Apraxia

Evidence Reviewed as of before: 28-08-2020
Author(s)*: Annabel McDermott, OT; Annie Rochette, erg./OT (c) Ph.D.
Content consistency: Gabriel Plumier
Patient/Family Information Table of contents

Introduction

Apraxia is a neuropsychological deficit that interrupts an individual’s ability to perform purposeful movement, in the absence of basic sensorimotor difficulties such as lack of sensation or muscle weakness. Approximately 30% of individuals display apraxia or partial signs of apraxia (i.e. dyspraxia) following stroke, with a greater incidence among individuals with left hemisphere damage. Apraxia effects an individual’s autonomy for work and daily activities.

Patient/Family Information

What is apraxia?

Apraxia is a cognitive disorder that can occur after stroke. Apraxia is the inability to make purposeful movement, but is not due to sensory or motor disturbances (e.g. loss of sensation, muscle weakness). Apraxia effects the ability to perform movements and gestures.

Why do people get apraxia?

Approximately 30% of people who have had a stroke will display apraxia or partial signs of apraxia (i.e. dyspraxia). Apraxia is more common among people with damage to the left hemisphere of the brain. However, apraxia can also result from damage to other parts of the brain.

Are there different types of apraxia?

There are many different types of apraxia. The most common type of apraxia is buccofacial (or orofacial) apraxia:

  • Buccofacial apraxia: difficulty making movements of the mouth, eyes or face.

The most common forms of limb apraxia (i.e. affecting use of the arms/legs) are ideational apraxia and ideomotor apraxia:

  • Ideational apraxia: difficulty organizing actions to achieve a goal.
  • Ideomotor apraxia: difficulty selecting, sequencing and using objects.

Different forms of apraxia can also affect speech, touch, writing/drawing skills, eye movements, and body movements.

How can I recognize limb apraxia?

Limb apraxia affects a person’s ability to perform simple movements. This may be seen as difficulty imitating an action, performing an action in response to a spoken command, or understanding an action. Limb apraxia can affect the person’s arm movements for communication (e.g. using gestures) and daily activities (e.g. using familiar objects for everyday tasks).

Who diagnoses and treats apraxia?

Apraxia is difficult to diagnose because of the many different types of apraxia, the different definitions used to describe apraxia, and a lack of suitable assessments. Medical/health professionals can assess for apraxia in several different ways including using formal tests, and by observing the patient’s movements when imitating gestures, following spoken commands (e.g. “pretend to drink from a cup”), or using common objects.

Treatment will depend on the type of apraxia.

  • A Speech Language Pathologist can help the person who is experiencing difficulties with speech, language, communication/gestures, feeding, swallowing and mouth movements.
  • A Physiotherapist can help the person who is experiencing difficulties moving their body and limbs to make intended movements.
  • An Occupational Therapist can help the person who is having difficulty doing activities around the home and at work.

How does apraxia affect my recovery?

Apraxia impacts on a person’s ability to perform movements and gestures. Apraxia can impact on the person’s ability to do rehab activities (e.g. walking), communicate with others (e.g. using gestures) and complete common tasks (e.g. self-care tasks). This can affect their ability to relearn movements or learn new skills after stroke, which can impact on the person’s recovery, as well as their ability to perform daily activities and work tasks.

Will my apraxia get better?

Apraxia typically spontaneously recovers in the first few months post-stroke and is responsive to rehabilitation. The recovery process and rate of recovery will be different for each individual.

What can I expect from apraxia therapies?

Intervention can be customized to suit the person’s difficulties. Interventions for apraxia include:

  • Strategy training for daily activities (i.e. teaching specific strategies to overcome the difficulties to patient experiences)
  • Gesture training (i.e. relearning gestures)
  • Direct ADL training (i.e. relearning – or learning new ways to perform – daily tasks)
  • Using assistive technology to compensate for difficulties.

Will apraxia therapies work?

A small number of studies have investigated apraxia treatment. Results from these studies show benefits immediately after the treatment, but benefits may not last several months later. The lack of research regarding apraxia interventions impacts on the ability to draw strong conclusions regarding their effectiveness at this time.

Are there any side effects?

There are no significant side-effects from apraxia treatments.

My family member has apraxia. How can I help?

Stroke recovery requires patience and persistence from the person who had a stroke and their family/caregivers. If you or your loved one is experiencing apraxia after a stroke, the recovery process might be frustrating and stressful. It is important to continue with therapies, even if apraxia makes it challenging.

Follow this link to the Stroke Association (https://www.stroke.org.uk) for useful tips for communicating with a person who has had a stroke.

Where can I find more information about apraxia?

