Mirror Therapy Versus Action Observation Therapy on Upper Limb Motor Function, Functional Independence, and Quality Oflife Among Chronic Stroke Patients

This randomized controlled trial aims to compare the effects of Mirror Therapy (MT) and Action Observation Therapy (AOT) on upper limb motor function, functional independence, and health-related quality of life in individuals with chronic stroke. Stroke-related upper limb impairment remains a major cause of long-term disability and reduced independence. Both MT and AOT are neurocognitive rehabilitation approaches based on activation of the mirror neuron system and promotion of neuroplasticity. Eligible participants with chronic stroke will be randomly allocated to either a Mirror Therapy group or an Action Observation Therapy group and will receive supervised interventions in addition to standard physiotherapy. Outcomes will be assessed using the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES), Fugl-Meyer Assessment for Upper Extremity (FMA-UE), and Short Form-36 Health Survey (SF-36). The study seeks to determine the comparative effectiveness of these interventions for improving upper limb function, functional independence, and quality of life among chronic stroke survivors.

Study Overview

• Status: Completed
• Conditions: Stroke
• Intervention / Treatment: Behavioral: Mirror Therapy; Behavioral: Action Observation Therapy

Detailed Description

Stroke is a leading cause of long-term disability worldwide and frequently results in persistent upper limb impairments that limit functional independence and participation in daily activities. Despite advances in rehabilitation, many stroke survivors continue to experience deficits in motor control, coordination, dexterity, and upper extremity function, particularly during the chronic phase of recovery. Therefore, identifying effective rehabilitation strategies that promote neuroplasticity and enhance motor recovery remains a priority in stroke rehabilitation.

Mirror Therapy (MT) and Action Observation Therapy (AOT) are neurocognitive rehabilitation interventions that have gained increasing attention because of their potential to facilitate motor recovery through activation of the mirror neuron system. Mirror Therapy involves observation of the reflection of movements performed by the unaffected limb, creating the visual illusion that the affected limb is moving normally. This visual feedback is believed to stimulate motor cortical areas and promote motor relearning. Action Observation Therapy involves observation of goal-directed motor tasks performed by another individual, followed by active imitation of the observed movements. Through observation and execution of actions, AOT is intended to enhance motor planning, motor learning, and cortical reorganization.

Although both interventions have demonstrated potential benefits in stroke rehabilitation, limited evidence exists directly comparing their effectiveness for improving upper limb function, functional independence, and quality of life among individuals with chronic stroke. This study has been designed to address this gap by evaluating and comparing the clinical effects of MT and AOT within a randomized controlled trial framework.

The study will be conducted at Goshe Shifa Hospital, Lahore, Pakistan. Participants diagnosed with chronic stroke (six months or more post-stroke), aged 45-75 years, with mild-to-moderate upper limb motor impairment, will be screened for eligibility. Eligible participants will be randomly assigned to one of two intervention groups using a computer-generated randomization sequence with allocation concealment through sealed opaque envelopes.

Participants allocated to the Mirror Therapy group will receive a structured upper limb rehabilitation program utilizing mirror-induced visual feedback. Sessions will include simple upper limb movements, functional activities, and task-specific training performed while observing the mirror reflection of the unaffected limb. Participants allocated to the Action Observation Therapy group will observe videos demonstrating goal-directed upper limb activities and subsequently practice the observed tasks under physiotherapy supervision.

Both interventions will be delivered for six weeks, five sessions per week, with each session lasting approximately 45 minutes. Outcome assessments will be performed at baseline and after completion of the intervention period by assessors blinded to group allocation.

The primary outcomes of interest include upper limb motor function, functional independence, and health-related quality of life. These outcomes will be measured using the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES), Fugl-Meyer Assessment for Upper Extremity (FMA-UE), and Short Form-36 Health Survey (SF-36), respectively.

The study is expected to contribute evidence regarding the comparative effectiveness of two widely used neurorehabilitation approaches and may assist clinicians in selecting appropriate interventions for upper limb rehabilitation in individuals with chronic stroke.

• Study Type: Interventional
• Enrollment (Actual): 76
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • Lahore, Pakistan, 54590
    • The University of Lahore Teaching Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Individuals diagnosed with chronic stroke (≥6 months post-stroke).
• Patients with stroke affecting either the left or right upper limb will be included.
• Mild-to-moderate upper limb motor impairment (Fugl-Meyer Upper Extremity Score between 19-55).
• Ability to follow verbal and visual instructions.
• Medically stable with no active comorbidities affecting rehabilitation (Tang et al., 2024).

