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Introduction
Mirror therapy (MT) harnesses the brain’s capacity to generate a visual illusion to trick the brain into perceiving the execution of an action without experiencing distress. Alternatively, it can provide favorable visual feedback regarding the movement of a limb [1]. 
The idea of using a mirror as a therapeutic intervention was first proposed by Ramachandran et al. (1995) to relieve phantom pain in amputees [2]. Reports of the effectiveness of this method in improving phantom pain, along with the novelty and simplicity of this method, led researchers to expand their studies using this non-invasive approach, thus developing the theoretical foundations supporting mirror visual feedback (MVF) [3].Most of these studies have focused on identifying and recording the activity of different parts of the nervous system when using MVF [4]. The results of these studies can be considered in three categories. The first is those that study the mirror neuron system and variables that affect the activity of the mirror neurons system while MVF is presented [5-10]. The second category of studies has documented the activity of the cerebral hemispheres and ipsilateral motor pathways and the strengthening of connections between healthy and involved brain hemispheres through MT [11, 12, 13]. As a third category, the increased cognitive activity of the brain due to attention to the involved limb [11, 14] and prevention of the learned non-use phenomenon [15, 16] when creating MVF has been investigated in some studies.
In 2009, Shemy conducted the initial clinical trial on MT in children. The study evaluated the impact of two intervention programs that incorporated MT and cross-education alongside occupational therapy and physical therapy. The primary focus was to assess the improvement in hand function among children diagnosed with hemiplegic cerebral palsy (HCP). The findings of this study provided evidence to support the superior effectiveness of mirror exercises for children with HCP [17]. 
In 2013, Gyax conducted a study to assess the feasibility of MT in children with HCP. This cross-over clinical trial compared the effects of MT and regular exercise on the strength and function of the affected arm. The findings of this study provided evidence supporting the feasibility of MT in children with HCP [18].
In a systematic review conducted by Park in 2016, the study emphasizes that despite the abundance of MT studies, there is still a lack of sufficient research on the effect of MT specifically in children with HCP [19]. Meanwhile, Ezendam et al. (2009) conducted a systematic review and found no studies available specifically focusing on the effect of MT in children [20]. Though a systematic review examined the impacts of MT on children with HCP [19], systematic review studies evaluate and interpret the results of research to clarify the latest evidence on the effectiveness of various interventions in the field understudy [21]. However, this type of research does not identify knowledge gaps and methodological components in the field under study [22]. While scoping reviews are designed to provide a comprehensive overview of the existing knowledge base and offer insights for future research, practice and policy development [23]. 
However, the primary objective of this scoping review study is to identify the methodological components of research related to MT in children, using the population-intervention-comparison-outcome-type of question-type of study method [24] and the international classification of functioning, disability and health (ICF) levels of function as the selection criteria. In other words, the present review identifies knowledge gaps in pediatric MT research based on the type of health condition, intervention modifications and outcome measurement that finally led to the design of new questions and appropriate and applied research in this field. Therefore, this review categorizes and synthesizes the scientific literature on the usage of MT interventions in the previous years to potentially inform, guide and inspire future efforts in using MT interventions in the rehabilitation of pediatric conditions.
Key review questions are as follows:
What are the nature and scope of MT in pediatric rehabilitation intervention research? What research designs have been used in MT studies on children? What interventions were used as the independent variables in the field of pediatric MT research? What outcome measurements were examined in MT studies on children (based on ICF levels)? What conditions have been examined in MT? What age range of children participated in MT research? What were the sample sizes of participants in pediatric MT studies?

Materials and Methods
This review was conducted according to five steps of the methodological framework scoping review based on Arksey and O Malley [25], in addition to the complementary recommendations of Levac et al. [26]. The report of the method and results was arranged by preferred reporting items for systematic reviews and meta-analyses–scoping review [27]. 

Identifying the research question and operationalize definitions
This study investigates the following questions: 
How much research is on rehabilitation in children using MT? What research designs were used in these studies? What groups of participants were involved in reported studies? What types of interventions report conducting these studies? What kind of outcome measures are used for evaluating the effectiveness of MT interventions?
In this study, MT defines the method that the affected limb in a person with a complication is covered, and the reflection of the movement of a healthy limb in the mirror causes a visual illusion (perceptual misinterpretation of a real external visual stimulus) of the affected limb in the child.”

Identifying relevant studies
This study used PubMed, Science-Direct, ProQuest, and the Web of Science databases to collect data using systematic search strategies. Meanwhile, Google Scholar was scanned for additional resources. An example of a search strategy is provided in Table 1.


Our search keywords in the field of MT included the following items: “Mirror,” “mirror therapy,” “mirror visual feedback,” and “mirror training” in combination with “children.” The date limit was set from inception to January 2023. After identifying studies related to the field, the authors reviewed references of articles to ensure that the search was complete.