  • American Stroke Association (https://www.stroke.org)

Clinician Information

When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Apraxia is a neuropsychological deficit that disrupts an individual’s ability to perform purposeful movement, in the absence of basic sensorimotor difficulties such as lack of sensation or muscle weakness (Koski, Iacoboni & Mazziotta, 2002; Landry & Spaulding, 1999; West et al., 2008). Approximately 30% of individuals display apraxia or dyspraxia (i.e. partial signs of apraxia) following stroke, with a greater incidence among individuals with left hemisphere damage (Koski, Iacoboni & Mazziotta, 2002; Pazzaglia & Galli, 2019). Apraxia effects an individual’s independence for work and daily activities (Cantagallo, Maini & Rumiati, 2012; Dovern, Fink & Weiss, 2012; Koski, Iacoboni & Mazziotta, 2002; van Heugten, 2001).

Apraxia is most common among individuals with damage to the left parietal lobe, however can also result from damage to the right parietal lobe, temporal lobe, frontal lobe or subcortical regions (Koski, Iacoboni & Mazziotta, 2002). Apraxia impacts on an individual’s mental representation of an action, which in turn affects his/her ability to organize and imitate actions to achieve a goal (Bowen et al., 2009). Accordingly, apraxia limits an individual’s participation in rehabilitation, use of gestures for non-verbal communication, and performance of daily activities (Koski, Iacoboni & Mazziotta, 2002).

Numerous forms of apraxia have been defined (Koski, Iacoboni & Mazziotta, 2002). Ideational apraxia and ideomotor apraxia are the most common forms of the disorder, and are defined as follows:

Ideational apraxia: Difficulty in the ability to organize actions required to achieve a goal.

Ideomotor apraxia: Difficulty in the ability to select, sequence and use objects (West et al., 2008).

The heterogeneity of apraxia, as well as inconsistent definitions and the absence of a gold standard for assessment contribute to difficulty diagnosing the disorder (Dovern, Fink & Weiss, 2012; Lindsten-McQueen et al., 2014; West et al., 2008). For research purposes diagnosis is based on (i) neuropsychological testing to determine the presence/absence of apraxia; and (ii) standardized assessment of activities of daily living (ADLs) to determine the degree of impairment (van Heugten, 2001).

Apraxia typically spontaneously recovers in the first few months post-stroke (Cantagallo, Maini & Rumiati, 2012) and is responsive to rehabilitation (Buxbaum et al., 2008). Intervention can be customized to the presenting difficulties (Landry & Spaulding, 1999). Accordingly, interventions used in the treatment of apraxia include strategy training for ADLs using internal/external compensatory strategies; sensory stimulation using proprioceptive/deep pressure and sharp/soft touch; cueing using verbal or physical prompts; error reduction through chaining (forward/backward strategies); gesture training; conductive education; and normal movement approaches (Buxbaum et al., 2008; West et al., 2008).

A number of systematic reviews of interventions for apraxia have been conducted (Bowen et al., 2009; Lindsten-McQueen et al., 2014; Pazzaglia & Galli, 2019; Saikaley et al., n.d.; Worthington, 2016; van Heugten, 2001). A Cochrane Review of apraxia interventions following stroke by West et al. (2008) included three randomized controlled trials (two of which were considered suitable for inclusion in this review) that used strategy training, gesture training and transfer of training. The review showed a significant treatment effect immediately following apraxia intervention, but results were not sustained at 6 months post-stroke. Conclusive evidence of the benefit of apraxia therapies was not attained.

This review of interventions for apraxia following stroke includes 1 high quality RCT, 3 fair quality RCTs and 6 non-randomized studies. The majority of studies were conducted with individuals in the subacute phase of stroke recovery. Interventions include gesture training (3 studies), strategy training (5 studies) and direct training of ADLs (2 studies). While strategy training and gesture training were both shown to benefit some outcomes, the lack of research regarding apraxia interventions impacts on the ability to draw strong conclusions regarding their effectiveness at this time.

Results Table

View results table

Outcomes

Acute phase

No studies have been conducted in the acute phase of stroke recovery.

Subacute phase: Direct training of Activities of Daily Living for apraxia

Activities of Daily Living (ADLs)
Effective
2b

One non-randomised study (Goldenberg & Hagmann, 1998) investigated the use of direct training for apraxia on activities of daily living (ADLs) in the subacute phase of stroke recovery. This study assigned patients with left hemisphere stroke and apraxia to receive direct training and explorative training of daily tasks. Performance of ADLs was measured according to the number of fatal and reparable errors made during three trained/untrained tasks, assessed weekly over the intervention period (2-5 weeks) and at follow-up (6-30 months). At end of treatment 10 participants were able to complete all three ADL tasks without fatal errors; the remaining 5 participants made one fatal error. There was no generalisation of training effects from trained to untrained tasks. Participants who continued to practice activities at home showed fewer fatal errors at follow-up.

Conclusion: There is limited evidence (level 2b) from one non-randomised study that direct training of activities of daily living is effective in improving performance of trained activities of daily living among individuals with apraxia in the subacute phase of stroke recovery.
Note: Between-group comparisons were not made.

