Research Article|Articles in Press

Is mirror therapy combined with a routine physiotherapy protocol effective for children with obstetrical upper brachial plexus palsy?

Published:January 24, 2023DOI:


      • Mirror therapy could be a complimentary conservative intervention in the treatment of the upper brachial plexus palsy.
      • Mirror therapy did not reveal any additional benefits when combined with a conservative treatment protocol.
      • Mirror therapy is effective for improving hand grip strength in children with upper brachial plexus palsy.


      Study design

      Randomized controlled study.


      Mirror therapy is a rehabilitation strategy based on the repeated use of the mirror illusion and also one of the treatment choice of brachial plexus injuries.


      We aimed to determine the effects of mirror therapy combined with a routine rehabilitation program on upper limb motor function in children with obstetric brachial plexus injury.


      Twenty children with obstetric brachial palsy were included in this study. They were randomly allocated to either control (n = 10) or mirror therapy (n = 10) group. The following clinical tools were used to assess the upper extremity function: Active Movement Scale (AMS), Modified Mallet Scale (MMS), Hand Grip Strength (HGS) Test, Finger Grip Strength (FGSM) Test, Box and Block Test (BBT), Nine Hole Peg Test (9-HPT), and goniometric measurement. Both groups received the same routine physiotherapy program for 8 weeks. The study group underwent mirror therapy in addition to the rehabilitation program.


      The mean age of the study population was 11.35 ± 4.12 years. There was no change in the goniometric values, AMS and MMS scores after the treatment in both groups (p > 0.05), except for the improvement of the wrist extension in the study group (p < 0.05). There was an increase in both HGS and FGS scores in the study group. Only FGS scores improved in the control group after the intervention (p < 0.05). 9-HPT and BBT scores improved in both groups (p < 0.05). All other parameters tested were comparable between the two groups after the treatment.


      The results of this study did not show any additional benefits of mirror therapy combined with a rehabilitation protocol compared to routine physiotherapy treatment, but was not adequately powered to do so.


