordination practiced during the preceding weeks into more complex representational drawings.

Overall, the drawing intervention will therefore progress from basic lines and geometric patterns, to combined forms, to irregular natural forms, and finally to freehand representational drawings. This progression will provide gradually increasing demands on fine motor control, visuomotor coordination, movement precision, and motor planning.

Fine Motor Hand Training Group Participants allocated to Group B will receive a progressively graded fine motor hand training program over four weeks. The intervention will also be performed on alternate days for 30-45 minutes, with 15 repetitions of each activity.

During Week 1, participants will perform activities including rolling paper pieces into wads, transferring large beads into a small jar, and picking up and rolling a pencil between the thumb and each finger. These activities will provide basic practice in finger coordination, grasp, release, and manipulation.

During Week 2, the program will progress to folding paper into half, picking and stacking medium cubes, flipping and placing cards, opening and closing a jar, twirling a pen between the fingers, and transferring medium-sized beads into a container. These activities will introduce greater demands on coordinated finger movement, object handling, and precision.

During Week 3, participants will perform more challenging activities, including tearing paper into large pieces, paper clip placement, picking and stacking small cubes, transferring small beads, and buttoning and unbuttoning. The reduction in object size and increased precision requirements will provide a greater challenge to fine motor coordination and controlled finger movements.

During Week 4, the intervention will progress to tearing paper into small pieces, picking up coins from a table, opening and closing a bottle cap, opening a lock using a key, and picking up a piece of paper using tweezers. These activities will require increasingly precise finger movements, grasp control, object manipulation, and coordinated use of the hand.

Both intervention programs will therefore follow a four-week progressive structure, with treatment activities becoming increasingly complex as the program advances. The primary focus of the study will be hand dexterity, while hand motor function will be considered the secondary outcome. Changes will be assessed from baseline to completion of the four-week intervention using the standardized outcome measures specified in the study protocol which is nine hole peg test for dexterity and Fugl-meyer assessment for hand motor function after stroke The comparison of these two interventions will provide evidence regarding their relative effectiveness in improving hand function following subacute stroke. The findings are expected to contribute to the evidence base for task-oriented neurological rehabilitation and may assist physiotherapists in selecting structured, progressively graded interventions for improving functional hand performance and promoting greater independence among individuals recovering from stroke.

Inclusion criteria

• Adults aged 40-70 years.
• Diagnosed with MCA ischemic or hemorrhagic stroke, confirmed by medical records.
• Sub-acute stroke patients and to perform minimal voluntary finger or wrist movement in the affected hand (_>30 pronation supination and wrist flexion)
• Ability to understand and follow simple verbal instructions.
• Able to sit without upper limb support.

Exclusion criteria

• Aphasia, cognitive deficits
• Modified Ashworth Scale >3 in the wrist or fingers of the affected hand.
• History of Parkinson's disease, multiple sclerosis, traumatic brain injury, or recurrent stroke.
• Fracture, arthritis, tendon injury, or deformity affecting the upper limb or hand.
• visuospatial neglect interfering with drawing tasks.