Subacute phase: Gesture training for apraxia

Gestural expression
Effective
2b

One non-randomised study (Daumuller & Goldenberg, 2010) investigated the effect of gesture training on gestural expression among individuals with apraxia in the subacute phase of stroke recovery. The non-randomised study assigned patients with left hemisphere stroke and severe aphasia (number of patients with apraxia not specified) to receive gestural therapy for 3 weeks or no gestural therapy. Gestural expression of participants who received gesture training was measured at week 1, week 2 and week 3 (practised gestures, unpractised gestures). A significant improvement in practised gestures was found at all timepoints, and a significant improvement in unpractised gestures was found at week 1 and week 2. A significant between-group difference in expression of unpractised gestures was found at week 2, in favour of gestural therapy vs. no therapy.

Conclusion: There is limited evidence (level 2b) from one non-randomised study that gesture training is more effective than no training for improving gestural expression in the subacute phase of stroke recovery. The study also reported a significant improvement in gestural expression following gesture training.

Chronic phase: Direct training of Activities of Daily Living for apraxia

Activities of Daily Living (ADLs)
Effective
2b

One non-randomised study (Goldenberg, Daumuller & Hagmann, 2001) investigated the use of direct training for apraxia on activities of daily living (ADLs) in the chronic phase of stroke recovery. This non-randomized crossover trial assigned patients with left hemisphere stroke and severe apraxia to receive direct training or explorative training of four activities. ADLs were measured according to number of errors and assistance provided during performance of trained and untrained tasks at 2-weekly intervals. A significant reduction in errors and assistance for ADL tasks was found at post-treatment (4 weeks) following direct training only. Results remained significant for assistance (but not errors) at follow-up (3 months).

Conclusion: There is limited evidence (level 2b) from one non-randomised study that direct training of activities of daily living is effective in improving performance of trained activities of daily living among patients with apraxia in the chronic phase of stroke recovery.
Note: Between-group comparisons were not made.

Phase not specific to one period: Gesture training for apraxia

Activities of Daily Living (ADLs) – carers’ perception
Effective
2a

One fair quality RCT (Smania et al., 2006) investigated the effect of gesture training for apraxia on carers’ self-perception of the patient’s ability to perform activities of daily living (ADLs) following stroke. The fair quality RCT randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. ADLs were measured by caregiver questionnaire at post-treatment (30 sessions) and follow-up (2 months post-treatment). A significant between-group difference was found at post-treatment, in favour of gesture training vs. aphasia rehabilitation. Results did not remain significant at follow-up.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is more effective than a comparison intervention (aphasia rehabilitation) for improving carers’ perception of the patient’s ability to perform activities of daily living immediately following treatment.

Constructional apraxia
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on constructional apraxia following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Constructional apraxia was measured at post-treatment (35 sessions). No significant improvement was found.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Constructional apraxia was measured at post-treatment (30 sessions). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is not more effective than a comparison intervention (aphasia rehabilitation) for improving constructional apraxia following stroke. A second fair quality RCT found no significant improvement in constructional apraxia following gesture-production training.

Gesture comprehension
Effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on gesture comprehension following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Gesture comprehension was measured by the gesture comprehension test at post-treatment (35 sessions). No significant improvement was found.

Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Gesture comprehension was measured at post-treatment (30 sessions) and follow-up (2 months post-treatment). A significant between-group difference was found at post-treatment, in favour of gesture training therapy vs. aphasia rehabilitation. Results did not remain significant at follow-up.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is more effective than a comparison intervention (aphasia rehabilitation) for improving gesture comprehension among patients with apraxia following stroke.
Note: However, a second fair quality RCT found no significant improvement in gesture comprehension following gesture production training.

Ideational apraxia
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on ideational apraxia following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Ideational apraxia was measured at post-treatment (35 sessions) according to the use of real objects and errors made (inadequate utilisation, sequence error, substitution, perplexity, localisation error, awkwardness, omission, total errors). A significant improvement in ideational apraxia was found following gesture-production training, but not conventional aphasia rehabilitation. Significant reduction in some errors (awkwardness, omissions, total errors) was also seen following gesture-production training.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Ideational apraxia was measured at post-treatment (30 sessions) and follow-up (2 months post-treatment). No significant between-group difference was found at either timepoint.
Note: There was a significant improvement in ideational apraxia at post-treatment, within the gesture training group only.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is not more effective than a comparison intervention (aphasia rehabilitation) for improving ideational apraxia following stroke.
Note:
However, both fair quality RCTs reported a significant improvement in ideational apraxia among participants who received gesture training.