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        • Galbiatti JA
        • Cardoso FL
        • Galbiatti MGP.
        Paralisia obstétrica: De quem é a culpa? Uma revisão sistemática de literatura.
        Rev Bras Ortop. 2020; 55: 139-146
        • O'Berry P
        • Brown M
        • Phillips L
        • Evans SH
        Obstetrical brachial plexus palsy.
        Curr Probl Pediatr Adolesc Health Care. 2017; 47: 151-155
        • Bahm J
        • Ocampo-Pavez C
        • Disselhorst-Klug C
        • Sellhaus B
        • Weis J.
        Obstetric brachial plexus palsy: treatment strategy, long-term results, and prognosis.
        Dtsch Ärztebl. 2009; 106: 83
        • Gbozee L
        • Abubakar MK
        • Hennings SS.
        Obstetric brachial palsy: challenges of management in a developing country.
        Arch Int Surg. 2019; 9: 57-60
        • Yeves-Lite A
        • Zuil-Escobar JC
        • Martínez-Cepa C
        • Romay-Barrero H
        • Ferri-Morales A
        • Palomo-Carrión R.
        Conventional and virtual reality mirror therapies in upper obstetric brachial palsy: a randomized pilot study.
        J Clin Med. 2020; 9: 3021
        • Barbin J
        • Seetha V
        • Casillas JM
        • Paysant J
        • Perennou D.
        The effects of mirror therapy on pain and motor control of phantom limb in amputees: a systematic review.
        Ann Phys Rehabil Med. 2016; 59: 270-275
        • Sturma A
        • Hruby L
        • Vujaklija I
        • Østlie K
        • Farina D.
        Treatment strategies for phantom limb pain.
        Bionic Limb Reconstruction. Cham. Springer Nature, Switzerland AG2021: 113-124
        • Medica EM.
        Give me a kiss! An integrative rehabilitative training program with motor imagery and mirror therapy for recovery of facial palsy.
        Eur J Phys Rehabil Med. 2019; 56: 58-67
        • Cantero-Téllez R
        • Naughton N
        • Algar L
        • Valdes K.
        Outcome measurement of hand function following mirror therapy for stroke rehabilitation: a systematic review.
        J Hand Ther. 2019; 32 (Apr-Jun): 277-291
        • Bakshi P
        • Chang WP
        • Fisher TF
        • Andreae B.
        Client buy-in: An essential consideration for graded motor imagery in hand therapy.
        J Hand Ther. 2021; 34 (Jul- Sep): 348-350
        • Korbus H
        • Schott N.
        Does mental practice or mirror therapy help prevent functional loss after distal radius fracture? A randomized controlled trial.
        J Hand Ther. 2022; 35 (Jan-Mar): 86-96
        • Thomas LH
        • French B
        • Coupe J
        • et al.
        Repetitive task training for improving functional ability after stroke: a major update of a Cochrane review.
        Stroke. 2017; 48: 102-103
        • Arya KN.
        Underlying neural mechanisms of mirror therapy: Implications for motor rehabilitation in stroke.
        Neurol India. 2016; 64: 38
        • Diers M
        • Christmann C
        • Koeppe C
        • Ruf M
        • Flor H.
        Mirrored, imagined and executed movements differentially activate sensorimotor cortex in amputees with and without phantom limb pain.
        Pain. 2010; 149: 296-304
        • Foell J
        • Bekrater-Bodmann R
        • Diers M
        • Flor H.
        Mirror therapy for phantom limb pain: brain changes and the role of body representation.
        Eur J Pain. 2014; 18: 729-739
        • Diers M
        • Kamping S
        • Kirsch P
        • Rance M
        • et al.
        Illusion-related brain activations: a new virtual reality mirror box system for use during functional magnetic resonance imaging.
        Brain Res. 2015; 1594: 173-182
        • Duymaz T.
        Use of mirror therapy to treat psychogenic tremors.
        Eur J Ther. 2018; 24: 118-120
        • Yilmaz V
        • Umay E
        • Tezel N
        • Gundogdu I.
        Timing of rehabilitation in children with obstetric upper trunk brachial plexus palsy.
        Child's Nerv Syst. 2018; 34: 1153-1160
        • Deconinck FJ
        • Smorenburg AR
        • Benham A
        • Ledebt A
        • Feltham MG
        • Savelsbergh GJ.
        Reflections on mirror therapy: a systematic review of the effect of mirror visual feedback on the brain.
        Neurorehabil Neural Repair. 2015; 29: 349-361
        • Ramachandran VS
        • Brang D.
        Sensations evoked in patients with amputation from watching an individual whose corresponding intact limb is being touched.
        Arch Neurol. 2009; 66: 1281-1284
        • Shenaq SM
        • Kim JY
        • Armenta AH
        • Nath RK
        • Cheng E
        • Jedrysiak A.
        The surgical treatment of obstetric brachial plexus palsy.
        Plast Reconstr Surg. 2004; 113: 54-67
        • Curtis C
        • Stephens D
        • Clarke HM
        • Andrews D.
        The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy.
        J Hand Surg. 2002; 27: 470-471
        • Nath RK
        • Somasundaram C.
