Mirror therapy for improving motor function after stroke

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.

Conflict of interest statement

Holm Thieme (HT) is principal investigator of an ongoing trial that may be relevant for the topic of this review. He has received and will receive honorarium for presentations and seminars on mirror therapy.

Christian Dohle (CD) is first author of one of the included studies on the effect of mirror therapy after stroke. He was not involved in checking this trial for eligibility, extracting data and assessing the methodological quality of the study. He has received and will receive honorarium for presentations and seminars on mirror therapy and is co‐author of a corresponding therapy manual (Nakaten 2009).

Figures

Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Analysis 1.1

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 1 Motor function at the end of intervention phase.

Analysis 1.2

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 2 Activities of daily living at the end of intervention phase.

Analysis 1.3

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 3 Pain at the end of intervention phase.

Analysis 1.4

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 4 Visuospatial neglect at the end of intervention.

Analysis 1.5

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 5 Motor function at follow‐up after 6 months.

Analysis 2.1

Comparison 2 Subgroup analysis: upper versus lower extremity, Outcome 1 Motor function at the end of intervention.

Analysis 3.1

Comparison 3 Subgroup analysis: sham intervention (covered mirror) versus other intervention (unrestricted view), Outcome 1 Motor function at the end of intervention phase.

Analysis 4.1

Comparison 4 Sensitivity analysis by trial methodology, Outcome 1 Motor function at the end of intervention.

Analysis 5.1

Comparison 5 Post‐hoc sensitivity analysis removing studies that only included patients with CRPS after stroke, Outcome 1 Motor function at the end of intervention.

Analysis 5.2

Comparison 5 Post‐hoc sensitivity analysis removing studies that only included patients with CRPS after stroke, Outcome 2 Pain at the end of intervention phase.

Analysis 5.3

Comparison 5 Post‐hoc sensitivity analysis removing studies that only included patients with CRPS after stroke, Outcome 3 Motor function at follow‐up after 6 months.