EFFICACY OF LOWER EXTREMITY MIRROR THERAPY ON BALANCE IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY: A Randomized Controlled Trail
Phase: NA
Conditions: HEMIPLEGIC CEREBRAL PALSY
Sponsor: South Valley University

Official Title of Study: - 
EFFICACY OF LOWER EXTRIMITY MIRROR 
THERAPY ON BALANCE IN CHILDREN WITH 
HEMIPLEGIC CEREBRAL PALSY:     A Randomized 
Controlled Trail  
 
 
 
 
 
 
 
 
Document Date: -   03/01/2020 
 
 
 
 
 
 
 
 
 
Human Subjects protection review board 
approval date: -    01/12/2019 
 
 

EFFICACY OF LOWER EXTRIMITY MIRROR THERAPY ON BALANCE 
IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY:     A 
Randomized Controlled Trail 
Abstract 
Background: Hemiplegic cerebral palsy in the most common type of 
cerebral palsy that has permanent motor disorders and associated with 
life-long disability. Aim: To assess the efficacy of mirror therapy on 
balance in children with hemiplegic cerebral palsy. Methods: Seventy 
child with hemiplegic cerebral were enrolled in this study and were 
assessed for eligibility. Their aged ranged from eight to twelve years. The 
children were assigned randomly into two equal groups. Group (a) 
control group received traditional physical therapy program. And group 
(b) study group received the same traditional physical therapy program in 
addition to mirror therapy three times / weak for three successful months. 
Biodex balance system was used to assess balance pre and post treatment. 
All children were assisted before and after three months of intervention. 
Results: Post treatment, significantly improvement was in overall 
stability index, antro-posterior stability index, and Medio-lateral stability 
indexonly in study group (P< 0.05). Conclusion: Lower extremity mirror 
therapy has significant effect on balance in children with hemiplegic 
cerebral palsy.  
Key words: cerebral palsy, balance, mirror therapy. 
Introduction: 
Cerebral Palsy (CP) is a group of motor disorders resulting from damage 
to the brain of child, affects motor system, and leads to poor balance, 
poor coordination, or abnormality in patterns of movement (Miller and 
Bachrach, 2017).The most common type of CP is hemiplegic CP that 

affecting one person per thousands of live births, that characterized by a 
clinical pattern of unilateral motor impairment, movement disabilities and 
postural disturbance(Robert J., Steven 2010).Hemiplegic CP has 
impaired postural balance that contributes to their gait abnormalities 
(Chen et al., 2013).All balance parameters affected in hemiplegic CP due 
to musculoskeletal asymmetry show significant differences than those of 
typically developing children (Kenis-Coskun et al., 2016). 
Mirror therapy (MT) is a simple, effective and low cost technique used to 
improve the mobility of affected limbs by visual feedback induced by of 
the non-affected limb movement in the mirror (McInnes and Friesen 
2016).MT explained by three main mechanisms 1) it facilitates 
locomotion recovery by visual feedback of the normal side movement 
that reflect stimulation of movement in affected side (Funase et, al. 
2007). 2) Activation of mirror neurons that facilitate movements of 
affected limb (Cattaneo & Rizzolatti 2009). 3) Simultaneous motion of 
normal and affected limbs that stimulate the affected cerebral cortex by 
interactions with the stimulation of non-affected cerebral cortex 
(Summers et, al. 2007). 
Subjects and methods: 
This randomized controlled study was conducted in the outpatient clinic 
in faculty of physical therapy, Cairo University. The Informed consent 
was submitted for each child by their parents. The procedures that 
followed were approved by the Institutional Ethical Committee Clearance 
of 
the 
Faculty 
of 
Physical 
Therapy 
Cairo 
University 
No: 
P.T.REC/012/002423.The study was registered on Clinicaltrial.gov and 
registration number wasNCT04187027. 
 
 

Study population: 
Children who were diagnosed as having hemiplegic CP based on careful 
clinical assessment by physiotherapist. After screening, children had 
ability in the investigation with these criteria: (i)Children`s aged ranged 
from eight to twelve years.(ii)Children participated in this study will from 
both sexes.(iii)Their degree of spasticity will ranged from mild to 
moderate according to Modified Ashworth Scale. (iv)Children with stable 
medical and psychological status. (v)Children able to follow the verbal 
commands or instructions. Children excluded from study if they exhibited 
any of the following criteria: (i) children with visual or auditory 
problems. (ii)Children with history of epilepsy. (iii)Children with history 
of surgical interference in lower limbs less than one year. (iv)Medically 
unstable children especially with cardiovascular disorders. (vi) Mentally 
retarded children. (vii) Un-cooperative children. 
Randomization: 
A total of seventy children with hemiplegic CP evaluated to eligibility. 
Six did not meet the study criteria, and four declined to participate. Sixty 
participants were assigned randomly in two groups of equal numbers. 
Random allocation software was used to minimize selection bias 
(Saghaei 2004).A diagram of children retention and randomization 
throughout the study is shown in fig (1). 
Random assigned was into studying groups. Group (a) control group 
received traditional physical therapy program. And group (b) study group 
received the same traditional physical therapy program in addition to 
mirror therapy three times / weak for three successful months.  All 
children were assisted using Biodex balance system before and after three 
months of intervention. 

