Mirror therapy for improving motor function after stroke

Holm Thieme; Jan Mehrholz; Marcus Pohl; Johann Behrens; Christian Dohle

doi:10.1002/14651858.CD008449.pub2

. 2012 Mar 14;2012(3):CD008449. doi: 10.1002/14651858.CD008449.pub2

Mirror therapy for improving motor function after stroke

Holm Thieme ^1,^2,^✉, Jan Mehrholz ^3,⁴, Marcus Pohl ⁵, Johann Behrens ⁶, Christian Dohle ^7,⁸

PMCID: PMC6464769 PMID: 22419334

Abstract

Background

Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the patient's midsagittal plane, thus reflecting movements of the non‐paretic side as if it were the affected side.

Objectives

To summarise the effectiveness of mirror therapy for improving motor function, activities of daily living, pain and visuospatial neglect in patients after stroke.

Search methods

We searched the Cochrane Stroke Group's Trials Register (June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), CINAHL (1982 to June 2011), AMED (1985 to June 2011), PsycINFO (1806 to June 2011) and PEDro (June 2011). We also handsearched relevant conference proceedings, trials and research registers, checked reference lists and contacted trialists, researchers and experts in our field of study.

Selection criteria

We included randomised controlled trials (RCTs) and randomised cross‐over trials comparing mirror therapy with any control intervention for patients after stroke.

Data collection and analysis

Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality of studies and extracted data. We analysed the results as standardised mean differences (SMDs) for continuous variables.

Main results

We included 14 studies with a total of 567 participants that compared mirror therapy with other interventions. When compared with all other interventions, mirror therapy may have a significant effect on motor function (post‐intervention data: SMD 0.61; 95% confidence interval (CI) 0.22 to 1.0; P = 0.002; change scores: SMD 1.04; 95% CI 0.57 to 1.51; P < 0.0001). However, effects on motor function are influenced by the type of control intervention. Additionally, mirror therapy may improve activities of daily living (SMD 0.33; 95% CI 0.05 to 0.60; P = 0.02). We found a significant positive effect on pain (SMD ‐1.10; 95% CI ‐2.10 to ‐0.09; P = 0.03) which is influenced by patient population. We found limited evidence for improving visuospatial neglect (SMD 1.22; 95% CI 0.24 to 2.19; P = 0.01). The effects on motor function were stable at follow‐up assessment after six months.

Authors' conclusions

The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, activities of daily living and pain, at least as an adjunct to normal rehabilitation for patients after stroke. Limitations are due to small sample sizes of most included studies, control interventions that are not used routinely in stroke rehabilitation and some methodological limitations of the studies.

Keywords: Humans, Recovery of Function, Stroke Rehabilitation, Activities of Daily Living, Exercise Movement Techniques, Exercise Movement Techniques/instrumentation, Exercise Movement Techniques/methods, Functional Laterality, Functional Laterality/physiology, Paresis, Paresis/etiology, Paresis/rehabilitation, Randomized Controlled Trials as Topic, Stroke, Stroke/complications

Mirror therapy for improving motor function after stroke

Paralysis of the arm or leg is common after stroke and frequently causes problems with activities of daily living such as walking, dressing or eating. Mirror therapy is a rehabilitation therapy in which a mirror is placed between the arms or legs so that the image of the non‐affected limb gives the illusion of normal movement in the affected limb. We found 14 relevant studies involving 567 participants. At the end of treatment, mirror therapy improved movement of the affected limb and the ability to carry out daily activities. Mirror therapy reduced pain after stroke, but only in patients with a complex regional pain syndrome. The beneficial effects on movement were maintained for six months, but not in all study groups. No adverse side effects were reported. Further research is needed with larger studies in natural clinical settings, and with a comparison of mirror therapy with more routine treatments.

Background

Description of the condition

Cerebrovascular diseases, taken together with ischaemic heart diseases, are the leading causes of death worldwide (WHO 2008). Each year approximately nine million people suffer a first‐ever stroke. Stroke is one of the leading causes of long‐term disability, particularly in high‐ and middle‐income countries (WHO 2008). Immediately after stroke onset, approximately 80% of survivors have an upper or lower limb motor impairment (Barker 1997; Jorgensen 1995; Nakayama 1994). Full upper limb function is achieved by nearly 80% of patients with mild paresis, but only by 20% of patients with severe paresis of the upper limb (Nakayama 1994). Of those patients with an initial plegic upper limb, only half regain some motor function in the paretic upper limb six months later (Kwakkel 2003). Two‐thirds of patients with lower limb impairment are not able to walk independently soon after their stroke, and after rehabilitation only half have independent walking function (Jorgensen 1995). The initial severity of upper and lower extremity paresis is one of the most important predictors of long‐term functional recovery after stroke (Hendricks 2002; Jorgensen 1995; Nakayama 1994), but variability is high, possibly influenced by therapeutic interventions.

Up to 50% of patients experience pain of the upper extremity during the first 12 months post‐stroke, especially shoulder pain and complex regional pain syndrome‐type I (CRPS‐type I) (Jönsson 2006; Kocabas 2007; Lundström 2009; Sackley 2008). Pain after stroke may restrict activities of daily living and reduce quality of life (Jönsson 2006; Lindgren 2007).

Additionally, about 40% of patients with an acute right hemispheric and 20% of patients with a left hemispheric stroke presented with a unilateral neglect (Ringman 2004). After three months a unilateral neglect was present in about 15% of patients with a right and 5% of patients with a left hemispheric stroke (Ringman 2004). Besides the spatial attention deficits, neglect is a negative factor for functional recovery (Farnè 2004; Katz 1999) and was found to be associated with a reduced health‐related quality of life (Franceschini 2010).

Therefore, effective training strategies to promote motor recovery and activities of daily living, reduce pain or visuospatial neglect or both are needed to reduce the burden of stroke.

Description of the intervention

Evidence suggests that effective therapeutic interventions for regaining motor function should potentially focus on the practice of functional tasks (Van Peppen 2004). However, task‐oriented training strategies, such as constraint‐induced movement therapy (French 2007; Liepert 1998; Miltner 1999b; Taub 1993), require some degree of voluntary movement, therefore they are not applicable for patients with severe paresis after stroke. Novel training strategies for this patient population use electromechanical training devices (Mehrholz 2007; Mehrholz 2008), electrical muscle stimulation (Urton 2007) or repetitive passive or assistive movement stimulation (Feys 2004; Platz 2005).

As an alternative treatment approach, mirror therapy has been proposed as potentially beneficial (Ramachandran 1994). In contrast to other interventions, which employ somatosensory input to assist motor recovery (Feys 2004), mirror therapy is based on visual stimulation. During mirror therapy, a mirror is placed in the patient's midsagittal plane, thus reflecting the non‐paretic side as if it were the affected side (Ramachandran 1995). By this setup, movements of the non‐paretic limb create the illusion of normal movements of the paretic limb. One of the possible advantages of mirror therapy is the relatively easy administration and the possibility for self‐administered home therapy for patients even with severe motor deficits. Mirror therapy was first described in Ramachandran 1995 and Ramachandran 1996 with the studies reporting the effects of mirror therapy on pain reduction in arm amputees. Furthermore, mirror therapy was claimed to alleviate hemiparesis after stroke (Ramachandran 1994). A pilot study confirmed the positive effects of mirror therapy on patients' movement ability in upper limb hemiparesis after stroke (Altschuler 1999).