Ideomotor apraxia
Effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on ideomotor apraxia following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Ideomotor apraxia was measured at post-treatment (35 sessions) using De Renzi’s test of ideomotor apraxia and errors made (unrecognisable, intrusion, position, perseveration, omission, inappropriate sequence, conduit d’approche, substitution, total errors). A significant improvement was found following gesture-production training, but not conventional aphasia rehabilitation. Significant reduction in some errors (unrecognisable, intrusion, position, total errors) was also seen following gesture-production training.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Ideomotor apraxia was measured at post-treatment (30 sessions) and follow-up (2 months post-treatment). A significant between-group difference was found at post-treatment, in favour of gesture training therapy vs. aphasia rehabilitation. Results did not remain significant at follow-up.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is more effective than a comparison intervention (aphasia rehabilitation) for improving ideomotor apraxia following stroke.
Note: The other fair quality RCT also reported a significant improvement in ideomotor apraxia following gesture training but not aphasia rehabilitation.

Intelligence
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on intelligence following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Intelligence was measured using Raven’s Progressive Matrices at post-treatment (35 sessions). No significant improvement was found.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Intelligence was measured using Raven’s Progressive Matrices at post-treatment (30 sessions). No significant between-group difference was found.
Note: There was a significant improvement in intelligence within the aphasia rehabilitation group only.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training is not more effective than a comparison intervention (aphasia rehabilitation) for improving performance on a test of intelligence following stroke.

Verbal comprehension
Not effective
2a

Two fair quality RCTs (Smania et al., 2000; Smania et al., 2006) investigated the effect of gesture training for apraxia on verbal comprehension following stroke.

The first fair quality RCT (Smania et al., 2000) randomized patients with subacute/chronic left hemispheric stroke and apraxia to receive gesture-production training or conventional aphasia rehabilitation. Verbal comprehension was measured using the Token Test at post-treatment (35 sessions). No significant improvement was found.
Note: Between-group differences were not reported.

The second fair quality RCT (Smania et al., 2006) randomized patients with subacute/chronic left hemisphere stroke and apraxia and aphasia to receive gesture training or conventional aphasia rehabilitation. Verbal comprehension was measured by the Token Test at post-treatment (30 sessions). No significant between-group difference was found.
Note: There was a significant improvement in verbal comprehension within the aphasia rehabilitation group only.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that gesture training for apraxia is not more effective than a comparison intervention (aphasia training) for improving verbal comprehension following stroke.

Phase not specific to one period: Strategy training for apraxia

Activities of Daily Living (ADLs)
Effective
1b

One high quality RCT (Donkervoort et al., 2001), one fair quality RCT (Geusgens et al., 2006), and two non-randomised studies (van Heugten et al., 1998; Geusgens et al., 2007) have investigated the effect of strategy training for apraxia on activities of daily living (ADLs) following stroke.

The high quality RCT (Donkervoort et al., 2001) randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. ADLs were measured using (i) the Barthel Index, (ii) standardised ADL observations for apraxia, and (iii) an ADL judgement list scored by the occupational therapist at post-treatment (8 weeks) and follow-up (3 months post-treatment). Significant between-group differences were found on two measures (Barthel Index, standardised ADL observations) at post-treatment, in favour of strategy training vs. occupational therapy alone; results did not remain significant at follow-up.

Further to the study by Donkervoort et al. (2001), a fair quality study (Geusgens et al., 2006) measured transfer of skills during trained and untrained ADLs on standardised observation of 4 tasks (washing face and upper body, putting on a shirt/blouse, preparing and eating a sandwich, preparing a cup of hot chocolate) at post-treatment (8 weeks) and follow-up (3 months). A significant between-group difference in non-trained ADLs was seen at post-treatment*, in favour of strategy training vs. occupational therapy alone; results did not remain significant at follow-up.
* Note: Results reflect change scores from baseline to post-treatment.

The first non-randomised study (van Heugten et al., 1998) assigned patients with acute/subacute left hemisphere stroke and apraxia to receive strategy training. ADLs were measured using (i) the Barthel Index, (ii) standardized observations of ADL performance (independence, initiation, execution and control) when completing 4 tasks (washing face and upper body, putting on a shirt, preparing and eating a sandwich, preparing coffee or tea), and (iii) a 16-item ADL questionnaire derived from the Rivermead ADL index, completed by the OT at post-treatment (12 weeks). Significant improvements were found on all measures at post-treatment.
Note: Further, van Heugten et al. (2000) noted a ceiling effect on ADL observations, whereby patients who were competent with ADLs prior to intervention demonstrated minimal improvement over time.

The second non-randomised study (Geusgens et al., 2007) assigned patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training of ADLs. ADLs were measured by (i) the Barthel Index at post-treatment (8 weeks), and (ii) standardised ADL observations (trained tasks, untrained tasks, total) at post-treatment and follow-up (20 weeks). A significant improvement in all measures of ADLs was found at post-treatment; results did not remain significant at follow-up.
Note: Lasting transfer effects from trained to non-trained tasks was seen at follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that strategy training for apraxia is more effective, in the short term, than a comparison intervention (occupational therapy alone) for improving performance of activities of daily living following stroke. Further, two non-randomised studies reported significant improvements in activities of daily living following strategy training (significant improvements were not maintained at follow-up in one of these non-randomised studies).