        Extended long-term (5 years) outcomes of triangle tilt surgery in obstetric brachial plexus injury.
        Open J Orthop. 2013; 7: 94-98
        • Alvarez-Rodríguez M
        • López-Dolado E
        • Salas-Monedero M
        • Lozano-Berrio V
        • Ceruelo-Abajo S
        • Gil-Agudo A
        De los reyes-guzmán a. concurrent validity of a virtual version of box and block test for patients with neurological disorders.
        World J Neurosci. 2020; 10: 79-89
        • Jongbloed-Pereboom M
        • Nijhuis-van der Sanden MW
        • Steenbergen B.
        Norm scores of the box and block test for children ages 3–10 years.
        Am J Occup Ther. 2013; 67: 312-318
        • Smith YA
        • Hong E
        • Presson C
        Normative and validation studies of the Nine-hole Peg Test with children.
        Percept Mot Skills. 2000; 90: 823-843
        • Fess FE.
        Grip strength. Casanova JS clinical assessment recommendations, 2nd American Society of Hand Therapists.
        Grip Strength, Chicago,. 1992; : 41-45
        • Massy-Westropp NM
        • Gill TK
        • Taylor AW
        • Bohannon RW
        • Hill CL.
        Hand Grip Strength: age and gender stratified normative data in a population-based study.
        BMC Res. Notes. 2011; 4: 1-5
        • Faul F
        • Erdfelder E
        • Lang AG
        • G* Buchner A.
        Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Methods. 2007; 39: 175-191
        • Karas HE
        • Atıcı E
        • Aydın G
        • Demirsöz M.
        The effects of virtual reality on upper extremity in patients with obstetric brachial plexus injury.
        J Pediatric Neurol. 2022; 20: 28-36
        • Nelson MR
        • Armenta AH.
        Birth brachial plexus palsy update.
        Curr Phys Med Rehabil Rep. 2014; 2: 79-85
        • Frade F
        • Gómez-Salgado J
        • Jacobsohn L
        • Florindo-Silva F.
        Rehabilitation of neonatal brachial plexus palsy: integrative literature review.
        J Clin Med. 2019; 8: 980
        • Yun GJ
        • Chun MH
        • Park JY
        • Kim BR.
        The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients.
        Ann Rehabil Med. 2011; 35: 316-321
        • De Santana Chagas AC
        • Wanderley D
        • De Oliveira Ferro JK
        • et al.
        Physical therapeutic treatment for traumatic brachial plexusinjury in adults: A scoping review.
        PM&R. 2021; 14: 120-150
        • Yeldan I
        • Huseyinsinoglu BE
        • Akıncı B
        • Tarakci E
        • Baybas S
        • Ozdıncler AR.
        The effects of very early mirror therapy on functional improvement of the upper extremity in acute stroke patients.
        J Phys Ther Sci. 2015; 27: 3519-3524
        • Pérez-Cruzado D
        • Merchán-Baeza JA
        • González-Sánchez M
        • Cuesta-Vargas AI.
        Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors.
        Aust Occup Ther J. 2017; 64: 91-112
        • Bruchez R
        • Jequier Gygax M
        • Roches S
        • et al.
        Mirror therapy in children with hemiparesis: a randomized observer-blinded trial.
        Dev Med Child Neurol. 2016; 58: 970-978
        • El Shemy SA
        • Abd El-Maksoud GM.
        Mirror therapy vs cross education on wrist extension and hand grip strength in children with hemiparesis.
        Bulletin Faculty Physical Therapy. 2009; 14: 85-93
        • Altschuler EL
        • Hu J.
        Mirror therapy in a patient with a fractured wrist and no active wrist extension.
        Scand J Plast Reconstr Surg Hand Surg. 2008; 42: 110-111
        • Lee JS
        • Kim YH.
        Factors associated with limited hand motion after hand trauma.
        Medicine. 2019; 98: e14183
        • Karaslan C
        • Berkoz O
        • Tarakci E.
        The effect of mirror therapy after carpal tunnel syndrome surgery: a randomized controlled study.
        Hand Surg Rehabil. 2020; 39: 406-412
        • Bayon-Calatayud M
        • Benavente-Valdepeñas AM
        • Vazquez-Muñoz MDP.
        Mirror therapy for distal radial fractures: a pilot randomized controlled study.
        J Rehabil Med. 2016; 48: 829-832
        • Gandhi DB
        • Sterba A
        • Khatter H
        • Pandian JD.
        Mirror therapy in stroke rehabilitation: Current perspectives.
        Ther Clin Risk Manag. 2020; 16: 75
        • Lee MM
        • Cho HY
        • Song CH.
        The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients.
        Am J Phys Med Rehabil. 2012; 91: 689-700
        • Chiang VCL
        • Lo KH
        • Choi KS.
        Rehabilitation of activities of daily living in virtual environments with intuitive user interface and force feedback.
        Disabil Rehabil Assist Technol. 2017; 12: 672-680
        • Golomb MR
        • McDonald BC
        • Warden SJ
        • Yonkman J
        • Saykin AJ
        • Shirley B
        • Burdea GC.
        In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic cerebral palsy.
        Arch Phys Med Rehabil. 2010; 91: 1-8