Recently, some authors have described 'mirror‐like' video or computer graphic setups, where a video or computer graphic image of the moving limb is presented as if it were the opposite one (Adamovich 2009; Dohle 2004; Dohle 2011; Eng 2007; Gaggioli 2004; Morganti 2003).

How the intervention might work

The concept of mirror therapy has been substantiated neurophysiologically. Evidence suggests that the same cortical motor areas that are active during observation of movements are involved in the performance of the observed actions (Grèzes 2001). Movement mirroring (i.e. the inversion of the visual feedback) leads to an additional activation of the hemisphere contralateral to the perceived limb laterality (Dohle 2004; Matthys 2009; Shinoura 2008). In normal people, the mirror illusion may increase cortico‐muscular excitability (Fukumura 2007; Garry 2005). However, the precise mechanisms of the effect of mirror therapy in stroke patients remain speculative. As the visual image of the paretic limb is perceived similarly to the patients' own moving limb (Dohle 2004), the mirror illusion might prevent or reverse a learned non‐use of the paretic limb (Liepert 1995). Also, by modulation of the cortico‐muscular excitability, mirror therapy might directly stimulate motor recovery. Finally, mirror therapy was regarded as a variant of motor imagery training, which is based on repetitive imagination and mental rehearsal of motor tasks (Miltner 1998; Stevens 2003). Behavioural studies suggest that the experience of agency (the attribution of visual images of body parts as being controlled by oneself) relies on a tight temporal coupling of the visual feedback of active, but not passive movements (Longo 2009). Imaging studies suggest that mirrored computer graphic images are processed similarly to those of real movements (Adamovich 2009; Dohle 2011) as long as the temporal and spatial consistency with real movements does not fall below certain thresholds (Franck 2001). Thus, even technically generated images of a human moving limb can be integrated into the body scheme with the same sense of agency as during 'real' mirroring.

Regarding non‐motor symptoms, mirror therapy was found to be effective in reducing pain in patients with CRPS‐type I (McCabe 2003). The authors hypothesised that mirror therapy may normalise central sensory processing by providing a physiological image of the affected limb (McCabe 2003). Another study found significant effects of mirror therapy on reducing unilateral visuospatial neglect after stroke (Dohle 2009). The strong visual stimulus of watching self‐induced movements in the neglected hemifield was postulated to be responsible for this effect.

Why it is important to do this review

Recently, randomised controlled trials (RCTs) have been conducted to evaluate the effectiveness of mirror therapy after stroke (Cacchio 2009a; Cacchio 2009b; Dohle 2009; Sütbeyaz 2007; Yavuzer 2008). These trials however, employed different outcome measures and only had small study samples. Ezendam 2009 and Rothgangel 2011 published systematic reviews on the effectiveness of mirror therapy in different conditions. However, their search strategies were limited and the authors did not provide pooled analyses.

Objectives

The main purpose of this review is to summarise the effectiveness of mirror therapy compared with no treatment, placebo or sham therapy, or other treatments for improving motor function after stroke. Further, this review aims to assess the effects of mirror therapy on activities of daily living, pain and visuospatial neglect.

Methods

Criteria for considering studies for this review

Types of studies

We included RCTs and cross‐over RCTs comparing mirror therapy (provided by a mirror or a simultaneous video or virtual setup) with any other therapy modality, no therapy or sham therapy. If we included cross‐over RCTs, we only analysed the first period as a parallel group trial.

Types of participants

We included studies examining participants with a paresis of the upper or lower limb, or both, caused by stroke (all types, severity and stages of stroke) aged over 18 years. If we identified studies with mixed populations of patients with neurological conditions, we included those studies if separate data for stroke patients were available.

Types of interventions

Mirror therapy is defined as an intervention that uses a mirror to create a reflection of the non‐paretic upper or lower limb, thus giving the patient visual feedback of normal movement of the paretic limb. Using this setup, different variations in the experimental protocol are possible (Dohle 2005; Nakaten 2009). We included studies that used direct mirroring of movement of any regimen and variation, i.e. including video or virtual reality settings. However, we only included those studies where the regimen and delivery of mirror therapy could be identified.

The control arm of the study could include a no treatment group, usual or standard practice, or any other control treatment (i.e. placebo or sham therapy). We excluded studies where the influence of mirror therapy could not be isolated due to the comparison of different mirror therapy regimens or delivery. We contacted trialists if regimen or delivery (or both) of mirror therapy or the control intervention was unclear.

Types of outcome measures

We evaluated outcome measures post‐intervention (or change scores between pre‐ and post‐intervention measures) and at follow‐up after six months or longer.

Primary outcomes

The primary outcome was motor function. Due to the wide variety of outcome measures, we selected outcome measures to facilitate quantitative pooling. If more than one outcome measure was available we prioritised measures as follows.

Upper limb and hand function:
- Fugl‐Meyer Assessment (Fugl‐Meyer 1975) ‐ upper limb or hand function or both;
- Action Research Arm Test (Lyle 1981), Motor Assessment Scale (Carr 1985) ‐ upper limb and hand function or both; and
- Wolf Motor Function Test (Wolf 2001), Brunnstrom Stages of the Upper Extremity (Brunnstrom 1966), Motricity Index (Demeurisse 1980) ‐ arm score.
Lower limb function:
- Fugl‐Meyer Assessment ‐ lower limb function (Fugl‐Meyer 1975); and
- Brunnstrom Stages of the Lower Extremity (Brunnstrom 1966).
Global motor function:
- Motor Assessment Scale (Carr 1985), Rivermead Motor Assessment Scale (Collen 1991).

However, if these scales were not available, we accepted other measurements that evaluate motor function.

Secondary outcomes

Secondary outcomes included measures of activities of daily living (e.g. Functional Independence Measure (Keith 1987), Barthel Index (Mahoney 1965)), pain (Visual Analogue Scale or Numeric Rating Scale) and visuospatial neglect. We also searched for reported adverse effects (e.g. swelling).

Search methods for identification of studies

See the 'Specialised register' section in the Cochrane Stroke Group module.

Electronic searches

We searched the Cochrane Stroke Group's Trials Register, which was last searched by the Managing Editor in June 2011, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to June 2011) (Appendix 1), EMBASE (1980 to June 2011) (Appendix 2), CINAHL (1982 to June 2011) (Appendix 3), AMED (1985 to June 2011), PsycINFO (1806 to June 2011) and the Physiotherapy Evidence Database (PEDro) (June 2011). We modified the MEDLINE and CINAHL search strategies for the other databases.