Activities of Daily Living (ADLs) – patient perception
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) investigated the effect of strategy training for apraxia on self-perception of activities of daily living (ADLs) following stroke. The high quality RCT randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Self-perception of ADLs was measured using an ADL judgement list scored by the patient at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either timepoint.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for improving individuals’ perception of their ability to perform activities of daily living following stroke.

Apraxia
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) and two non-randomised studies (van Heugten et al., 1998; Geusgens et al., 2007) investigated the effect of strategy training for apraxia on apraxia following stroke.

The high quality RCT (Donkervoort et al., 2001) randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Apraxia was measured using the Apraxia Test (object use, gesture imitation) at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either time point.

The first non-randomised study (van Heugten et al., 1998) assigned patients with acute/subacute left hemisphere stroke and apraxia to receive strategy training. Apraxia was measured at post-treatment (12 weeks) using a 2-item assessment adapted from De Renzi evaluating use of objects and imitation of gestures. A significant improvement in was found.

The second non-randomised study (Geusgens et al., 2007) assigned patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training of activities of daily living. Apraxia was measured by the Apraxia Test at post-treatment (8 weeks). A significant improvement was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for improving apraxia following stroke.
Note: However, two non-randomised studies found a significant improvement in apraxia following strategy training. Results suggest that strategy training is as effective as occupational therapy alone for improving apraxia following stroke.

Motor function
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) and two non-randomised studies (van Heugten et al., 1998; Geusgens et al., 2007) investigated the effect of strategy training for apraxia on motor function following stroke.

The high quality RCT (Donkervoort et al., 2001) randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Motor function was measured using the Functional Motor Test at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either time point.

The first non-randomised study (van Heugten et al., 1998) assigned patients with acute/subacute left hemisphere stroke and apraxia to receive strategy training. Motor functioning was measured at post-treatment (12 weeks) using an 8-item assessment of contralateral function (trunk balance, shoulder movement, arm movement, grasp and release of a cylinder, grasp and release a dice, tactile sensitivity). A significant improvement in motor functioning was found.

The second non-randomised study (Geusgens et al., 2007) assigned patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training of activities of daily living. Motor function was assessed by the Functional Motor Test at post-treatment (8 weeks). No significant improvement was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for improving motor function following stroke.
Note: Further, a non-randomized study found no significant improvement in motor function following strategy training. However, another non-randomized study found a significant improvement in motor function following strategy training.

Motor impairment
Not effective
1b

One high quality RCT (Donkervoort et al., 2001) investigated the effect of strategy training for apraxia on motor impairment following stroke. The high quality RCT randomised patients with subacute/chronic left hemisphere stroke and apraxia to receive strategy training integrated with occupational therapy or occupational therapy alone. Voluntary movement of the affected limbs was measured using the Motricity Index at post-treatment (8 weeks) and follow-up (3 months post-treatment). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strategy training for apraxia is not more effective than a comparison intervention (occupational therapy alone) for reducing motor impairment following stroke.

References

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Smania, N., Aglioti, S.M., Girardi, F., Tinazzi, M., Fiaschi, A., Cosentino, A., & Corato, E. (2006). Rehabilitation of limb apraxia improves daily life activities in patients with stroke. Neurology, 67, 2050-2. https://doi.org/10.1212/01.wnl.0000247279.63483.1f

van Heugten, C.M., Dekker, J., Deelman, B.G., van Dijk, A.J., Stehmann-Saris, J.C., & Kinebanian, A. (1998). Outcome of strategy training in stroke patients with apraxia: a phase II study. Clinical Rehabilitation, 12, 294-303. https://doi.org/10.1191/2F026921598674468328

Van Heugten, C.M., Dekker, J., Deelman, B.G., Stehmann-Saris, J.C., & Kinebanian, A. (2000). Rehabilitation of stroke patients with apraxia: the role of additional cognitive and motor impairments. Disability and Rehabilitation, 22(12), 547-54. https://doi.org/10.1080/096382800416797

Excluded studies:

Bolognini, N., Convento, S., Banco, E., Mattioli, F., Tesio, L., & Vallar, G. (2015). Improving ideomotor limb apraxia by electrical stimulation of the left posterior parietal cortex. Brain, 138, 428-39.
Reason for exclusion: study compared anodal transcranial direct current stimulation with sham stimulation.

Buchmann, I., Finkel, L., Dangel, M., Erz, D., Harscher, K.M., Kaupp-Merkle, M., Liepert, J., Rockstroh, B., & Randerath, J. (2019). A combined therapy for limb apraxia and related anosognosia. Neuropsychological Rehabilitation. https://doi.org/10.1080/09602011.2019.1628075
Reason for exclusion: case study (n=2)

Edmans, J.A., Webster, J., & Lincoln, N.B. (2000). A comparison of two approaches in the treatment of perceptual problems after stroke. Clinical Rehabilitation, 14, 230-243.
Reason for exclusion: the majority of participants did not present with limb dyspraxia.