Inclusion-exclusion criteria
The inclusion criteria for articles in the study included the following items:
Original articles published in peer-reviewed journals and written in Persian and English languages; clinical trial and single-case designs; childhood age range of 0 to 18 years for the research participants; articles published between January 2005 to September 2021; studies involving MT intervention.
Meanwhile, grey literature articles and studies that involved children and adults simultaneously were excluded.
After completing the search process, the titles and the abstracts of articles were checked out and irrelevant studies were excluded. In the next step, the full text of the articles were scrutinized and relevant articles were selected. Finally, the remaining articles were included in the study.
All steps of the selection procedure were conducted separately by two authors (FM and HS) based on inclusion and exclusion criteria.

Charting the data
After studying the full text of articles, the information classification was extracted based on the components of the research design, namely study participants, design, intervention, and outcome measure.
Data charting was accomplished based on the components related to design, participants, intervention, and outcome measures based on the population, intervention, comparison, outcome – type of study design, and type of clinical questions method.
According to the study design, the articles were classified into three categories, including, randomized control clinical trials (RCT), case series and single-case designs. 
The sample size and characteristics of the participants (age and condition) were extracted and charted.
According to the independent variables for the MT program in the intervention group and comparison group (if any), we classified the studies into five categories:
a) MT: The MT group program includes only MT; b) MT versus modified mirror therapy (mMT): The intervention group underwent modified MT and the comparison group received conventional MT; c) MT versus other interventions: The intervention group performed MT exercises and the control group performed different exercises. Studies in this group of interventions, according to the exercises of the control group divided into two subgroups:
1) MT versus other interventions: Children in the control group performed a different intervention program than the MT group. 2) MT versus the same movement without a mirror: The exercise of the control groups performed the same as the MT group without using the mirror.
d) MT plus other interventions versus other interventions: The protocol of the intervention group included a combination of mirror exercises with other programs or training (integrated MT program) while the control group received other interventions (conventional occupational therapy). e) MT versus MT plus other interventions versus other interventions: The independent variable contains three levels including MT, MT in addition to other intervention programs and another treatment program (without MT).
The classification of outcome measures based on ICF levels can provide a clear picture of the studies related to MT in children. Therefore, we classified the outcome measure of the studies based on the level of functions based on ICF. Levels of functioning based on ICF include body functions (BF) and body structures (BS), activities, and participation, each with different components. One of the important questions in related research is what effect the interventions have on each level of the ICF [28, 29].

Collating, summarizing, and reporting results
All team members discussed the data extracted to analyze the data (involving a descriptive numeric overview and a thematic analysis), reporting results, and applying intentions to the results. The studies were summarized descriptively and assessed for similarities and dissimilarities.

Results
In the initial search, by using the keywords, 73 articles were identified from the databases. By excluding duplicates (n=8) and scanning titles, 29 papers and after screening the abstracts, 22 papers were selected. By reading the full texts, 20 eligible articles that satisfied the inclusion criteria were selected for the qualitative analysis (Figure 1). According to the method categorized in the charting data section, the information obtained from the studies is as follows.

Design
Among the articles that matched the inclusion criteria, the types of study design were as follows. In 18 studies, RCT design were used. Among these group projects, 16 studies were parallel-group, and two were crossover studies. In one study, the single-subject design was used, and in another study, the case series design was applied. Among these designs, three studies [30-32] had measurements in the follow-up stage (Table 2).









Participants’ characteristic
A total of 17 studies investigated the impact of MT on children with HCP. In one study, children with complex regional pain syndrome participated. All documented studies evaluated the effectiveness of mirror exercises on upper limbs. 
Overall, in all studies on pediatric MT, 461 children with HCP, 30 children with complex regional pain syndrome, and 12 children with obstetric brachial palsy participated, and the age range of participants was from 2.5 to 18 years. The lowest number of participants in the study was related to a single-subject study with one child [30] and, the highest number of participants in an RCT study was 76 people [31] (Table 2).

Study intervention
According to Table 3, this review demonstrated that two articles were included in the MT group.


One study was in the MT versus mMT category. MT versus other interventions design was used in nine studies. Of these, in four studies, the participants of the control group performed a different program than the mirror exercises group (MT versus other interventions), and in five studies the exercise of the comparison group was the same as the MT group without using the mirror (MT versus the same movement without the mirror). In the intervention program of the five studies, the study group received an integrated intervention program that combined MT with other rehabilitation methods. A comparative analysis was conducted between this group and a control group (MT plus other interventions versus other interventions). In one study with a three-group design, intervention groups include the MT group, MT with other intervention, and, another intervention (modified constraint-induced movement therapy).
These intervention programs accomplished in duration ranging from 42 sessions, in a single subject study [33] to one intervention session with unimanual and bimanual training [34]. Three research were performed as the home base and 16 studies were performed in clinical and laboratory settings (Table 3). 