Searching other resources

In an effort to identify further published, unpublished and ongoing trials not available in the major databases we:

handsearched the following conference proceedings:
- Deutsche Gesellschaft für Neurologie (2008, 2009);
- Deutsche Gesellschaft für Neurorehabilitation (2000, 2001, 2003, 2005, 2007, 2009, 2010);
- Deutsche Gesellschaft für Neurotraumatologie und klinische Neurorehabilitation (2005, 2007, 2009, 2010);
- European Stroke Congress (2001 to 2009);
- World Congress of Neurorehabilitation (1999, 2002, 2006, 2010);
- World Congress of Physical Therapy (2003, 2007, 2011);
- World Stroke Congress (2000, 2004, 2008, 2010);
screened reference lists of all relevant articles and books;
identified ongoing trials and research registers, including:
- Current Controlled Trials (http://www.controlled‐trials.com/) (searched June 2011);
- ClinicalTrials.gov (http://clinicaltrials.gov/) (searched June 2011);
- Stroke Trials Registry (http://www.strokecenter.org/trials/) (searched June 2011);
- International Clinical Trials Registry Platform (ICTRP) (http://www.who.int/ictrp/en/) (searched June 2011);
contacted trialists, experts, researchers and commercial companies (Reflex Pain Management Ltd) in our field of study to obtain information of unpublished studies and studies not available in the electronic databases;
searched OpenSIGLE ‐ System for Information on Grey Literature in Europe (http://www.opengrey.eu/) (searched June 2011); and
searched the REHABDATA database (http://www.naric.com/research/rehab/) (searched June 2011).

We did not impose any restrictions on language or publication status when deciding on including studies.

Data collection and analysis

Selection of studies

Two review authors (HT and CD) independently screened titles of the references identified from the electronic database searches and excluded obviously irrelevant references. We obtained abstracts or full texts or both of the remaining studies and used our inclusion criteria (types of studies, types of participants, types of interventions and outcome measures) to assess whether they were eligible for inclusion. We resolved disagreements by discussion. If the inclusion of a study was unclear due to missing information, we tried to contact the authors of the studies for further details.

Data extraction and management

Two review authors (HT and CD) independently extracted trial and outcome data of the included trials using a checklist. Because one author (CD) is principal investigator of an included trial, another author (JB) did the data extraction of this study. The checklists for data extraction contained:

methods of randomisation;
methods of concealment of allocation;
blinding;
use of an intention‐to‐treat (ITT) analysis (all participants initially randomised were included in the analysis as allocated to groups);
adverse events;
drop‐outs for all reasons;
imbalance of important prognostic factors;
participants (country, number of participants, age, gender, type of stroke, time since stroke onset to study entry);
inclusion and exclusion criteria;
details of interventions in treatment and control groups;
outcomes; and
time points of measurement.

We tried to establish all unclear characteristics of the studies by contacting the trial co‐ordinator or principal investigator. We checked the extracted data for agreement between authors and entered the data into Review Manager 5 (RevMan 5).

Assessment of risk of bias in included studies

We used the risk of bias assessment tool according to Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) to assess the adequacy of methods for sequence generation, concealment of allocation, ITT analysis, and blinding of assessors.

Furthermore, we used the PEDro scale, with 11 criteria, for methodological assessment of the included studies (Maher 2003). The PEDro scale assesses:

specified eligibility criteria;
random allocation;
concealed allocation;
similarity of baseline characteristics of the patients;
blinding of patients;
blinding of therapists;
blinding of assessors;
outcome data of at least 85% of participants of at least one key outcome;
ITT analysis;
between‐group statistical comparisons; and
point measures and measures of variability.

We scored each fulfilled criteria in the PEDro scale except the first one (specified eligibility criteria) with one point. Therefore, the maximum possible score was 10 points. Two review authors (HT and CD) independently assessed the PEDro scale of included studies. Because one author (CD) is principal investigator of an included trial, another author (JB) did the quality assessment of this study. We resolved disagreements in methodological assessment by consulting a third review author (MP or JB) and reached consensus through discussion. If an article did not contain information on any methodological criteria, we contacted the study authors for additional information. If no further information was available, we rated the criteria as 'unclear'.

Measures of treatment effect

The primary and secondary outcome variables of interest were continuous outcomes. We entered data of post‐intervention assessment and follow‐up assessment at six months as means and standard deviations (SDs) and calculated the standardised mean difference (SMD) with 95% confidence intervals (CIs) for each trial. We pooled data through calculation of the overall SMD and 95% CI. However, if post‐intervention data were not available we used changes between pre‐ and post‐assessment and summarised them in a separate analysis using the SMD and 95% CIs.

Unit of analysis issues

We considered randomised cross‐over trials prior to cross‐over and analysed only the first intervention phase.

Dealing with missing data

We contacted study authors if appropriate data for analysis were not adequately reported. If authors did not respond within one month after contact, we tried to get in contact with them at least one more time. We considered an ITT analysis as part of the risk of bias assessment.

Assessment of heterogeneity

We evaluated clinical heterogeneity through reported clinical and methodological diversity, variability of participants, interventions and outcomes in an additional table. The variability did not influence pooling trials. However, we used the I² statistic to quantify heterogeneity (cut‐off 50%) for all comparisons. If we found substantial heterogeneity, we used a random‐effects model instead of a fixed‐effect model.

Assessment of reporting biases

We tried to minimise reporting bias through an extensive search of databases, handsearching of references lists and conference abstracts, and by contacting authors, trialists and experts in the field for other unpublished or ongoing trials. Furthermore, we conducted a sensitivity analysis, excluding studies of low methodological quality.

Data synthesis

Where possible, we conducted a pooled analysis of primary (motor function) and secondary (activities of daily living, pain, visuospatial neglect) outcomes as described above, using a random‐effects model instead of a fixed‐effect model if heterogeneity of the studies was high. We performed a subgroup analysis to establish the effectiveness relative to upper or lower extremity and type of control intervention. We also analysed subgroups by separating immediate and long‐term results of mirror therapy.

Sensitivity analysis

To test the robustness of the results we conducted a sensitivity analysis, removing studies that we assessed to be of lower or ambiguous methodological quality (all studies with total PEDro scores less than seven points, all studies without adequate methods of sequence generation, concealment of allocation, ITT analysis and blinded assessors). We also reanalysed the data by removing cross‐over RCTs.

Based on the inclusion criteria of the studies, we found two studies (Cacchio 2009a; Cacchio 2009b) that only included stroke patients with a diagnosis of CRPS‐type I as defined by Bruehl 1999. One could argue that this is a special stroke population selected by a prominent feature. Furthermore, studies reported positive effects of mirror therapy in populations with CRPS of different origin (Ezendam 2009). This fact may influence the effects of mirror therapy in stroke patients with this feature. Therefore, we performed a post‐hoc sensitivity analysis of the data without these two studies for all outcome measures.

Results

Description of studies

See: Characteristics of included studies, Characteristics of excluded studies, Characteristics of studies awaiting classification, Characteristics of ongoing studies and Table 6.

Table 1.