Additional references:

Bowen, A., West, C., Hesketh, A., & Vail, A. (2009). Rehabilitation for apraxia: evidence for short-term improvements in activities of daily living. Stroke, 40:e396-e397. https://doi.org/10.1161/STROKEAHA.108.536946

Buxbaum, L.J., Haaland, K.Y., Hallett, M., Wheaton, L., Heilman, K.M., Rodriguez, A., & Gonzalez Rothi, L.J. (2008). Treatment of limb apraxia: moving forward to improved action. American Journal of Physical Medicine & Rehabilitation, 87(2), 149-61. https://europepmc.org/article/med/18209511

Cantagallo, A., Maini, M., & Rumiati, R.I. (2012). The cognitive rehabilitation of limb apraxia in patients with stroke. Neuropsychological Rehabilitation, 22(3), 473-88. http://dx.doi.org/10.1080/09602011.2012.658317

Dovern, A., Fink, G.R., & Weiss, P.H. (2012). Diagnosis and treatment of upper limb apraxia. Journal of Neurology, 259, 1269-83. https://link.springer.com/article/10.1007/s00415-011-6336-y

Koski, L., Iacoboni, M., & Mazziotta, J.C. (2002). Deconstructing apraxia: understanding disorders of intentional movement after stroke. Current Opinion in Neurology, 15, 71-7. https://europepmc.org/article/med/11796953

Landry, J. & Spalding, S. (1999). Assessment and intervention with clients with apraxia: contributions from the literature. Canadian Journal of Occupational Therapy, 66(1), 52-61. https://doi.org/10.1177%2F000841749906600106

Lindsten-McQueen, K., Williamson Weiner, N., Wang, H.-Y., Josman, N., & Tabor Connor, L. (2014). Systematic review of apraxia treatments to improve occupational performance outcomes. OTJR: Occupation, Participation and Health, 34(4), 183-92. https://doi.org/10.3928/2F15394492-20141006-02

Pazzaglia, M. & Galli, G. (2019). Action observation for neurorehabilitation in apraxia. Frontiers in Neurology, 10:309. https://doi.org/10.3389/fneur.2019.00309

Saikaley, M., Iruthayarajah, J., Orange, J., Welch-West, P., Salter, K., Macaluso, S., & Teasell, R. (n.d.) Chapter 14: Aphasia and apraxia rehabilitation (19th edition). Evidence-Based Review of Stroke Rehabilitation. Retrieved from http://www.ebrsr.com/sites/default/files/ch%2014_version19.pdf

van Heugten, C. (2001). Rehabilitation and management of apraxia after stroke. Reviews in Clinical Gerontology, 11, 177-84.

West, C., Bowen, A., Hesketh, A., & Vail, A. (2008). Interventions for motor apraxia following stroke. Cochrane Database of Systematic Reviews, 2008(1), 1-17. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004132.pub2/abstract

Worthington, A. (2016). Treatment and technologies in the rehabilitation of apraxia and action disorganization syndrome: a review. NeuroRehabilitation, 39, 163-74 https://pubmed.ncbi.nlm.nih.gov/27314872/

Mirror Therapy – Upper Extremity

Evidence Reviewed as of before: 26-10-2018
Author(s)*: Annabel McDermott, OT; Adam Kagan, B.Sc.; Samuel Harvey-Vaillancourt, PT U3; Shahin Tavakol, PT U3; Dan Moldoveanu, PT U3; Phonesavanh Cheang, PT U3; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT
Content consistency: Gabriel Plumier
Patient/Family Information Table of contents

Introduction

Mirror therapy is a type of motor imagery whereby the patient moves his unaffected limb while watching the movement in a mirror; this in turn sends a visual stimulus to the brain to promote movement in the affected limb. Some of the effects of mirror therapy on the brain have already been demonstrated. A crossover study on healthy individuals by Garry, Loftus & Summers (2004) showed that viewing the mirror image of an individual’s active hand increased the excitability of neurons in the ipsilateral primary motor cortex significantly more than viewing the inactive hand directly (no mirror). The study also found a trend toward significance in favour of viewing a mirror image of the active hand compared to viewing the active hand directly (no mirror).

There is a growing body of evidence regarding the use of mirror therapy on the upper extremity following stroke. Please also see our Mirror Therapy – Lower Extremity module for studies that have investigated the use of mirror therapy with the lower limbs.

Patient/Family Information

What is mirror therapy?

Mirror therapy is a specific therapy designed to strengthen arms and hands weakened by a stroke. In mirror therapy, we use movements of the stronger hand and arm to “trick our brain” into thinking that the weaker arm is moving. Researchers have shown that this “tricking of the brain” actually works – the brain areas responsible for making the weaker arm move become stimulated. There is also some new work being done using mirror therapy on the leg (see photographs – under section – How often do I need to practice?)

How do I set up mirror therapy at home?

