RESEARCH ARTICLE

A Single Session of Mirror-based Tactile and Motor

Training Improves Tactile Dysfunction in Children with
Unilateral Cerebral Palsy: A Replicated Randomized
Controlled Case Series
Megan L. Auld1,2*, Leanne M. Johnston1,2, Remo N. Russo3,4 & G. Lorimer Moseley5
1
Cerebral Palsy League, Brisbane, Australia
2
School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
3
Paediatric Rehabilitation Department, Women’s and Children’s Hospital Campus, Adelaide, Australia
4
The Flinders University School of Medicine, Bedford Park, Australia
5
Sansom Institute for Health Research, University of South Australia, Adelaide, Australia

Abstract
Introduction. This replicated randomized controlled crossover case series investigated the effect of mirror-based
tactile and motor training on tactile registration and perception in children with unilateral cerebral palsy (UCP).
Methods. Six children with UCP (6–18 years; median 10 years, five male, three-left hemiplegia, four-manual ability
classification system (MACS) I, one MACS II and one MACS III) participated. They attended two 90-minute ses-
sions — one of mirror-based training and one of standard practice, bimanual therapy — in alternated order. Tactile
registration (Semmes Weinstein Monofilaments) and perception (double simultaneous or single-point localization)
were assessed before and after each session. Change was estimated using reliable change index (RCI). Results. Tac-
tile perception improved in four participants (RCI > 1.75), with mirror-based training, but was unchanged with bi-
manual therapy (RCI < 1.0 for all participants). Neither intervention affected tactile registration. Discussion.
Mirror-based training demonstrates potential to improve tactile perception in children with UCP. Copyright ©
2016 John Wiley & Sons, Ltd.

Received 20 January 2016; Revised 10 May 2016; Accepted 4 June 2016

Keywords
cerebral palsy; mirror therapy; tactile; upper limb

*Correspondence
Megan Auld, PhD, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD 4072, Australia.
E-mail: mauld@uq.edu.au

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1674

Introduction unilateral cerebral palsy (UCP) has focused on reduc-

Cerebral palsy is the most common physical disability
in childhood, affecting one in 500 children (Surveil-
lance of Cerebral Palsy in Europe (SCPE), 2002;
Australian Cerebral Palsy Register (ACPR), 2009). His-
torically, upper-limb management in children with
ing motor impairments and improving movement
quality. Recent studies demonstrate that tactile (touch)
deficits are prevalent in over 70% of children with
UCP, and that these deficits have implications for
motor performance (Auld et al., 2012a). In other