Patient characteristics of included studies

Study ID	Experimental: age, mean (SD)	Control: age, mean (SD)	Experimental: time post‐stroke	Control: time post‐stroke	Experimental: sex	Control: sex	Experimental: side paresis	Control: side paresis
Acerra 2007	65.9 (11.5) years	70.8 (5.4) years	5.2 (3.4) days	5.4 (2.7) days	12 female, 8 male	10 female, 10 male	8 left, 12 right	8 left, 12 right
Altschuler 1999	55.8 (4.3) years	60.2 (7.6) years	1.85 (1.98) years	7.72 (10.48) years	2 female, 2 male	2 female, 3 male	1 left, 3 right	0 left, 5 right
Cacchio 2009a	57.9 (9.9) years	58.8 (9.4) years	5.1 (2.5) months	4.9 (2.8) months	13 female, 11 male	13 female, 11 male	16 left, 8 right	18 left, 6 right
Cacchio 2009b	63.4 (9.7) years	Control 1: 61.8 (8.4) years Control 2: 62.3 (9.2) years	16.8 (6.6) months	Control 1: 14.9 (4.8) months Control 2: 15.4 (5.3) months	4 female, 4 male	Control 1: 5 female, 3 male Control 2: 4 female, 4 male	5 left, 3 right	Control 1: 5 left, 3 right Control 2: 5 left, 3 right
Dohle 2009	54.9 (13.8) years	58.0 (14.0) years	26.2 (8.3) days	27.8 (12.1) days	5 female, 13 male	5 female, 13 male	Not provided	Not provided
Ietswaart 2011	69.3 (10.8) years	Control 1: 68.6 (16.3) years Control 2: 64.4 (15.9) years	82.0 (55.0) days	Control 1: 90.8 (63.4) days Control 2: 80.5 (62.7) days	18 female, 23 male	Control 1: 17 female, 22 male Control 2: 16 female, 25 male	24 left, 17 right	Control 1: 23 left, 16 right Control 2: 22 left, 19 right
Manton 2002	Not provided	Not provided	Not provided	Not provided	Not provided	Not provided	Not provided	Not provided
Michielsen 2011	55.3 (12.0) years	58.7 (13.5) years	4.7 (3.6) years	4.5 (2.6) years	13 female, 7 male	7 female, 13 male	6 dominant, 14 non‐dominant	6 dominant, 14 non‐dominant
Rothgangel 2004	Experimental 1: 74.0 (12.5) years Experimental 2: 72.0 (15.3) years	Control 1: 77.7 (4.9) years Control 2: 72.0 (15.3) years	Median (range) Experimental 1: 12 (9 to 15) months Experimental 2: 7 (3 to 14) months	Median (range) Control 1: 12 (5 to 18) months Control 2: 7 (5 to 24) months	6 female, 2 male	4 female, 4 male	Experimental 1: 2 left, 1 right Experimental 2: 3 left, 2 right	Control 1: 1 left, 2 right Control 2: 2 left, 3 right
Seok 2010	56.4 (14.8) years	46.4 (21.5) years	4.3 (1.6) months	3.7 (1.9) months	8 female, 11 male	10 female, 11 male	11 left, 8 right	6 left, 14 right
Sütbeyaz 2007	62.7 (9.7) years	64.7 (7.7) years	3.5 (1.3) months	3.9 (1.9) months	10 female, 10 male	7 female, 13 male	14 left, 6 right	13 left, 7 right
Tezuka 2006	64.6 (16.5) years	63.7 (10.3) years	38.3 (16.5) days	29.7 (8.2) days	4 female, 5 male	5 female, 1 male	4 left, 5 right	2 left, 4 right
Yavuzer 2008	63.2 (9.2) years	63.3 (9.5) years	5.4 (2.9) months	5.5 (2.5) months	8 female, 9 male	9 female, 10 male	10 left, 7 right	11 left, 8 right
Yun 2010	63.1 (7.8) years	61.4 (8.7) years	3.4 (1.6) weeks	4.1 (1.8) weeks	14 female, 6 male	13 female, 7 male	11 left, 9 right	12 left, 8 right

Study ID	Extremity	Mirror therapy variation	Control intervention	Type of movements	Minutes per session	Sessions per week	Total duration (weeks)	Total amount of therapy (minutes)	Setting
Acerra 2007	Upper extremity	Bilateral activities	Bilateral activities; covered mirror	Functional motor tasks (i.e. with objects); motor co‐ordination tasks; sensory discrimination tasks; grip strength; active range of motion	20 to 30	7	14	280 to 420	Inpatient hospital
Altschuler 1999	Upper extremity	Bilateral activities	Bilateral activities; transparent plastic between limbs	Proximal and distal movements	15, 2 times a day	12	4 (first period)	720	Not stated
Cacchio 2009a	Upper extremity	Activities of the unaffected limb	Activities of the unaffected limb; covered mirror	Flexion/extension of shoulder, elbow and wrist; prone/supination forearm	30 first 2 weeks; 60 last 2 weeks	5	4	900	Inpatient and outpatient rehabilitation centre
Cacchio 2009b	Upper extremity	Activities of the unaffected limb	Activities of the unaffected limb; covered mirror (control group 1); imagination of movements of the affected limb (control group 2)	Flexion/extension of shoulder, elbow and wrist; prone/supination forearm	30	Daily	4	840	Inpatient and outpatient rehabilitation centre
Dohle 2009	Upper extremity	Bilateral activities	Bilateral activities; without mirror	Execution of arm, hand and finger postures	30	5	6	900	Inpatient rehabilitation centre
Ietswaart 2011	Upper extremity	Activities of the unaffected limb (additionally to a motor imagery intervention)	Control 1: mental rehearsal of non‐motor related images Control 2: standard care	Elementary movements and patient selected movements	10	1 to 2	4	60	Hospital and home
Manton 2002	Upper extremity	Not stated	Not stated; transparent plastic between limbs	Not stated	Not stated	Not stated	4	Not stated	Home
Michielsen 2011	Upper extremity	Bilateral activities; once a week under supervision; 5 times a week at home	Bilateral activities; once a week under supervision, 5 times a week at home; without mirror	Exercises based on the Brunnstrom phases of motor recovery; functional tasks (i.e. with objects)	60	1 (under supervision) + 5 (at home)	6	2160	Home
Rothgangel 2004a	Upper extremity	Bilateral activities (hypotone muscles); unilateral activities (hypertone muscles)	Bilateral activities; without mirror	Gross motor arm and hand movements; functional activities (i.e. with objects); fine motor activities (i.e. with objects)	30	Total number of sessions: 17	5	510	Outpatient centre
Rothgangel 2004b	Upper extremity	Bilateral activities (hypotone muscles); unilateral activities (hypertone muscles)	Bilateral activities; without mirror	Gross motor arm and hand movements; functional activities (i.e. with objects); fine motor activities (i.e. with objects)	30	Total number of sessions: 37	5	1110	Inpatient rehabilitation centre
Seok 2010	Upper extremity	Activities of the unaffected limb	No therapy	5 movements of wrist and fingers, each 6 minutes	30	5	4	500	Inpatient rehabilitation centre
Sütbeyaz 2007	Lower extremity	Activities of the unaffected limb	Activities of the unaffected limb; covered mirror	Dorsiflexion movements of the ankle	30	5	4	600	Inpatient rehabilitation centre
Tezuka 2006	Upper extremity	Activities of the unaffected limb; affected limb passively moved by therapist	Activities of the unaffected limb; affected limb passively moved by therapist; without mirror	13 kinds of movements, i.e. flexion/extension of wrist, pinching fingers, gripping ball	10 to 15	Daily	4 (first period)	280 to 420	Inpatient rehabilitation centre
Yavuzer 2008	Upper extremity	Activities of the unaffected limb	Activities of the unaffected limb; covered mirror	Flexion/extension of wrist and fingers	30	5	4	600	Inpatient rehabilitation centre
Yun 2010	Upper extremity	Experimental 1: activities of the unaffected limb Experimental 2: activities of the unaffected limb and additionally neuromuscular electrical stimulation of the affected arm	Neuromuscular electrical stimulation of finger and wrist extensors of the affected arm	Flexion/extension of wrist and fingers	30	5	3	450	Inpatient rehabilitation centre