You start by placing a solid stand-alone mirror on a table lengthwise in front of you. NOTE: You should sit in a sturdy chair while doing this activity. Place both your arms on the table one on either side of the mirror. The mirror side (where you can see the reflection of your arm) is placed so that you see your stronger arm. It is important that the mirror is large enough so that you can see your whole arm and hand in it. You should not look at your weaker hand and arm – only focus on looking into the mirror. Now move your stronger hand while you watch the mirror. The image that you see in the mirror will make it seem like your weak hand is moving. This information on arm movement is sent to your brain that is then “tricked” into thinking that your weaker arm is moving.

Will it be of benefit to me?

Mirror therapy is especially useful for people who have very little movement of their arm and hand after a stroke. The research on how well this intervention works is still quite new. There is some encouraging evidence that suggests that by using mirror therapy, the part of your brain that is damaged is stimulated, encouraging recovery. In fact, research has shown that some patients experience greater improvements in movement when they participate in mirror therapy in addition to their regular therapy, instead of just regular therapy alone. More research in the future will give us more information on just how beneficial mirror therapy is after a stroke.

Are there any risks to me?

There are no specific risks involved in participating in mirror therapy. It is important to use a non-breakable mirror just in case it falls over. It is also important to work in a seated position so that you can focus on your arm and hand without having to think about your balance and standing safety.

Mirror therapy is actually quite easy to do at home and many people find it a fun way of having additional therapy for their hand and arm.

Do I need any special equipment?

While specialized mirror boxes are available for purchase, using a sturdy table-sized mirror with a good solid stand works just as well.

How often do I need to practice?

There is no standardized protocol for mirror therapy. You should start with whatever amount of time you can tolerate and enjoy, and then gradually work up to a full series of movements and activities.

How do I begin?

Your rehabilitation therapist should be able to provide you with a program that will meet your individual needs. She or he can guide you as to:

  • how many times a week you should do mirror therapy,
  • what specific activities and movements you should do,
  • what activities you should not do,
  • how long each mirror therapy session should be,
  • how to change activities as your hand and arm get stronger.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Thirty-five studies (18 high quality RCTs, 14 fair quality RCTs, two poor quality RCTs and one non-randomized study) have investigated the effect of mirror therapy post-stroke. Of these, just three studies (one high quality RCT, one fair quality RCT and one non-randomized study) were conducted specifically with patients in the acute phase of stroke recovery, whereas the majority of studies were conducted with patients in the subacute or chronic phases of recovery. Across studies, outcomes included functional independence, dexterity, grip strength and hand function, upper extremity kinematics, sensory function, motor function and activity, pain, range of motion, and unilateral spatial neglect.

Results from this StrokEngine review showed strong evidence (level 1a) to support the use of mirror therapy to improve unilateral spatial neglect in the subacute phase of stroke recovery, and to improve upper extremity kinematics and motor function in the chronic phase of stroke recovery. Mirror therapy was comparable with other interventions for other outcomes. No adverse effects were reported.

Results Table

View results table

Outcomes

Acute Phase

Functional independence
Effective
2A

One fair quality RCT (Invernizzi et al., 2013) and one non-randomized study (Yeldan et al., 2015) investigated the effect of mirror therapy on functional independence in patients with acute stroke.

The fair quality RCT (Invernizzi et al., 2013) randomized patients to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure at post-treatment (4 weeks). There was a significant between-group difference, in favour of mirror therapy vs. sham mirror therapy.

The non-randomized study (Yeldan et al., 2015) assigned patients to receive mirror therapy or no mirror therapy; both groups received neurodevelopmental treatment. Functional independence was measured by the Barthel Index at post-treatment (3 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving functional independence in patients with acute stroke.

Note: A non-randomized study found no difference between mirror therapy and no mirror therapy, when both patient groups also received neurodevelopmental treatment.

Motor function
Effective
2A

One fair quality RCT (Invernizzi et al., 2013) and one non-randomized study (Yeldan et al., 2015) investigated the effect of mirror therapy on upper extremity motor function in patients with acute stroke.

The fair quality RCT (Invernizzi et al., 2013) randomized patients to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Action Research Arm Test at post-treatment (4 weeks). There was a significant between-group difference, in favour of mirror therapy vs. sham mirror therapy.

The non-randomized study (Yeldan et al., 2015) assigned patients to receive mirror therapy or no mirror therapy; both groups received neurodevelopmental treatment. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity, and Stroke Upper Limb Capacity Scale at post-treatment (3 weeks). No significant between-group differences on any of the measures were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving upper extremity motor function in patients with acute stroke.

Note: A non-randomized study found no difference between mirror therapy and no mirror therapy, when both patient groups also received neurodevelopmental treatment.