Physiother. Res. Int. (2016) © 2016 John Wiley & Sons, Ltd.
Mirror-based Training in Cerebral Palsy
paediatric populations, tactile deficits are associated
with disabilities in reading, learning and behaviour
(Stine et al., 1975; Summerfield and Michie, 1993;
Nyden et al., 2004). Improving tactile function should
promote motor performance and the ability to explore
and interpret the environment. Therefore, tactile dys-
function is considered a viable therapeutic target for
children with UCP.
A recent systematic review established that there are
currently no effective treatments for tactile dysfunction
in children with UCP (Auld et al., 2014). Of treatments
that are successful in adults, most would be unsuitable
for use in children because they are invasive (electrical
stimulation), potentially unsafe (ice therapy) or require
bimanual function (topical anaesthesia, pneumatic
cuff). The only successful therapies used in adults that
would appear suitable for UCP are stimulus-specific
training (Carey et al., 2011) and mirror-based tactile
(Moseley and Wiech, 2009) and movement (Dohle
et al., 2009) training. These approaches integrate multi-
sensory methods (i.e. vision) to facilitate tactile func-
tion. However, stimulus-specific training is a
multimodal intervention undertaken over multiple ses-
sions, making it difficult to untangle which strategies
contribute to the effect. Stimulus- specific training also
requires extended periods of attention and draws on
pre-injury sensory experience, both of which would
be problematic for children with UCP.
Incorporating vision into training appears impor-
tant, but is not part of many treatments for tactile dys-
function, which occlude vision to interrogate touch.
There is a growing body of evidence that non-
informative visual input can actually enhance tactile
function — the so-called visual enhancement of touch
effect (Kennett et al., 2001a, 2001b; Spence et al., 2004).
Mirror-based tactile training is one easy and inexpen-
sive method to exploit the visual enhancement of touch
effect, and indeed, it is more effective for improving
tactile function than identical stimulation without vi-
sual input, in people with pathological pain (Moseley
and Wiech, 2009).
We devised a mirror-based tactile and motor train-
ing protocol for use in children with UCP and
established its feasibility in a clinical setting. Here we
describe the initial trial in which we undertook a repli-
cated randomised controlled crossover case series de-
sign. We hypothesized that mirror-based tactile and
motor training would improve tactile perception more
than standard practice in children with UCP.
M. Auld et al.
Method
Participants
Participants were children with UCP aged 6–18 years.
Participants were excluded if they could not under-
stand or follow test instructions due to intellectual or
behavioural difficulties, had received an upper-limb in-
tramuscular Botulinum toxin injection in the last
3 months and had previous upper-limb orthopaedic
surgery, uncorrected visual impairment or known im-
pairment in visual perception. A mail-out of project in-
formation went to parents of children who had UCP
and were on the database of a statewide service for peo-
ple with cerebral palsy. A follow-up telephone call was
made to all families 2-weeks later. Thus, we used a con-
venience sample, self-selected by response to the mail-
out. Allocation to the order of condition was made by
concealed randomisation, using sealed envelopes. Ethi-
cal approval was granted for both initial contact of
parents and the trial itself, by the Institutional Ethics
Committees.
Assessment
Handedness was established using the Edinburgh
Handedness Inventory (Oldfield, 1971), and typical
manual performance in daily activities for children
with UCP was classified using the Manual Ability Clas-
sification System (Eliasson et al., 2006). During the
physical assessment, the participant sat in a quiet,
well-lit room with their arms resting on a table at elbow
height. Over the upper forearms there was a frame
supporting a curtain to occlude the child’s view of their
hands. The less impaired hand was always assessed first.
Observations made during all assessments were re-
corded. Assessments were identical in structure and
completed by the same therapist each time. Assessment
took approximately 20 minutes.
Tactile assessments
Tactile assessments were selected according to a
recent systematic review (Auld et al., 2011) and were
undertaken according to methods of highest reliability
(Auld et al., 2012b). Full methods and reliability are
presented elsewhere (Auld et al., 2012b). At session
one, children received a 20-minute tactile assessment.
If it was established at this assessment that the child
did not have a tactile impairment (Semmes Weinstein
monofilament value < 2.83, single-point localization
Physiother. Res. Int. (2016) © 2016 John Wiley & Sons, Ltd.
M. Auld et al.
score >10; double-simultaneous score >21), the child
was excluded without receiving unnecessary treatment,
and their data were not analysed.
Tactile registration Tactile registration was measured
using the full 20-item Semmes–Weinstein monofila-
ment kit (Bell-Krotoski, 1990).
Spatial tactile perception Single-point localization was
assessed using the largest of the monofilaments (from
the Semmes–Weinstein Monofilaments) according to
Auld et al. (2012b). Double simultaneous was assessed
using two identical tactile stimulators according to
Auld et al. (2012b).
The beneficial effect of multisensory training should
be most obvious in measures of perception rather than
registration (Gallace and Spence, 2008). As such, a hi-
erarchy of tactile perception was used, such that the
primary outcome for each participant was the measure
for which a reliable score could be determined, in the
following order: double simultaneous, single-point lo-
calization. That is, double simultaneous was used un-
less a reliable score could not be obtained, in which
case single-point localization was used. To minimize
the likelihood of false-positive findings within partici-
pants, only one outcome was analysed. Secondary
outcome was tactile registration. Assessment was
undertaken before and after each session.
Intervention
There were two interventions: mirror-based tactile and
motor training, herein called mirror training, and stan-
dard practice bimanual motor-learning approach,
herein called bimanual training.
The active treatment: mirror training
Children sat in a quiet, well-lit room. The impaired
arm was placed inside a commercially available mirror
box (noigroup.com, Adelaide, Australia), with the el-
bow and wrist extended and forearm supinated. The
unimpaired limb also rested in the extended, supinated
position, aligned so that the participant saw the mirror