Exclusion Criteria:

• Severe cognitive or communication impairments prevent task understanding.
• Presence of severe upper limb spasticity or contractures.
• History of severe visual or perceptual deficits (e.g., neglect, hemianopia).
• Uncontrolled epilepsy or active psychiatric disorders.
• Participation in other upper limb rehabilitation programs during the study period.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Mirror Therapy Group; Participants assigned to this group will receive Mirror Therapy in addition to standard physiotherapy. A mirror will be positioned in the midline so that movements of the unaffected upper limb are reflected, creating the visual illusion that the affected limb is moving normally. Treatment sessions will last 45 minutes, five days per week for six weeks. The intervention will include simple joint movements, functional upper limb activities, and task-specific training designed to promote motor recovery, functional independence, and neuroplasticity.	Behavioral: Mirror Therapy; Participants assigned to the Mirror Therapy intervention will receive supervised upper limb rehabilitation using mirror-induced visual feedback. A mirror will be positioned in the participant's midline, allowing observation of the reflection of the unaffected upper limb while the affected limb remains hidden. Sessions will include simple joint movements, functional tasks, and task-specific activities designed to promote motor relearning and cortical reorganization. Treatment will be delivered for 45 minutes per session, five days per week, for six weeks, alongside standard physiotherapy.
Experimental: Action Observation Therapy Group; Participants assigned to this group will receive Action Observation Therapy in addition to standard physiotherapy. Participants will observe videos demonstrating goal-directed upper limb activities and subsequently imitate the observed movements under physiotherapist supervision. Treatment sessions will last 45 minutes, five days per week for six weeks. The intervention will include observation, guided imitation, and repetitive practice of functional tasks aimed at improving motor planning, motor execution, upper limb function, and functional independence.	Behavioral: Action Observation Therapy; Participants assigned to the Action Observation Therapy intervention will observe videos demonstrating goal-directed upper limb activities and subsequently practice the observed movements under physiotherapist supervision. The intervention consists of an observation phase, guided imitation, and repetitive task practice to facilitate motor learning and neuroplasticity. Treatment sessions will last 45 minutes and will be conducted five days per week for six weeks in addition to standard physiotherapy.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Upper Limb Motor Function	Upper limb motor function will be assessed using the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES). Higher scores indicate better upper extremity motor performance and functional ability.	Baseline and 6 weeks (end of intervention)
Upper Extremity Motor Recovery	Motor recovery will be evaluated using the Fugl-Meyer Assessment for Upper Extremity (FMA-UE). The scale assesses motor impairment, coordination, reflex activity, and voluntary movement, with higher scores indicating improved motor recovery.	Baseline and 6 weeks (end of intervention)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Health-Related Quality of Life	Health-related quality of life will be measured using the Short Form-36 Health Survey (SF-36). The questionnaire evaluates physical and mental health domains, with higher scores representing better perceived health status and quality of life.	Baseline and 6 weeks (end of intervention)

Collaborators and Investigators

• Sponsor: University of Lahore

Publications and helpful links

General Publications

• Binks JA, Emerson JR, Scott MW, Wilson C, van Schaik P, Eaves DL. Enhancing upper-limb neurorehabilitation in chronic stroke survivors using combined action observation and motor imagery therapy. Front Neurol. 2023 Mar 2;14:1097422. doi: 10.3389/fneur.2023.1097422. eCollection 2023.
• Effectiveness of Home-Based Mirror Therapy on Enhancing the Upper Limb Sensory- Motor Recovery of Elderly Patients Post-Stroke. Assiut Scientific Nursing Journal, 12(41), 137-149.
• Kim YS, Song JY, Park SH, Lee MM. Effect of functional electrical stimulation-based mirror therapy using gesture recognition biofeedback on upper extremity function in patients with chronic stroke: A randomized controlled trial. Medicine (Baltimore). 2023 Dec 29;102(52):e36546. doi: 10.1097/MD.0000000000036546.
• Tang E, Moran N, Cadman M, Hill S, Sloan C, Warburton E; guideline committee. Stroke rehabilitation in adults: summary of updated NICE guidance. BMJ. 2024 Mar 22;384:q498. doi: 10.1136/bmj.q498. No abstract available.

Study record dates

Study Major Dates

• Study Start (Actual): February 3, 2025
• Primary Completion (Actual): March 19, 2026
• Study Completion (Actual): April 28, 2026

Study Registration Dates

• First Submitted: June 6, 2026
• First Submitted That Met QC Criteria: June 6, 2026
• First Posted (Actual): June 11, 2026

Study Record Updates

• Last Update Posted (Actual): June 11, 2026
• Last Update Submitted That Met QC Criteria: June 6, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: Quality of Life; Chronic Stroke; Action Observation; Motor Recovery; Mirror Therapy
• Additional Relevant MeSH Terms: Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases; Stroke; Therapeutics; Physical Therapy Modalities; Rehabilitation; Mirror Movement Therapy
• Other Study ID Numbers: UOL/IREB/25/09/0032

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No