Outcome measure
In this scoping study, 45 outcome measures were extracted from the articles. According to this, 35 outcome measures were in the BF and BS level and 10 outcome measures were in the activities and participation level.
At the level of BF and BS, dexterity has been used in more studies as an outcome (n=5). At the levels of activities and participation, the variable of upper limb function (n=2) has the highest frequency (Table 4).



Discussion
The objective of this scoping review was to present a comprehensive overview of studies about MT in children and the classification of studies with an emphasis on methodological components of research design, characteristics of participants, types and patterns of interventions, and outcomes.
Our review indicated that most authors have used RCT design in the MT studies in children. The designs of the two remaining studies were the case series [35] and single-subject [33]. RCT is a valid design for measuring the effectiveness of clinical and therapeutic research. Although this design was applied in most studies in the field of MT in children, the number of research is yet insufficient for evaluation of efficacy.
The persistence of changes resulting from therapeutic intervention over time is clinically valuable [36]; therefore, one of the essential goals of interventional research in this field can be to examine the persistence of changes that are achieved by following up the study. Considering that in this review, only in three studies, the long-term effectiveness of interventions has been followed up, it is suggested that a follow-up phase be considered in the design of future research in the field of MT in children.
Despite the importance of the lower limbs in children’s overall participation in life [37, 38], only one study investigated the impact of MT specifically on the lower limbs. Therefore, the impact of MT on the BF and BS, and activities related to the lower extremities of children can be researched. In this regard, due to the concurrent involvement of upper and lower extremities in most functional performance [39], it is suggested that in future research, upper and lower extremities be considered concurrently in MT intervention protocol.
Looking at the scope of the MT studies in the children, we recognized that in early research, the MT programs were compared with similar programs without mirror feedback (or other interventions) that had two levels of independent variables, while in more recent studies, research designs had two or three levels of independent variables, which includes different intervention programs of MT and modified MT interventions that have been compared with each other and other interventions. 
Through classifying outcome measures based on ICF levels of function, we found that in about %78 of the studies of MT on children, the outcome measurements predominantly focused on the BF and BS levels and levels of activities and participation had less attention. Regarding the importance of levels of activity and participation in health and quality of life (QoL), in MT studies, focusing on these levels of ICF as an outcome measure should be given more consideration by researchers.
According to the results, no study has examined the impact of MT on kinetic and kinematic parameters of movement. According to the overview of motor control, movement with any level of quality is related to the interaction and cooperation between the control and executive levels of the motor system [40]. This means that in addition to measuring performance variables, focusing on movement mechanisms and motor system strategies to overcome motor dysfunctions in children with motor impairments can provide more knowledge about the control process and the impact of MT and exercise program [41, 42]. Thus, based on theories, such as motor variability, it is possible to study the underlying mechanisms of movement, including biomechanical connections between the joints to produce coordinated movements following MT interventions [40, 43]. Additionally, the study of visual receptive strategies (such as eye-tracking) in MT can have useful results in investigating the neural bases of MT.
According to the findings of this review, in terms of conditions of participants, in most studies, individuals with HCP participated, while less attention was paid to other unilateral lesions such as phantom limbs. Therefore, it is suggested that the variety of unilateral lesions of extremities be further addressed as conditions of the participants in future research. In addition, theoretically, MT has the potential to limit the complications of casting following orthopedic injuries, such as atrophy and movement dysfunctions. The study of this issue can also be the target of future research in the field of MT in children.
Finally, since methods of direct study of brain activity using tools such as transcranial magnetic stimulation [44-46], functional magnetic resonance imaging [11, 47], positron emission tomography [45, 48] and brain mapping [49] were interesting for researchers to study the effects of MT on adults with unilateral extremity dysfunction, similarly in MT research on children, applying these advanced types of equipment to assess children’s brain activities as an outcome measure during and after MT can answer fundamental questions.

Conclusion
In summary, the main finding of our study was that MT studies in children are insufficient and limited to children with HCP, and in most of the studies, the functions of BF and BS levels of ICF are considered as research outcomes.
The findings of this scoping review showed that more studies are needed on the efficacy of MT in children. Based on the literature, it is suggested that the impacts of MT beyond HCP on other unilateral conditions of children be examined. Also, variables related to levels of activities and participation of ICF as an outcome measure should be given more deliberation by researchers. Finally, it is recommended to use modern instruments to measure kinetic and kinematic motion as well as advanced measurements of brain activity in MT studies in children.

Study limitations
The first limitation of this review was that only studies written in English and Persian were included. This can lead to missing studies that have been reported in other languages. Another limitation was that only a partial range of grey literature was searched. For instance, we did not search academic conferences or seminars for potential materials.

Ethical Considerations
Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conceptualization: Fatemeh Mohamadian; Supervision: Alireza Farsi and Behrouz Abdoli; Methodology, data collection and analysis: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors are grateful to Hossein Sourtiji for his consultations in the process of study.

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