image of the unimpaired limb as though it was the im-
paired limb. There were two components to mirror
training.
• Mirror-based tactile training: The protocol was sim-
ilar to that reported by Moseley and Wiech (2009).
Participants received tactile stimuli (SWM filament,
one larger than threshold; 1.5-seconds duration;
Physiother. Res. Int. (2016) © 2016 John Wiley & Sons, Ltd.
Mirror-based Training in Cerebral Palsy
20-seconds inter-stimulus interval) on their im-
paired hand inside the mirror box, randomly given
to one of five locations. During stimulation, partici-
pants looked in the direction of their impaired hand
but in doing so saw the image of their unimpaired
hand in the mirror. After each stimulus, participants
responded by pointing to the location on a picture
of a hand or verbally indicating the finger that was
touched. There were 24 stimuli in a block, which
took 8 minutes. There were three blocks, separated
by a 3-minute rest. To maintain the child’s attention
(i.e. younger children), and motivation, a game was
played during the test session with the child
progressing a game piece following each response.
Some example games were the following: lego as-
sembly (every correct answer achieves another piece
with the Lego item being constructed at the end of
the session) and making puzzles (every correct an-
swer the child added a puzzle piece with the aim that
they could complete the puzzle at the end of the ses-
sion). So that the child did not need to move, the ex-
aminer moved the piece of the game within the
child’s visual display, before the child turned their
attention back to the mirror image for the next
stimulus.
• Mirror-based movement training: In the same posi-
tion as for tactile training, participants copied
upper-limb movement positions on verbal command
as provided by the investigator. The methodology has
been modified from Dohle et al., 2009 to be suitable
for children. Hand positions copied were age-
appropriate and are those specified in the upper-
limb motor planning examination of the Neurosen-
sory Motor Developmental Assessment (Burns,
2014). No tactile stimuli were provided during this
condition. Children were asked to respond to the in-
structions of the next position as quickly as possible.
This section lasted up to 30 minutes per session (in
two 15-minute blocks), moving through the stan-
dardized movement positions within the physical
and motor planning ability of the child.
Tactile and motor components were alternated
throughout the treatment session (Table 1).
The control treatment: bimanual therapy
A comparative standard therapy protocol targeting
the development of specific hand skills and motor
Mirror-based Training in Cerebral Palsy
planning abilities using repetitive practice of bimanual
activities was carried out. To ensure that tasks were
age-appropriate, directed play tasks similar to those
included in the Assisting Hand Assessment
(Krumlinde-Sundholm et al., 2007) were carried out
for the treatment time (approximately 50 minutes), in
a manner similar to that described in the comparative
treatment in Hoare et al. (2013). Bimanual therapy
is currently considered standard care for the upper
limb in children with UCP (Sakzewski, 2012; Hoare
et al., 2013).
Procedure
Participants attended two 1.5-hour treatment sessions
at a clinic venue or at the child’s home, carried out
by an experienced physiotherapist. At both sessions,
children were assessed, treated and then assessed again.
In one treatment session, the child received mirror-
based training, and in the other, the child received
control bimanual therapy, with the order of these
therapy types randomized between children. Appoint-
ments were scheduled so that the duration between
sessions varied across participants between 2 and
7 days, so as to comply with recommended best prac-
tice to control for time in replicated case series designs
(Ferron and Onghena, 1996; Onghena and Edgington,
2005).
Data analysis
Reliable change index (RCI) (Jacobsen and Truax,
1991) was calculated for all participants for both
interventions. RCI provides an indication of how sure
we can be that a change in status was achieved, when
the inherent reliability of the measurement tool
and the minimum clinically detectable change are
considered. RCI is recommended when individual
responses are analysed, or for studies that involve
small samples, such as in a replicated case series
such as this. RCI is expressed as standard deviation
unit, such that an RCI of greater than 1.7 means
Table 1. Mirror-based training session schedule
Activity Pre-assessment Sensory MT Motor MT
Time → (minutes) 20 8 15
Total time = 94 minutes
MT, mirror-based training.
M. Auld et al.
that we can be 90% confident, and an RCI of 1.96
means that we can be 95% confident, that there really
was a clinically meaningful change in status for that
individual.
Results
Ten children agreed to participate. Three children were
excluded. One child dropped out prior to the second
appointment. Thus, six children with UCP between
the ages of 6–18 years (median 10 years, five male,
three-left hemiplegia, four MACS I, one MACS II and
one MACS III) (Table 2), participated. None of the
participants received any other treatments that might
have influenced tactile function during the course of
the trial.
Participant one (P1): A 7-year-old male with right-
sided UCP; MACS I. Although P1 had a diagnosis of
right UCP throughout the assessment and treatment
sessions, he regularly used two hands together and
would occasionally use his right hand to perform the
dominant role in a task (e.g. hold a cup). At the time
of assessment, P1 had also commenced a trial of Ritalin
to aid concentration at school. On initial examination,
P1 was unable to reliably report for double simulta-
neous and had a significant impairment in single-
point localization and a mild impairment in tactile
registration. P1 required several breaks during mirror
therapy to maintain attention.
P2: A 10-year-old female with right UCP, MACS III.
P2 was born at 40 + 5 weeks gestation (5 days overdue).
P2 was diagnosed with right-sided UCP at 6 months of
age. At 10 months of age, P2 began to experience
seizures, which continued until 5 years of age when
P2 had a hemispherectomy to alleviate these seizures.
An MRI at 11 months and the surgical intervention at
5 years confirmed a diagnosis of left-hemispheric
polymicrogyria. Although all assessment items were
attempted, P2’s reporting was most consistent and
reliable on single-point localization, in which under-
standing of the task could be easily confirmed with
her achieving perfect perception on her unimpaired
Sensory MT Motor MT Sensory MT Post-assessment
8 15 8 20
Physiother. Res. Int. (2016) © 2016 John Wiley & Sons, Ltd.
M. Auld et al. Mirror-based Training in Cerebral Palsy

