Action Observation Versus Mirror Therapy in Children With Spastic Hemiplegic Cerebral Palsy

Hemiplegia is one of the most common movement disorders among children. It occurs in approximately 2.11 out of every 1000 live births. In hemiplegia, one side of the body is affected and the upper limb is usually more affected than the lower limb. Children with hemiplegic CP typically present with impaired selective motor control in the wrist, hand, and fingers. Common deformities include elbow and wrist flexion, thumb-in-palm deformity, and forearm pronation, which reduce the ability to reach, grasp, release, and manipulate objects. Many children compensate by relying on their non-affected hand, leading to developmental disregard of the weaker arm. Impaired upper limb (UL) function affects independence, participation, and quality of life and require effective rehabilitation. Innovative rehabilitation methods that harness neuroplasticity, such as Mirror Therapy (MT) and Action Observation Therapy (AOT), have been increasingly investigated. Both approaches are based on the activation of the mirror neuron system, which plays a key role in motor learning and motor recovery. Mirror Therapy, which is based on visual stimulation from the movements of unaffected limbs, has shown promising results for sensory and upper extremity motor performance of children with hemiplegic CP. Similarly, AOT, which involves observation of purposeful actions with the intention to imitate and then performing those actions, had a significant improvement on grip power, hand function, activities, and participation in activity of daily living in hemiplegic CP children. However, despite the evidence supporting both interventions individually, there is limited research directly comparing their relative effectiveness. Thus, a comparison of MT and AOT is important for a number of reasons. First, it could help clinicians prioritize therapy choices by clarifying whether one intervention results in better improvements in motor outcomes. Second, it will help develop a more sophisticated understanding of how to best utilize various mirror neuron system engagement modalities for pediatric neuro-rehabilitation. Findings may also help create accessible, affordable, and interesting treatment plans that can be incorporated into home-based rehabilitation programs and clinical settings, ultimately enhancing the lives of kids with cerebral palsy and their families.

• Mirror Therapy (Behavioral): Participants will receive 45-minute mirror therapy sessions in addition to the traditional physical therapy program, three sessions per week for 12 consecutive weeks. During mirror therapy, the child will be seated with a mirror positioned in the midsagittal plane to reflect movements of the unaffected upper limb while concealing the affected upper limb, creating the visual illusion of normal movement in the affected limb. Children will observe the reflected movements while simultaneously attempting to perform the same functional tasks with the affected upper limb. The intervention includes task-oriented upper extremity activities such as object transfer, grasp and release, coin placement, ball gripping, card turning, circle drawing, block building, and water pouring.
• Action Observation Therapy (Behavioral): Participants will receive 45-minute action observation therapy sessions in addition to the traditional physical therapy program, three sessions per week for 12 consecutive weeks. During each session, children will observe videos demonstrating goal-directed upper extremity activities matched to their functional level, followed by performance of the same activities using the affected upper limb under therapist supervision. The intervention includes task-oriented activities such as block transfer, line drawing, card turning, coin placement, cup stacking, ball squeezing, water pouring and drinking, and moving beverage cans. Video demonstrations are presented from multiple viewing angles to facilitate motor learning and action observation.

Primary outcomes

• gross manual dexterity [After 12 Weeks]: Hand dexterity will be assessed using the Box and Block Test by recording the number of blocks transferred from one compartment to the other within 60 seconds.

Secondary outcomes

• Spontaneous Functional Analysis (SFA) of the Shriners Hospital Upper Extremity Evaluation (SHUEE) [After 12 weeks]: The SFA evaluates the child's spontaneous use of the affected upper limb while performing standardized functional tasks, with higher scores indicating better spontaneous functional use.
• Grip strength assessed using a hand dynamometer [After 12 weeks]: Grip strength of the affected hand will be measured using a calibrated hand dynamometer. The maximum voluntary grip strength will be recorded in kilograms (kg), with higher values indicating greater grip strength.

Sex: All, ages: 5 Years to 10 Years

Inclusion Criteria:

* 1- Children diagnosed with spastic hemiplegic CP. 2- Their ages between 5-10 years. 3- Lack of use of the affected upper limb. 4- They will be at level II-III of the Manual Ability Classification System (MACS) 5- The will be at level I-II in the Gross Motor Function Classification System (GMFCS) 6- They will be graded 1 to 1+ in the affected U.L. on Modified Ashworth's Scale 7- The children should be capable of understanding and following instructions.

Exclusion Criteria:

1. The children will be excluded if they have one of the following:
2. Children with fixed contracture in the affected U.L.
3. Injection of botulinum toxin into the upper limb muscles during the previous 6 months.
4. Visual or Auditory disorders.
5. Upper limb surgery in the last one year.
6. Epilepsy.