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Motor function at the end of intervention phase	14		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
1.1 All studies with post‐intervention data	11	481	Std. Mean Difference (IV, Random, 95% CI)	0.61 [0.22, 1.00]
1.2 All studies with change scores	10	283	Std. Mean Difference (IV, Random, 95% CI)	1.04 [0.57, 1.51]
2 Activities of daily living at the end of intervention phase	4		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only
2.1 All studies	4	217	Std. Mean Difference (IV, Fixed, 95% CI)	0.33 [0.05, 0.60]
3 Pain at the end of intervention phase	5		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
3.1 All studies	5	188	Std. Mean Difference (IV, Random, 95% CI)	‐1.10 [‐2.10, ‐0.09]
4 Visuospatial neglect at the end of intervention	1		Std. Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.1 All studies	1		Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Motor function at follow‐up after 6 months	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only
5.1 All studies	4	157	Std. Mean Difference (IV, Random, 95% CI)	1.09 [0.30, 1.87]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Motor function at the end of intervention phase	9	331	Std. Mean Difference (IV, Random, 95% CI)	0.75 [0.32, 1.19]
1.1 Studies that used a covered mirror in the control group	6	240	Std. Mean Difference (IV, Random, 95% CI)	0.90 [0.27, 1.52]
1.2 Studies that used unrestricted view in the control group	3	91	Std. Mean Difference (IV, Random, 95% CI)	0.42 [0.00, 0.84]

Methods	RCT
Participants	Country: Australia Sample size: 40 participants (20 in each group) Inclusion criteria: acute stroke (< 2 weeks) Exclusion criteria: previous stroke; vision or hearing impairment; acute trauma or impairment of the limbs; inability to sit for < 1 hour; MMSE < 22/30; major co‐morbidities
Interventions	2 arms: mirror therapy: participants were instructed to move both arms while looking in the mirror box, sensory stimulation sham therapy: patients performed the same treatment protocol as in group 1 but only viewing the unaffected arm 1 and 2: 5 days a week, 20 to 30 minutes for 2 weeks; additional usual rehabilitation programme
Outcomes	Outcomes were recorded at baseline, after 2 weeks of treatment and 1 month after treatment MAS (item 7 and 8, each 0 to 6) Resting pain intensity (NRS 0 to 10); differential CRPS‐type 1 diagnosis grip strength (handheld dynamometer) sensory detection (synchiria yes/no, QST) adverse events
Notes	Unpublished data We used means and SDs of Item 7 of the MAS, and combined the scores on pain intensity of shoulder and hand
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated random number sequence
Allocation concealment (selection bias)	Low risk	Generated list was used by an independent person for group allocation
ITT analysis	Low risk	Results were analysed on an ITT basis
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	Randomised cross‐over trial
Participants	Country: USA Sample size: 9 participants (9 in each group) Inclusion criteria: at least 6 months post‐stroke
Interventions	2 arms: 4 weeks of mirror therapy: participants were instructed to move the non‐paretic arm while looking in the mirror and moving the paretic arm as best they could; followed by 4 weeks of control therapy, using transparent plastic instead of a mirror vice versa
Outcomes	Outcomes were recorded at baseline, after 2, 4, 6 and 8 weeks self‐developed scale (‐3 to +3); assessing changes in patients' movement ability in terms of range of motion, speed and accuracy by video analysis
Notes	Data not included in the analysis
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Patients were randomly assigned (authors' statement)
Allocation concealment (selection bias)	Unclear risk	Not stated
ITT analysis	Unclear risk	Not stated
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT
Participants	Country: Italy Sample size: 48 participants (24 in each group; 6 dropped out post‐treatment, 3 more dropped out after 6 months) Inclusion criteria: hemiparesis after first ever ischaemic or haemorrhagic stroke; during first 6 months post‐stroke; diagnosed with CRPS‐type 1 with a VAS pain score > 4 cm Exclusion criteria: an intra‐articular injection into the affected shoulder during the previous 6 months or use of systemic corticosteroids during the previous 4 months; presence of another explanation of pain; prior surgery to shoulder or neck; serious uncontrolled medical conditions; global aphasia or cognitive impairments; visual impairments which might interfere with the aims of the study; evidence of recent alcohol or drug abuse; or severe depression
Interventions	2 arms: 4‐week conventional stroke rehabilitation programme and additional mirror therapy: participants performed upper extremity movements while looking in the mirror, without additional verbal feedback sham therapy: patients performed the same treatment protocol as in group 1 but with covering the reflecting side of the mirror 1 and 2: 5 days a week, 30 minutes of therapy for the first 2 weeks; and 5 days a week, 60 minutes of therapy for the last 2 weeks
Outcomes	Outcomes were recorded at baseline, 1 week after the intervention period and after 6 months WMFT/FA; 0 to 5, lower scores indicating better functioning WMFT/PT; in seconds QOM item in the MAL (0 to 5) Pain at rest (VAS 0 to 10) Pain on movement (VAS 0 to 10) Pain tactile allodynia (VAS 0 to 10)
Notes	Published and unpublished data
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Patients were randomly allocated (authors' statement)
Allocation concealment (selection bias)	Unclear risk	Not stated
ITT analysis	Low risk	Results were analysed on an ITT basis
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT
Participants	Country: Italy Sample size: 24 Participants (8 in each group) Inclusion criteria: first ischaemic or haemorrhagic stroke (> 6 months); diagnosis of CRPS‐type 1 (pain VAS > 4 cm) Exclusion criteria: intra‐articular shoulder injection in the previous 6 months or systemic corticosteroid in the previous 4 months; another obvious explanation for pain; prior surgery to shoulder or neck region; serious uncontrolled medical conditions; global aphasia or cognitive impairments interfering with understanding instructions, motor testing and treatment; visual impairments interfering with aims of the study; evidence of recent alcohol or drug abuse; or severe depression
Interventions	3 arms: mirror therapy: participants performed cardinal upper extremity movements while looking in the mirror sham therapy: patients performed the same treatment protocol as in group 1 but with covering the reflecting side of the mirror mental imagery: participants performed mental imagery 1, 2 and 3: 5 days a week; 30 minutes of therapy for 4 weeks
Outcomes	Outcomes were recorded at baseline and after the intervention period WMFT/FA: 0 to 5, lower scores indicating better functioning WMFT/PT: in seconds Pain (VAS 0 to 10) Brushed induced allodynia Oedema
Notes	Published and unpublished data; we only analysed the first intervention period (4 weeks); we summarised groups 2 and 3 to one control group
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Block randomisation; sequence generation method not stated
Allocation concealment (selection bias)	Low risk	A therapist not involved in the treatments; opened sealed envelopes and assigned appointments according to treatment group (authors' statement)
ITT analysis	Low risk	Results were analysed on an ITT basis
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT
Participants	Country: Germany Sample size: 48 participants (24 in each group, 12 dropped out) Inclusion criteria: first ever ischaemic stroke in the territory of the middle cerebral artery; not more than 8 weeks post‐stroke; between 25 and 80 years old; able to follow therapy instructions; capable of participating in 30‐minute daily therapy sessions Exclusion criteria: experienced previous stroke; major haemorrhagic changes; increased intracranial pressure; hemicraniectomy or orthopedic, rheumatologic, or other diseases interfering with their ability to sit or to move either upper limb
Interventions	2 arms: mirror therapy: participants were instructed to move both arms "as well as possible" while looking in the mirror bilateral arm training: patients performed the same treatment protocol as in group 1 but without a mirror 1 and 2: 5 days a week; 30 minutes of therapy for 6 weeks
Outcomes	Outcomes were recorded at baseline and after the intervention FM‐UE motor, ROM, pain and sensory section (FM‐UE 0 to 126) ARAT 0 to 57 FIM self‐care and mobility items (7 to 77) self‐defined Neglect score (0 to 4)
Notes	Published and unpublished data; we extracted the motor section of the FM‐UE (without reflex activity, 0 to 60)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Sealed, numbered envelopes were created
Allocation concealment (selection bias)	Low risk	Sealed envelopes were broken after study inclusion
ITT analysis	High risk	Drop‐outs were not included in analysis
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors of primary outcome were blinded to group allocation

