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 person'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 compared with no treatment, placebo or sham therapy, or other treatments for improving motor function and motor impairment after stroke. We also aimed to assess the effects of mirror therapy on activities of daily living, pain, and visuospatial neglect.

Search methods: We searched the Cochrane Stroke Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, PsycINFO and PEDro (last searched 16 August 2017). 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 people after stroke.

Data collection and analysis: Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality, assessed risks of bias in the included studies, and extracted data. We assessed the quality of the evidence using the GRADE approach. We analysed the results as standardised mean differences (SMDs) or mean differences (MDs) for continuous variables, and as odds ratios (ORs) for dichotomous variables.

Main results: We included 62 studies with a total of 1982 participants that compared mirror therapy with other interventions. Of these, 57 were randomised controlled trials and five randomised cross-over trials. Participants had a mean age of 59 years (30 to 73 years). Mirror therapy was provided three to seven times a week, between 15 and 60 minutes for each session for two to eight weeks (on average five times a week, 30 minutes a session for four weeks).When compared with all other interventions, we found moderate-quality evidence that mirror therapy has a significant positive effect on motor function (SMD 0.47, 95% CI 0.27 to 0.67; 1173 participants; 36 studies) and motor impairment (SMD 0.49, 95% CI 0.32 to 0.66; 1292 participants; 39 studies). However, effects on motor function are influenced by the type of control intervention. Additionally, based on moderate-quality evidence, mirror therapy may improve activities of daily living (SMD 0.48, 95% CI 0.30 to 0.65; 622 participants; 19 studies). We found low-quality evidence for a significant positive effect on pain (SMD -0.89, 95% CI -1.67 to -0.11; 248 participants; 6 studies) and no clear effect for improving visuospatial neglect (SMD 1.06, 95% CI -0.10 to 2.23; 175 participants; 5 studies). No adverse effects were reported.

Authors' conclusions: The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, motor impairment, activities of daily living, and pain, at least as an adjunct to conventional rehabilitation for people after stroke. Major limitations are small sample sizes and lack of reporting of methodological details, resulting in uncertain evidence quality.

Conflict of interest statement

Holm Thieme (HT) is an author of an included study on the effect of mirror therapy after stroke. He was not involved in checking this trial for eligibility, extracting data or assessing the methodological quality of this study. He has received and will receive honorarium for presentations and seminars on mirror therapy.

Christian Dohle (CD) is author of two included studies on the effect of mirror therapy after stroke. He was not involved in checking these trials for eligibility, extracting data or assessing the methodological quality of the studies. He has received and will receive honorarium for presentations and seminars on mirror therapy.

Christian Dohle (CD) and Nadine Morkisch (NM) are authors of corresponding therapy manuals (Bieniok 2011; Morkisch 2015).

Jan Mehrholz: None known

Marcus Pohl: Marcus Pohl (MP) is an author of an included study on the effect of mirror therapy after stroke. He was not involved in checking this trial for eligibility, extracting data or assessing the methodological quality of this study.

Johann Behrens: Johann Begrens (JB) is an author of an included study on the effect of mirror therapy after stroke. He was not involved in checking this trial for eligibility, extracting data or assessing the methodological quality of this study.

Bernhard Borgetto: None known

Figures

1

Study flow diagram of updated search and selection process

2

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

1.1. Analysis

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

1.2. Analysis

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

1.3. Analysis

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 3 Fugl‐Meyer Assessment upper extremity at the end of intervention phase.

1.4. Analysis

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 4 Activities of daily living at the end of intervention phase.

1.5. Analysis

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 5 Pain at the end of intervention phase.

1.6. Analysis

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 6 Visuospatial neglect at the end of intervention.

1.7. Analysis

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 7 Motor function at follow‐up after 6 months.

1.8. Analysis

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 8 Motor impairment at follow‐up after 6 months.

1.9. Analysis

Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 9 Dropouts at the end of intervention phase.

2.1. Analysis

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

3.1. Analysis

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

4.1. Analysis

Comparison 4 Subgroup analysis: subacute versus chronic stage after stroke, Outcome 1 Motor function at the end of intervention phase.

5.1. Analysis

Comparison 5 Sensitivity analysis by trial methodology, Outcome 1 Motor function at the end of intervention.

5.2. Analysis

Comparison 5 Sensitivity analysis by trial methodology, Outcome 2 Motor impairment at the end of intervention.

6.1. Analysis

Comparison 6 Post hoc sensitivity analysis removing studies that only included participants with CRPS after stroke. Subgroup analysis: pain without complex regional pain syndrome (CRPS), Outcome 1 Pain at the end of intervention.