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Paper text:
mirror therapy is a form of mental practice , and it excites the primary motor cortex and 
 evokes movement of the paralyzed side as patients confirmed movement of the non - paralyzed 
 side visually1 .
a mirror neuron is neuron 
 that responds to observation of a person s movement as if in response to real movement and 
 can be activated through mirror therapy2 .
yayuzer et al.3 reported that subacute 
 stroke patients who received mirror therapy showed improved function of upper and lower 
 extremities , and stevens and stoykov4 
 reported that visual information of sound side movement was conveyed and that movement of 
 the affected side was improved .
functional electrical stimulation is a method used for 
 inducing improvement of functional movement such as strength and gait ability with 
 electrical stimulation in patients who suffer from upper motor neuron diseases such as 
 stroke , multiple sclerosis , and spinal cord injury5 .
sullivan and hedman6 reported that muscle strength , range of motion , and functional 
 movement are more improved after applying both functional task performance and fes than 
 after applying functional task performance alone .
peurala et al.7 also reported that a group that received both gait training 
 and fes show better improvement of gait ability than another group that only received gait 
 training .
the effect of functional task performance in conjunction with fes has been demonstrated in 
 stroke patients , but the effect of application of both mirror therapy and fes to stroke 
 patients is not yet known .
the aim of the present study was to examine whether mirror 
 therapy in conjunction with fes in stroke patients can improve gait ability .
this study was conducted with 30 subjects who were diagnosed with hemiparesis due to 
 stroke .
sufficient explanation of this study s intent and the overall purpose was given , and 
 voluntary consent to participation in this study was obtained from all of the subjects .
all 
 procedures were reviewed and approved by the institutional ethics committee of eulji 
 university hospital .
experimental group i 
 contained 10 subjects who received mirror therapy in conjunction with fes , experimental 
 group ii contained 10 subjects who received mirror therapy , and the control group contained 
 10 subjects who received a sham therapy .
all subjects performed a pnf neurodevelopment 
 technique for 30 minutes a day , 5 times a week for 6 weeks .
the subjects in experimental 
 groups i and ii were instructed to sit on a table for therapeutic purposes based on the 
 mirror therapy program proposed by stbeyaz et al.8 , and to use a 60  90  cm mirror designed such that its angle could 
 be adjusted . after placing the mirror between the non - affected and affected lower limbs ,
the mirror s angle was then controlled 
 according to the patient s sitting height so that the movement of the non - affected lower 
 limb could be seen in the mirror . for functional electrical stimulation ( fes ) equipment , 

this study used a microstim , which consisted of one pair of surface electrodes ( 50  50  mm ) , 
 a stimulator , and a foot switch .
the foot switch was attached to the bottom of the forefoot 
 on the patient s affected side and set to activate fes as soon as the forefoot on the 
 affected side came off the ground .
in addition , the patients were taught to create 
 simultaneous active movements for dorsiflexion of the foot on the affected side when 
 dorsiflexion of the foot on the non - affected side was seen in the mirror .
the patients had 
 to repeat maintenance of dorsiflexion for 10 seconds and then rested for 5 seconds . 