Methods	RCT
Participants	Country: Scotland, UK Sample size: 121 participants (experimental: 41; control 1: 39; control 2: 41; 18 dropped out) Inclusion criteria: stroke in the prior 1 to 6 months; ARAT score 3 to 51; no evidence of alcohol or substance abuse; no severe cognitive deficits ‐ Mental Status Questionnaire > 6; no severe aphasia
Interventions	3 arms: motor imagery: 30 minutes of mental practice of elementary movements, goal directed movements and ADL; 10 minutes mirror therapy or active motor using video (alternated between sessions); 5 minutes motor imagery attention‐placebo control: 25 minutes active visual and sensory imagery of non‐motor tasks; 10 minutes of tasks for controlling cognitive inhibition; 5 minutes watching optical illusions; 5 minutes visual imagery of objects standard care without additional intervention 1 and 2: 3 days a week; 45 minutes of therapy for 4 weeks additional to standard; additional 8 sessions of 30 minutes unsupervised motor imagery 1 or non‐motor imagery 2
Outcomes	Outcomes were recorded at baseline and after 5 weeks: ARAT (0 to 57) BI Grip strength (hand held dynamometer) Timed manual dexterity performance Modified functional limitation profile
Notes	Only 8% of the intervention included mirror therapy as defined in the review
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Automated randomisation procedure
Allocation concealment (selection bias)	Low risk	Patients were randomised using the automated randomisation procedure up to 1 week after baseline assessment
ITT analysis	Low risk	For completeness an ITT analysis was performed which rendered very similar results
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT
Participants	Country: USA Sample size: 10 participants Inclusion criteria: 6 months or more post‐cerebrovascular accident
Interventions	2 arms: home exercise programme with a mirror exercise unit same programme with a plexiglas exercise unit 1 and 2: 4 weeks
Outcomes	Outcomes were recorded at pre‐treatment, mid‐treatment, post‐treatment and after 3 months WMFT
Notes	Abstract data only; not included in the analysis due to insufficient data
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Ability matched pairs were created and randomly assigned to groups
Allocation concealment (selection bias)	Unclear risk	Not stated
ITT analysis	Unclear risk	Not stated
Blinding of outcome assessment (detection bias) primary outcome	Unclear risk	Not stated

Methods	RCT
Participants	Country: Netherlands Sample size: 40 participants (20 in each group,; 4 dropped out during intervention period, 4 more dropped out after 6 months) Inclusion criteria: knowledge of Dutch language, Brunnstrom score upper extremity between 3 and 5; home dwelling status; at least 1 year post‐stroke Exclusion criteria: neglect; co‐morbidities that influenced upper extremity usage; history of multiple strokes
Interventions	2 arms: mirror therapy: participants were instructed to move both arms while looking in the mirror (moving arm covered) bilateral arm training: patients performed the same treatment protocol as in group 1, but without a mirror 1 and 2: once a week physiotherapeutic supervision for 60 minutes; 5 times a week, 60 minutes of practice at home for 6 weeks
Outcomes	Outcomes were recorded at baseline, post‐treatment and after 6 months FM‐UE motor score (0 to 66) Pain (VAS 0 to 100 mm) Grip force (in kg) TS elbow and wrist ARAT (0 to 57) ABILHAND questionnaire (self‐perceived arm use) Stroke ULAM (accelerometric measurement of arm movements during 24 hours) EuroQol (quality of life, EQ‐5D)
Notes	Published and unpublished data
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated random number sequence
Allocation concealment (selection bias)	Low risk	Patients received group allocation after baseline measurement
ITT analysis	Low risk	Results were analysed on an ITT basis
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT; 2 baseline subgroups
Participants	Country: Netherlands Sample size: 16 participants (6 in the outpatient centre group (Rothgangel 2004a), 10 in the inpatient rehabilitation group (Rothgangel 2004b) Inclusion criteria: first stroke in the territory of the middle cerebral artery; minimal 3 months post‐stroke; minimal score of 1 in the ARAT Exclusion criteria: bilateral stroke; severe neglect; severe visual impairments
Interventions	2 arms: mirror therapy: patients were instructed to move either both arms (muscle hypotonia), or just the unaffected arm (muscle hypertonia); therapist was moving the affected arm; gross, functional and fine‐motor movements were trained bilateral arm training: same treatment protocol as in group 1 but without a mirror 1 and 2: day hospital group (6 participants): 17 treatments during 5 weeks for 30 minutes each; inpatient rehabilitation group (10 participants): 37 treatments during 5 weeks for 30 minutes each
Outcomes	Outcomes were recorded at baseline, in the middle of the treatment, after 5 weeks of treatment and 10 weeks after baseline ARAT (0 to 57) Patient‐specific problem scale (0 to 100) Adverse events
Notes	Due to sufficient differences in treatment intensity, we analysed both experimental and both control groups separately Significant differences in baseline characteristics (age, ARAT, patient‐specific problem scale)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated random number sequence
Allocation concealment (selection bias)	Low risk	Patients received group allocation after baseline measurement
ITT analysis	Low risk	All patients were analysed as allocated to groups. No drop‐outs
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT; subgroup: outpatient centre
Participants	Country: Netherlands Sample size: 6 participants (3 in each group) Inclusion criteria: first stroke in the territory of the middle cerebral artery; minimal 3 months post‐stroke; minimal score of 1 in the ARAT Exclusion criteria: bilateral stroke; severe neglect; severe visual impairments
Interventions	2 arms: mirror therapy: patients were instructed to move either both arms (muscle hypotonia), or just the unaffected arm (muscle hypertonia); therapist was moving the affected arm; gross, functional and fine‐motor movements were trained bilateral arm training, same treatment protocol as in group 1 but without a mirror 1 and 2: 17 treatments during 5 weeks for 30 minutes each
Outcomes	Outcomes were recorded at baseline, in the middle of the treatment, after 5 weeks of treatment and 10 weeks after baseline ARAT (0 to 57) Patient‐specific problem scale (0 to 100)
Notes	Significant differences in baseline characteristics: patients in the experimental group were younger and had a lower ARAT score