Table 2. Participant demographics diagnosis of pre-eclampsia. P5 had not received regular

Participant Age (years) Gender Side of CP
1 7.8 M Right
2 10.1 F Right
3 10.4 M Left
4 11.1 M Left
5 12.6 M Left
6 17.0 M Right
M, male; F, female; MACS, manual ability classification system.
hand and significant impairment on her impaired
hand. P2 required several breaks during mirror training
to maintain attention.
P3: A 10-year-old male with left-sided UCP, MACS
I. He was born prematurely at 32 weeks gestation and
has a twin brother. P3 was diagnosed with CP at 2 years
of age. Early in his life, he was receiving more regular
therapy, which reduced to approximately three to four
times per year in recent years for assistance with hand-
writing. P3 had almost typical results on initial tactile
assessment, with only marginal deficits in tactile regis-
tration, with the attainment of monofilament 5 (log
3.22 — one monofilament outside of typical registra-
tion). P3 required several breaks during mirror training
to maintain attention.
P4: An 11-year-old male with left-sided UCP, MACS
II. He had not had upper-limb therapy since he was
8 years old, which also coincided with his most recent
upper-limb Botulinum toxin injection. P4 was born at
38 weeks gestation, with no known cause for his cerebral
palsy. On initial examination, P4 demonstrated a signif-
icant impairment in both single-point localization and
double simultaneous. P4 was able to concentrate with-
out any breaks during the mirror training intervention.
P5: A 12-year-old male with left-sided UCP, MACS I.
He was born at 27 weeks gestation following maternal
upper-limb therapy of recent years. On initial examina-
MACS
tion, P5 had a mild impairment in double-simultaneous
1 perception. P5 was able to concentrate without any
3
breaks during the mirror training intervention.
1
2 P6: A 17-year-old male with right-sided UCP; MACS
1 I. P6 was born at 41 weeks gestation and suffered a grade
1 IV brain haemorrhage at 3 days of age. He had only
minimal upper-limb therapy in the early years of his
life, followed by exercises integrated into everyday life.
On initial examination, his results in tactile registration
and single-point localization were at the limits of per-
formance. P6 was able to concentrate without any
breaks during the mirror training intervention.
Reliable change index
For the session of bimanual training, no participant
showed a reliable change in tactile perception
(RCI < 1.0) (Table 3). Four participants had an RCI of
greater than 1.7 for the mirror training, which means
we can be at least 90% confident that an improvement
in tactile perception occurred (Table 4). There were
no changes in tactile registration for either condition.
Discussion
This pilot study examined the effect of mirror-based
training on tactile registration and perception in chil-
dren with UCP (Figure 1). Of the six participants, four
showed an improvement in tactile perception that is
likely to be clinically significant (Table 4) and takes into
consideration the reliability of the assessment approach
(Auld et al., 2012b), and in which we can be at least
90% confident. Two participants demonstrated no
change with mirror-based training. One such partici-
pant was close to the ceiling of the tool, which