Materials for evaluation: 
The Biodex Balance System (BBS) is an important therapeutic tool 
that used for evaluating and training of patients with balance deficits. (El-
Shamy and Abd El-Kafy, 2014) 
The Biodex balance system is a valid and reliable device that used 
to assess the child's ability to maintain static and dynamic postural 
stability on the unstable tilting platform; clinicians could assess 
neuromuscular control by quantifying the ability to maintain dynamic 
unilateral and bilateral posture stability on an unstable surface. During 
posture stability test, patient ability to control the platforms angle of tilt is 
quantified as a variance from center. (Gstöttner et al., 2009 and Arifin 
et, al. 2014). 
The outcome measures were: Over All Stability Index (OASI) that 
refers to the ability of child to maintain his balance in all directions, 
Anteroposterior Stability Index (APSI) that refers to the ability of child to 
maintain his balance from forward to backward direction and 
Mediolateral Stability Index (MLSI) that refers to the ability of child to 
maintain his balance from side to side directions. 
 
 
 
 
 
 
 
 
 
 

Flow chart 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig 1, flow chart 
Assessed for 
eligibility (n= 70)
 
Randomized 
(n=60)
 
Allocation
 
Allocated to intervention (n=30)  
 Received allocated intervention (n=30)  
 Did not receive allocated intervention (give 
reasons) (n= 0) 
Allocated to intervention (n=30)  
 Received allocated intervention (n= 30) 
 Did not receive allocated intervention 
(give reasons) (n=0) 
Excluded (n=10)  
 Not meeting inclusion criteria 
(n=6)  
Refused to participate (n=4)  
Analysis
 
Analysis
 
Analyzed (n=22)
 
 Excluded from analysis 
(n=0)
 
Analyzed (n=25)
 
 Excluded from analysis 
(n= 0)
 
Lost to follow-up (n=3)
 
Discontinued to intervention (n=2)
 
Lost to follow-up (n=5)
Discontinued to intervention (n=3)
 

 
Methods of Treatment 
           Group (a) control group received traditional physical therapy 
program. And group (b) study group received the same traditional 
physical therapy program in addition to mirror therapy three times / weak 
for three consecutive months. The children were instructed to sitting on 
chair and a mirror is placed in midsagittal plane of the child, with the 
normal limb in front of mirror and the affected limb is blocked so the 
patient see  only the reflected movement of the sound limb (non affected). 
Statistical analysis  
           For analysis of data in the present study, Using SPSS version 
21inresults analysis. Descriptive statistics was used to identify the mean 
and standard deviation for each variable. Paired t-test was used to test pre 
and post changes. 
References: 
1) Miller F. and Bachrach S. (2017): Cerebral Palsy: A complete guide 
for cargiving. 3rd edition, Part one: What is cerebral palsy? Publisher: 
John Hopking University Press, Baltimore; 3-28. 
2) Kenis-Coskun O., Giray E., Eren B., Ozkok O. and Karadag-
Saygi E. (2016): Evaluation of postural stability in children with 
hemiplegic cerebral palsy. J Phys Ther Sci; 28(5):1398-1402. 
3) El-Shamy S.M. and Abd El-Kafy E.M. (2014): Effect of balance 
training on postural balance control and risk of fall in children with 
diplegic cerebral palsy. Disabil Rehabil; 36: 1176–83. 
4) Gstöttner M., Neher A., Scholtz A., Millonig M., Lembert S. and 
Raschner C. (2009): Balance ability and muscle response of the 

preferred and non-preferred leg in soccer players. Motor Control; 13: 
218-31. 
5) Robert J., Steven E., Peter L., and Beth T. Probability of walking, 
wheeled mobility, and assisted mobility in children and adolescents 
with cerebral palsy. J. Dev. Med. Dev. 2010. 52 (1): 66–71.  
6) Chen L., Chen Y., Liaw Y., Chung Y., Wang J. and Hong H. 
(2013): Efficacy of home-based virtual cycling training on bone 
mineral density in ambulatory children with cerebral palsy. 
Osteoporosis Int; 24:1399–406. 
7) Altschuler EL, Hu J. (2008). Mirror therapy in a patient with a 
fractured wrist and no active wrist extension. Scand J Plast Reconstr 
Surg Hand Surg 42:110–111.  
8) Zeng W, Guo Y, Wu G, Liu X, Fang Q. (2018). Mirror therapy for 
motor function of the upper extremity in patients with stroke: a meta-
analysis. J Rehabil Med 50:8–15. 
9) Garry MI, Loftus A, Summers JJ. (2005). Mirror, mirror on the 
wall: viewing a mirror reflection of unilateral hand movements 
facilitates ipsilateral M1 excitability. Exp Brain Res 163:118–122.  
10) McInnes K, Friesen C, Boe S. Specific brain lesions impair 
explicit motor imagery ability: A systematic review of the evidence. 
Arch Phys Med Rehabil. 2016; 97(3):478–89.e1.  
11) Funase K, Tabira T, Higashi T, Liang N, Kasai T. Increased 
corticospinal excitability during direct observation of self-movement 
and indirect observation with a mirror box. Neurosci Lett. 2007; 
419:108–112.  
12) Cattaneo L, Rizzolatti G. The mirror neuron system. Arch 
Neurol. 2009; 66:557–560.  
13) Summers JJ, Kagerer FA, Garry MI, Hiraga CY, Loftus A, 
Cauraugh JH. Bilateral and unilateral movement training on upper 

limb function in chronic stroke patients: a TMS study. J Neurol Sci. 
2007; 252:76–82.  
14) SutbeyazS., Yavuzer G., SezerN., and Koseoglu B.F. “Mirror 
therapy enhances lower-extremity motor recovery and motor 
functioning after stroke: a randomized controlled trial,” Archives of 
Physical Medicine and Rehabilitation, vol. 88. No. 5, 2007, pp. 555 –
559. 
15) Saghaei M. Random allocation software for parallel group 
randomized trials. BMC Med Res Methodology. 2004; 4:26. [PMC 
free article] [PubMed] [Google Scholar