Methods	RCT; subgroup: inpatient rehabilitation
Participants	Country: Netherlands Sample size: 10 participants (5 in each group) Inclusion criteria: first stroke in the territory of the middle cerebral artery; minimal 3 months post‐stroke; minimal score of 1 in the ARAT Exclusion criteria: bilateral stroke; severe neglect; severe visual impairments
Interventions	2 arms: mirror therapy: patients were instructed to move either both arms (muscle hypotonia), or just the unaffected arm (muscle hypertonia); therapist was moving the affected arm; gross, functional, and fine‐motor movements were trained bilateral arm training; same treatment protocol as in group 1 but without a mirror 1 and 2: day hospital group (6 participants): 17 treatments during 5 weeks for 30 minutes each; inpatient rehabilitation group (10 participants): 37 treatments during 5 weeks for 30 minutes each
Outcomes	Outcomes were recorded at baseline, in the middle of the treatment, after 5 weeks of treatment and 10 weeks after baseline ARAT (0 to 57) Patient‐specific problem scale (0 to 100)
Notes	Significant differences in baseline characteristics: patients in the experimental group were younger

Methods	RCT
Participants	Country: South Korea Sample size: 40 participants (19 in mirror therapy group, 21 in control group) Inclusion criteria: stroke within 6 months Exclusion criteria: not able to understand treatment instructions; communication difficulties due to aphasia; MMSE < 15 points; musculoskeletal or neurological damage of the unaffected upperextremity; modified Ashworth Scale of 3 or more points; Brunnstrom stage of recovery (arm) of 1 or more than 5 points
Interventions	2 arms: mirror therapy no additional therapy 1 and 2: 5 days a week, 30 minutes of therapy for 4 weeks
Outcomes	Outcomes were recorded at baseline and after 4 weeks of treatment MFT MMT Grip strength
Notes	Published data only, extracted in part on the basis of an unauthorised, automatic translation of the original publication in Korean Significant difference in MFT between groups at baseline measurement
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated random number sequence
Allocation concealment (selection bias)	Unclear risk	Not stated
ITT analysis	Unclear risk	Not stated
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT
Participants	Country: Turkey Sample size: 40 participants (20 in each group; 7 dropped out at 6 months follow‐up) Inclusion criteria: first unilateral stroke during previous 12 months; a score of 1 or 2 in the Brunnstrom stages of lower extremity; ambulatory before stroke Exclusion criteria: severe cognitive disorders
Interventions	2 arms: mirror therapy: participants were instructed to move the non‐paretic leg while looking in the mirror sham therapy: patients performed the same treatment protocol as in group 1 but with the non‐reflecting side of the mirror to the non‐affected leg 1 and 2: 5 days a week, 30 minutes of therapy for 4 weeks
Outcomes	Outcomes were recorded at baseline, after 4 weeks and after 6 months Brunnstrom stages lower extremity (0 to 6) FIM motor items (13 to 91) MAS (0 to 4)) FAC (0 to 5)
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Block randomisation, computer generated allocation of blocks
Allocation concealment (selection bias)	Low risk	The physicians who assessed potential participants to determine eligibility did not know to which group the participants would be allocated
ITT analysis	High risk	Drop‐outs were not included in analysis
Blinding of outcome assessment (detection bias) primary outcome	Low risk	Assessors were blinded to group allocation

Methods	RCT
Participants	Country: South Korea Sample size: 60 participants (20 in each of the 3 groups) Drop‐outs during intervention period: 0 Inclusion criteria: first unilateral stroke; Brunnstrom stage I‐IV; MMSE > 21 Exclusion criteria: not stated
Interventions	3 arms: mirror therapy: patients performed flexion and extension of fingers and wrist while looking in the mirror NMES was applied to extensor muscles on the paretic side and simultaneously underwent flexion and extension of fingers and wrist an the non‐paretic side while looking at the wooden board combined mirror therapy and NMES 1,2 and 3: 5 days a week, 30 minutes of therapy for 3 weeks
Outcomes	Outcomes were recorded at baseline and after 3 weeks of treatment FM (hand, wrist and co‐ordination) Hand power Muscle tone
Notes	Parts of the study were published on the World Stroke Congress 2010. Metaanalysis based on unpublished data We combined group 1 and 3 for analysis using raw data
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random sampling number table as stated by authors (unpublished information)
Allocation concealment (selection bias)	High risk	Stated by authors (unpublished information)
ITT analysis	High risk	Stated by authors (unpublished information)
Blinding of outcome assessment (detection bias) primary outcome	High risk	assessors not blinded, Stated by authors (unpublished information)

Study	Reason for exclusion
Adamovich 2009	Study on healthy people
Altschuler 2005	Study on healthy people
Dohle 2009b	Study did not use motor function as primary outcome
Eng 2007	Protocol. Study is not an RCT
Ezendam 2009	Review
Gaggioli 2009	Study is not an RCT
Garry 2005	Study on normal people
Grünert‐Plüss 2008	Study is not an RCT
Hamzei 2009	Review
Johnson 1999	Study is not an RCT
Krause 2007	Study was not finished
Merians 2009	Study is not an RCT
Michielsen 2011b	Study is not an RCT
Miltner 1998	Study is not an RCT. Method of randomisation was not adequate
Miltner 1999	Copy of Miltner 1998
Miltner 2000	Study is not an RCT
Miltner 2001	Study is not an RCT
Morganti 2003	Protocol. Study is not an RCT
Moseley 2004	Study did not include patients after stroke
Ramachandran 1999	Study is not an RCT
Ramachandran 2009	Review
Rothgangel 2007	Publication of the results of Rothgangel 2004
Sathian 2000	Study is not an RCT
Sathian 2009	Editorial
Shinoura 2008	Study is not an RCT
Stevens 2003	Study is not an RCT
Stevens 2004	Study is not an RCT
Wanschura 2010	Randomised controlled study on healthy people
Zhu 2009	Study is not an RCT. Method of randomisation was not adequate