Table 3. Tactile scores pre-bimanual and post-bimanual training (control) on the impaired hand

Registration Single-point localization Double simultaneous

Child Pre Post Pre Post Pre Post Reliable change index

1 3 3 11 10 — — 0.56
2 — — 0 0 — — 0.00
3 4 5 11 11 21 24 0.97
4 5 5 1 2 10 10 0.00
5 3 3 12 12 19 17 0.50
6 4 5 12 10 17 17 0.00

Scores within typical range are in italics.

Physiother. Res. Int. (2016) © 2016 John Wiley & Sons, Ltd.
Mirror-based Training in Cerebral Palsy
probably means there was little room for improvement
anyway. Bimanual therapy, the control condition, did
not improve tactile perception in any participant.
Given that it is known that over 77% of children with
UCP have an impairment in tactile function (Auld
et al., 2012a) and that there are currently no known
treatments for managing this impairment (Auld
et al., 2014), these results raise the possibility of better
outcomes for children with UCP.
Performance in single-point localization and double
simultaneous has an established relationship with
upper-limb motor function. Indeed, over 30% of the
variance in unimanual capacity can be explained by
outcomes in single-point localization, and over 30%
Figure 1. Improvement in spatial tactile perception following mirror-based training and bimanual training
M. Auld et al.
of the variance in bimanual performance can be
explained by outcomes in double simultaneous (Auld
et al., 2012c). One might predict that improved tactile
perception could facilitate improved motor function,
although clearly this needs to be empirically evaluated.
No significant changes in tactile perception were
noted following the one-control session of bimanual
therapy, concurring with the previous systematic
review indicating that treatments aimed at motor
impairments do not also improve tactile impairments
(Auld et al., 2014). A recent study indicates that
90 hours of bimanual therapy delivered over 3 weeks
leads to improvements in tactile perception, as mea-
sured by the grating orientation task (Kuo et al.,
Physiother. Res. Int. (2016) © 2016 John Wiley & Sons, Ltd.
M. Auld et al.
Table 4. Tactile scores pre-mirror and post-mirror training on the impaired hand
Registration Single-point localization
Child Pre Post Pre
1 5 5 7
2 — — 1
3 5 4 12
4 5 5 1
5 3 2 12
6 4 4 11
Scores within typical range are in bold.
*Significant improvement pre-intervention and post-intervention (change greater than SDC and/or indicating typical performance post-
intervention).
2016). This same treatment only led to a trend in
improvement in stereognosis and no improvements
in either spatial tactile perception as measured by
two-point discrimination or tactile registration as mea-
sured by the Semmes Weinstein Monofilaments (Kuo
et al., 2016). Notably, however, the dose in the Kuo
et al. paper was extremely high in comparison with
the current study (90 hours compared with less than
1 hour). That clinically important change was observed
after a single session of mirror training, strongly sug-
gests that it may be a potent treatment approach. There
are data from adults with pathological pain and tactile
dysfunction that show similar improvements with
one-training session (Moseley and Wiech, 2009), and
in that group, repeated training has been shown to have
a greater effect that is maintained for at least 3 months
post-training (Moseley et al., 2008).
For mirror-based training to be successful, it is
essential that the child attends to the visual display of
their unimpaired hand in the mirror for both the
sensory and motor exercises (Kennett et al., 2001b;
Dohle et al., 2009). In the current study, Participants
4, 5 and 6 showed the largest improvement in double-
simultaneous perception. They were also the eldest of
the sample and able to complete the tasks without the
interruption of games or breaks. Although attempts
were made to maintain engagement in the younger chil-
dren, it seems reasonable that the ability to attend was a
limiting factor in improvement. One way to mitigate
this may be to undertake repeated sessions that are
shorter, or to incorporate mirror training into a regular
aspect of life. Another factor that probably affects re-
sponse to mirror training is the severity of initial tactile
impairment — those with the poorest performance
Physiother. Res. Int. (2016) © 2016 John Wiley & Sons, Ltd.
Mirror-based Training in Cerebral Palsy
Reliable change
Double simultaneous index
Post Pre Post
12* — — 2.78
5* — — 2.22
12 24 23 0.25
2 9 16* 1.76
12 17 24* 1.76
11 16 20* 1.01
initially showed the greatest improvement. Critically,
however, those same participants did not respond to bi-
manual therapy, which rules out the possibility that the
effect of mirror training was simply a reflection of tactile