experimental group ii was instructed to perform the same training without application of 
 fes .
the control group did not receive fes , and performed the same training after covering 
 the mirror with a white cloth .
a 
 gait analysis was performed using a three - dimensional motion capture system , which was a 
 real - time tracking device that delivers data in an infrared mode via reflective markers 
 using six cameras .
the reflective markers were attached to the left and right anterior 
 superior iliac spines ( asiss ) , left and right posterior superior iliac spines ( psiss ) , left 
 and right femoral regions , lateral epicondyles of the left and right knees , left and right 
 tibial regions , left and right lateral malleoli , heads of the left and right second 
 metatarsal bones , and left and right posterior calcaneal bones .
the eva real - time ( evart ) 
 were used for data processing . to measure gaits ,
each subject was instructed to walk inside 
 a 7  m capture area from the starting to end points three times at a comfortable speed .
the 
 average of the measurement values after excluding 1  m from each of the starting and end 
 points was adopted for a gait analysis .
in addition , temporal gait characteristics of 
 velocity and cadence and spatial gait characteristics of step length and stride length were 
 recorded .
paired t - tests were used to verify statistical significance in performances before 
 and after the experiment . to make comparisons between the groups ,
in addition , a post hoc test was performed using fisher s least significance 
 difference ( lsd ) test .
general characteristics and results of the homogeneity test of the subjects are shown in 
 table 1table 1 .
general and medical characteristics of the subjects ( n=30)eg i ( n=10)eg ii ( n=10)cg ( n=10)age ( years)52.99.948.68.554.69.2since onset ( months)7.13.47.32.96.72.3weight ( kg)63.48.663.19.565.57.3height ( cm)167.77.0166.18.1168.07.4gender ( male / female)6/47/36/4affected side ( left / right)3/74/64/6causes ( infarction / hemorrhage)6/47/37/3meansd , eg i : mirror therapy + fes group , eg ii : mirror therapy group , 
 cg : sham therapy group . velocity , cadence , step length and stride length of all groups were 
 significantly improved after the experiment ( p<0.05 ) .
the results showed a significant 
 difference in gait velocity ( p<0.01 ) between groups after the experiment , and post hoc 
 analysis revealed significant differences between experimental group i and the control group 
 and between experimental group ii and the control group , respectively .
there were also 
 significant differences in step length and stride length ( p<0.01 ) between the groups 
 after the experiment , and post hoc analysis revealed significant differences between 
 experimental group i and control group ( p<0.05 ) ( table 2table 2 .
comparison of gait ability between groups ( n=30)eg i ( n=10)eg ii ( n=10)cg ( n=10)post hocvelocity ( cm / s)pre47.34.645.36.246.65.3/post63.36.4**60.58.4**53.45.6*a , b > ccadence ( steps / min)pre71.512.170.510.169.210.3/post84.614.0**78.08.7 * 75.010.5*/step length ( cm)pre30.16.130.42.830.23.4/post38.54.7**35.93.6 * 33.44.6*a > cstride length ( cm)pre64.611.660.37.957.45.0/post77.09.1**72.46.7**67.39.6**a > cmeansd , * p<0.05 , * * p<0.01 , eg i : mirror therapy + fes group , eg 
 ii : mirror therapy group , cg : sham therapy group ) .
meansd , eg i : mirror therapy + fes group , eg ii : mirror therapy group , 
 cg : sham therapy group meansd , * p<0.05 , * * p<0.01 , eg i : mirror therapy + fes group , eg 
 ii : mirror therapy group , cg : sham therapy group
according to the results of this study , velocity , step length , and stride length in 
 experimental group i were improved after the experiment compared with experimental group ii 
 and the control group .
this showed that mirror therapy in conjunction with fes is more 
 effective for improving gait ability than mirror therapy alone .
fes increased activation of 
 the sensory - motor cortex area of stroke patients and the influence on functional movement . 

it is known to improve treatment effects and to have a positive effect on motor 
 learning9 .
we thought that this may be 
 due to brain reorganization in response to mirror therapy occurring at the same time as 
 recovery of muscle function due to fes .
stbeyaz et al.8 randomly assigned 40 
 stroke patients to a mirror therapy group and a control group .
the subjects repeatedly 
 performed dorsiflexion of the ankles with the non - affected lower limb placed in front of a 
 mirror .
measurement of their functional ambulation categories ( fac ) during exercise showed 
 that the mirror therapy group achieved a statistically significant higher level of 
 improvement in gait ability than the control group .
fes increases the activity of the cerebral sensory - motor cortex in stroke 
 patients and has an effect on functional movement , and it has a positive effect on motor 
 learning and improves the effect of treatment9 .
we suspect that the gait abilities were improved due to synergistic 
 effects of fes and mirror therapy . in a cross - sectional study in which fes was applied to 
 the ankle dorsiflexors of stroke patients ,
sabut et al.10 reported that statistically significant increases were found in 
 gait velocity , cadence , and stride length .
kesar et al.11 noted that application of fes to the tibialis anterior muscle of 
 stroke patients during walking improved gait ability by correcting foot drop .
limitations of 
 this study include its small sample size , the difficulty in generalizing its results , and 
 the fact that we did not confirm the durability of the effects through follow - up .
future 
 studies should employ larger sample sizes , and compare the effects of mirror therapy with 
 those of other interventions .
[ purpose ] the aim of the present study was to examine whether mirror therapy in 
 conjunction with fes in stroke patients can improve gait ability . 
 [ subjects ] this study 
 was conducted with 30 subjects who were diagnosed with hemiparesis due to stroke . 
 
 [ methods ] experimental group i contained 10 subjects who received mirror therapy in 
 conjunction with functional electrical stimulation , experimental group ii contained 10 
 subjects who received mirror therapy , and the control group contained 10 subjects who 
 received a sham therapy . 
 a gait analysis was performed using a three - dimensional motion 
 capture system , which was a real - time tracking device that delivers data in an infrared 
 mode via reflective markers using six cameras . 
 [ results ] the results showed a significant 
 difference in gait velocity between groups after the experiment , and post hoc analysis 
 revealed significant differences between experimental group i and the control group and 
 between experimental group ii and the control group , respectively . 
 there were also 
 significant differences in step length and stride length between the groups after the 
 experiment , and post hoc analysis revealed significant differences between experimental 
 group i and control group . 
 [ conclusion ] the present study showed that mirror therapy in 
 conjunction with fes is more effective for improving gait ability than mirror therapy 
 alone .