Trial name or title	Mirror therapy in unilateral neglect after stoke ‐ MUST
Methods	RCT
Participants	Country: India Inclusion criteria: all stroke patients within 48 hours of onset with thalamic and parietal lobe lesions will be included
Interventions	Setting: stroke unit and College of Physiotherapy 2 arms: mirror therapy with limb activation only limb activation 1 and 2: 20 sessions, 1 to 2 hours each, for 4 weeks
Outcomes	Outcomes will be assessed before treatment, after 4 weeks and 2 months follow‐up Brunnstrom’s stage of recovery star cancellation and line bisection tests Catherine Bergegoscale FIM
Starting date
Contact information	Principal investigator: Dheeraj K, Christian Medical College and Hospital, Physiotherapy, Brown Road, Ludhiana, India Tel: +91 161 2229011 21
Notes	Estimated enrolment: 48 in each group

Trial name or title	Mirror therapy as group intervention after stroke: a randomised controlled trial
Methods	RCT
Participants	Country: Germany Inclusion criteria: first supratentorial stroke within the previous 3 months; aged between 18 and 80 years; clinically diagnosed severe hemiparesis or hemiplegia of the distal upper limb with Medical Research Council grading of 0 or 1 of wrist and finger extensors Exclusion criteria: visual impairments that may limit the participation in mirror therapy; severe cognitive and/or language deficits which preclude participants from following instructions in the group training protocol; other neurological or musculoskeletal impairments of the upper extremity not due to stroke; severe neglect (head is not turned to the affected side due to instruction)
Interventions	3 arms: mirror therapy: group intervention; participants exercise in open groups of 2 to 6 patients sham therapy: group intervention; participants exercise in open groups of 2 to 6 patients with the non‐reflecting side of the mirror positioned to the unaffected arm mirror therapy, single therapy: participants perform movements with both arms (the affected arm as best as could be) while watching the mirror image of the unaffected arm 1, 2 and 3: 20 sessions, 30 minutes each during 5 weeks
Outcomes	Outcomes will be assessed before and after treatment, and 7 months after treatment Fugl‐Meyer Assessment arm motor score (0 to 66) Fugl‐Meyer Assessment sensory assessment, range of motion and pain arm ARAT (0 to 57) Modified Ashworth Scale (0 to 5) Barthel Index (0 to 100) Stroke Impact Scale (quality of life) Neglect: Star Cancellation Test, Line Bisection Test
Starting date	April 2009
Contact information	Principal investigator: Holm Thieme, Schule für Physiotherapie (School for Physiotherapy), Erste Europäische Schule für Physiotherapie, Ergotherapie und Logopädie, Klinik Bavaria Kreischa, Kreischa, Germany Tel: +49 35206 64240 Email: holm.thieme@physiotherapie‐schule‐kreischa.de
Notes	Estimated enrolment: 66

PERMALINK

Mirror therapy for improving motor function after stroke

Holm Thieme

Jan Mehrholz

Marcus Pohl

Johann Behrens

Christian Dohle

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Mirror therapy for improving motor function after stroke

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Sensitivity analysis

Results

Description of studies

Table 1.

Results of the search

Included studies

Design

Sample Size

Participants

Interventions

Table 2.

Outcome

Primary outcome: motor function

Secondary outcomes: activities of daily living, pain and visuospatial neglect

Follow‐up assessment

Adverse effects

Excluded studies

Risk of bias in included studies

Table 3.

Figure 1.

Allocation

Blinding

Other potential sources of bias

Effects of interventions

Comparison 1: Mirror therapy versus all other interventions

Outcome 1.1: Motor function at the end of the intervention phase

Analysis 1.1.

Outcome 1.2: Activities of daily living at the end of the intervention phase

Analysis 1.2.

Outcome 1.3: Pain at the end of the intervention phase

Analysis 1.3.

Outcome 1.4: Visuospatial neglect at the end of the intervention

Analysis 1.4.

Outcome 1.5: Motor function at follow‐up after six months

Analysis 1.5.

Comparison 2: Subgroup analysis ‐ upper versus lower extremity

Outcome 2.1: Motor function at the end of the intervention phase

Trial name or title	Use of tendon vibration and mirror for the improvement of upper limb function and pain reduction
Methods	RCT
Participants	Country: Israel Inclusion criteria: stroke; 18 to 85 years of age; stroke onset between 1 month and 1 year ago; NIHSS 3 to 15 on study admission; affected upper limb function 10% to 90% on Fugl‐Meyer Scale; ability to understand instructions and to move the unaffected limb freely Exclusion criteria: severe cognitive impairment; severe aphasia; severe neglect that impairs ability to understand instructions or to execute tasks
Interventions	3 arms: mirror therapy: moving the healthy hand while watching the mirror tendon vibration and mirror therapy: vibration of 50 Hz to 100 Hz administrated to the elbow and wrist muscles together with the use of a mirror no mirror and sham vibration: moving both hands, the affected hand covered, sham vibration on bones 1, 2 and 3: 10 sessions, 30 minutes each
Outcomes	Outcomes will be assessed after treatment and 3 months after treatment Fugl Meyer Assessment arm FIM
Starting date	September 2009
Contact information	Principal Investigator: Elior Moreh, MD, Hadassah University Hospital, Jerusalem, Israel Email: elior@hadassah.org.il
Notes	Estimated enrolment: 30

Trial name or title	Mirror arm exercises for stroke
Methods	RCT
Participants	Country: United Kingdom Inclusion criteria: first time stroke at least 1 week previously and inpatient in a stroke rehabilitation unit; no premorbid conditions limiting upper limb function; sufficient cognitive and communication skills to give consent (as judged by the clinical team); medically stable and able to participate in rehabilitation (as judged by the clinical team); upper limb weakness which limits activity (Motricity Index Upper Limb score less than 99) Exclusion criteria: unable to consent; not a first time stroke; previous condition limiting upper limb function; unable to participate in rehabilitation; no upper limb weakness
Interventions	2 arms: mirror therapy for the upper extremity exercises to the legs delivered in the same way as the mirror therapy (but with no mirror) 1 and 2: 30 minutes a day for 4 weeks
Outcomes	Outcomes will be assessed at baseline, immediately after the trial and 1 month after the trial How well the patient can move and use their weak arm and hand Acceptability of therapy to patients and clinical team How much the patients used the treatment Side effects
Starting date	3 January 2011
Contact information	Principal Investigator: Miss Nessa Thomas, University of Salford, Centre for Rehabilitation and Human Performance Research, Allerton Building, Frederick Road, Salford, UK Email: n.thomas@salford.ac.uk
Notes	Estimated enrolment: 83