impairment severity.
That non-informative vision augments tactile
evoked cortical responses in healthy volunteers
(Taylor-Clarke et al., 2002) –— responses that are con-
sistent with primary sensory cortex activation — raised
the possibility that we would see improved
performance on tests of registration. That we did not
is consistent with a recent systematic review of behav-
ioural evidence of tactile improvement with non-
informative vision (Eades, 2015), which shows clear
benefits on tests of tactile perception rather than
registration. This finding might be predicted on the
grounds that multisensory processing is important for
awareness and occurs after the primary touch signal
has been processed in the primary sensory cortex, yet
before a percept is generated (Gallace and Spence,
2008). Further research incorporating evaluation of
the effect of mirror-based training on cortically evoked
responses to touch would cast light on this issue.
Hand position during assessment and treatment may
also be critical to the success of mirror-based training.
This was particularly relevant for Participant 5, who
achieved significant gains on double simultaneous
(identifying the digits that were stimulated on both
hands) but not on single-point localization (identify-
ing the exact location of touch on the impaired
hand). Participant 5 held an atypical posture with
his impaired hand throughout treatment and assess-
ment, so, although the therapy may have assisted his
ability to distinguish between fingers, he remained
Mirror-based Training in Cerebral Palsy
unable to distinguish specific locations on his
impaired hand.
It is not possible to determine from the current
study whether the sensory or motor component of
training had more effect on tactile perception, or if
both were equally useful for improving function. In a
previous pilot study in children with UCP, a version
of motor mirror training was shown to improve
upper-limb strength and function as measured by the
Shriners Hospital Upper Extremity Evaluation (Gygax
et al., 2011). However, our objective was to determine
if a broad visual-enhanced tactile and motor pro-
gramme was beneficial, rather than attempt to untangle
the contributions of different components. If the cur-
rent results are replicated in a randomized controlled
trial, such a study would clearly be warranted.
Interpretation of the current results should consider
several limitations. A small sample increases the likeli-
hood of erroneous results. However, we employed the
gold standard design for replicated case series
approach, which controls for time and order of condi-
tions (Ferron and Onghena, 1996; Onghena and
Edgington, 2005). We also implemented the RCI
(Jacobsen and Truax, 1991), which provides a conser-
vative estimate of how likely it is, in light of the
variability of the score in the studied cohort, the
reliability of the assessments used and the clinically
important effect, that a true change in status occurred.
That we can be over 90% confident that four out of six
participants showed a clinically meaningful improve-
ment in tactile function is very encouraging indeed.
That our sample was heterogeneous adds to the weight
of our finding but also reduces the likelihood of finding
effects in either condition. We did not obtain neuroim-
aging data for the studied cohort. This is relevant
because the location, timing and extent of lesion may
be critical for patient selection (Staudt, 2010) and
may also influence response to mirror-based training.
Conclusion
This study demonstrated for the first time the potential
for a 1-hour mirror-based tactile and motor training
session to improve tactile perception in children with
UCP. That four out of six participants had a clinically
important improvement in tactile impairment is
promising but needs to be verified in a randomized
controlled trial. Such a study might also permit inves-
tigation of dose response and evaluate the influence of
M. Auld et al.
age, attention and lesion characteristics to aid optimal
patient selection. Subsequent studies should also inves-
tigate the specific treatment benefit of the separate
tactile and motor components of the mirror-based
training.
Implications for physiotherapy
practice
• A single session of mirror-based training shows
potential to improve tactile perception in children
with UCP.
Acknowledgements
The authors would like to thank the Cerebral Palsy
League for assistance with recruitment and the children
and families who participated in the study. G. L. M. was
supported by a Research Fellowship from the National
Health & Medical Research Council of Australia (ID
1061279).
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