Cerebral palsy (CP) is a neurologic disorder that affects motor function, balance, and posture, and spastic hemiplegia is found in about one-third of persons with CP and often leads to devastating upper limb disability. Rehabilitation interventions such as aquatic therapy and mirror therapy are commonly utilized to improve motor function and functional independence. Water therapy takes advantage of water resistance and buoyancy to relax tightened muscles, promote gross motor function, and increase muscle endurance and strength with studies showing significant improvements in motor skills as well as a reduction in spasticity in CP children, especially hemiplegic children. Water therapy can also be more enjoyable and convenient for kids, but safety has to be considered. Mirror therapy does utilize visual feedback, but to cause the movement in the paralyzed limb, and can increase hand dexterity and grip strength by stimulating the neural pathways through the illusion of movement. Although aquatic therapy has shown well-defined advantages in motor functioning and muscle tone, comparison of the efficacy of aquatic exercises and mirror therapy for hand dexterity and grip strength in hemiplegic CP has been limited, and further studies are indicated to establish their relative merits and potential complementary uses.

Cerebral palsy (CP) is a neurological impairment of motor disorder, balance, movement disorder, and postural deformities that appear during infancy and early childhood, although muscle tone and posture related abnormalities becomes more prominent in later years . Globally CP occurs 1.5 to more than 4 per 1000 live births.

One of the types of CP is spastic hemiplegia, known as half-body paralysis and the prevalence is about 35.1% of all children with CP . Upper limb function impairment is a common and disability consequence of problems in reaching, pointing, and taking, releasing and manipulating objects . The ability to reach and grasp things is one of the basic tasks in activities of daily living.

Multiple approaches in the physical therapy are being used in the rehabilitation of CP such as stretching, strengthening, Neuro-developmental technique (NDT), motor relearning programs in reducing the spasticity and improving functional level in CP (Dimitrijević et al., 2012). During current practices, primary focus on improving the functional independency and motor skills, thus aquatic therapy is good approach in this regard (Declerck et al., 2013).

Furthermore, hydrotherapy is effective treatment mode due to buoyancy and hydrostatic properties of water. Buoyancy force is equal to the weight of the fluid displaced by the object. According the hydrotherapy is an effective treatment option in CP due to its thermal and mechanical effects.

Thermal effects relax the muscle and facilitates in reducing the spasticity while mechanical effects of water are sufficient in reducing the effect of gravity and minimizing the joint loading, furthermore, water provides enjoyable environment to perform multiple functional activities for cerebral palsy (Getz et al., 2012). Exercises in the pool are always performed at the temperature of 33°- 35oC that is essential in reducing the spasticity by relaxing the muscles (Adar et al., 2017). Besides these effects hydrotherapy has effects on strengthening the muscles and endurance since water creates resistance during walking that strengthens the muscles (Khalaji et al., 2017). Activities performed in water are easier and effective as compared to the land but it has a major safety issue that should be identified before the start of exercises for the better results (Adar et al., 2017). Hydrotherapy has several positive effects in the management of spasticity, joint range of motion and improving balance in CP. Since the aquatic exercise reduces spasticity thus has potential effects in improving the gross motor functions among CP.

Among non-invasive approaches, mirror therapy is a relatively new approach that focuses on visual stimulation and the movements of limbs without damage. The reflection of the healthy limb movement in the mirror is thought the affected limb is moving naturally (Fukumura et al., 2007). In this method, the patient places his hands on the two sides of the mirror. Thus, the patient understands the reflection of his healthy hand in the mirror as his affected hand (Mc Cabe et al., 2008).

Statement of problem:

Is there difference between effects of aquatic based exercises and mirror therapy on hand dexterity and hand grip strength in children with hemiplegic cerebral palsy?

Purpose of study:

The purpose of this study is:

• To investigate the effect of aquatic based exercises and mirror therapy on hand dexterity and hand grip strength in children with hemiplegic cerebral palsy
• To investigate the correlations between the effects of aquatic based exercises, mirror therapy and control group on hand dexterity and hand grip strength in children with hemiplegic cerebral palsy.

Inclusion Criteria:

• Children with Hemiplegic cerebral palsy
• Children with mild to moderate spasticity of wrist muscles spasticity will range between (0-4) score according to Modified Ashworth Scale.
• Children will be able to follow the instructions.
• Children without any genetic disorders.

Exclusion Criteria:

• Cognitive impairment.
• Unilateral neglect disorders.
• Orthopedic dysfunction.
• Visual impairment.
• Verbal impairment.
• Open wound or infection
• Fixed contractures.
• Previous limb surgeries within 6 months.
• Resting angina.

It will provided only upon reasonable request

Blinding to the assessor