Sensory integration
Not effective
2b

One non-randomized study (Yeldan et al., 2015) investigated the effect of mirror therapy on upper extremity sensory integration in patients with acute stroke. This study assigned patients to receive mirror therapy or no mirror therapy; both groups received neurodevelopmental treatment. Somatosensory perception was measured by the Ayres Southern Californian Sensory Integration Tests (Finger identification, Right-left discrimination items) at post-treatment (3 weeks). No significant between-group differences on any of the measures were found.

Conclusion: There is limited evidence (Level 2b) from one non-randomized study that mirror therapy is not more effective than no mirror therapy for improving somatosensory perception in patients with acute stroke.

Strength
Effective
2a

One fair quality RCT (Invernizzi et al., 2013) and one non-randomized study (Yeldan et al., 2015) investigated the effect of mirror therapy on upper extremity strength in patients with acute stroke.

The fair quality RCT (Invernizzi et al., 2013) randomized patients to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity strength was measured by the Motricity Index at post-treatment (4 weeks). There was a significant between-group difference, in favour of mirror therapy vs. sham mirror therapy.

The non-randomized study (Yeldan et al., 2015) assigned patients to receive mirror therapy or no mirror therapy; both groups received neurodevelopmental treatment. Upper extremity strength was measured by the Motricity Index at post-treatment (3 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving upper extremity strength in patients with acute stroke.

Note: A non-randomized study found no difference between mirror therapy and no mirror therapy, when both patient groups also received neurodevelopmental treatment.

Unilateral spatial neglect
Effective
1B

One high quality RCT (Pandian et al., 2014) investigated the effect of mirror therapy on unilateral spatial neglect in patients with acute stroke. This high quality RCT randomized patients to receive mirror therapy or sham mirror therapy. Unilateral spatial neglect was measured by the Star Cancellation Test, Line Bisection Test and Picture Identification Task at post-treatment (1 month) and follow-up (3 months, 6 months). There were significant between-group differences in all measures at all time points, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving unilateral spatial neglect in patients with acute stroke.

Subacute Phase

Dexterity
Conflicting
4

Two high quality RCTs (Kim, Lee & Song, 2014; Samuelkamaleshkumar et al., 2014) investigated the effect of mirror therapy on dexterity in patients with subacute stroke.

The first high quality RCT (Kim, Lee & Song, 2014) randomized patients to receive mirror therapy and functional electrical stimulation (FES) or sham mirror therapy and FES; both groups received conventional rehabilitation. Dexterity was measured by the Box and Block Test at post-treatment (4 weeks). No significant between-group difference was found.

The second high quality RCT (Samuelkamaleshkumar et al., 2014) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Dexterity was measured by the Box and Block Test at post-treatment (3 weeks). A significant between-group difference was found, in favour of mirror therapy vs. no mirror therapy.

Conclusion: Conflicting evidence (Level 4) between two high quality RCTs was found regarding the effect of mirror therapy on dexterity in patients with subacute stroke . These evidence indicate that mirror therapy is not more effective than simulated mirror therapy and functional electrical stimulation, but more effective than no mirror therapy.

Functional independence
Not effective
1A

Three high quality RCTs (Dohle et al., 2009; Thieme et al., 2012; Lim et al., 2016) and two fair quality RCTs (Radajewska et al., 2013, 2017; Gurbuz et al., 2016) investigated the effect of mirror therapy on functional independence in patients with subacute stroke.

The first high quality RCT (Dohle et al., 2009) randomized patients to receive mirror therapy or upper extremity training while watching the affected limb. Functional independence was measured by the Functional Independence Measure (FIM – Motor score) at post-treatment (6 weeks). No significant between-group difference was found.

The second high quality RCT (Thieme et al., 2012) randomized patients to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Functional independence was measured by the Barthel Index (BI) at post-treatment (5 weeks). No significant between-group differences were found.

The third high quality RCT (Lim et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy. Functional independence was measured by the modified BI at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

The first fair quality RCT (Radajewska et al., 2013, 2017) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional stroke rehabilitation. Functional independence was measured by the Functional Index ‘Repty’ at post-treatment (3 weeks). No significant between-group difference was found.

The second fair quality RCT (Gurbuz et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy. Functional independence was measured by the FIM at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and two fair quality RCTs that mirror therapy is not more effective than comparison interventions (upper extremity training while watching the affected limb, sham group mirror therapy, no mirror therapy) in improving functional independence in patients with subacute stroke.

Note: However, a third high quality RCT found that mirror therapy was more effective than sham mirror therapy.

Motor activity
Effective
1b

One high quality RCT (Cacchio et al., 2009a) investigated the effect of mirror therapy on upper limb motor activity in patients with subacute stroke. This high quality RCT randomized patients with subacute stroke and Complex Regional Pain Syndrome type 1 to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity motor activity was measured by the Motor Activity Log – Quality of Movement score at post-treatment (4 weeks) and follow-up (6 months). A significant between-group difference was found at both time points, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving upper extremity motor activity in patients with subacute stroke.

Motor function
Conflicting
4

Six high quality RCTs (Cacchio et al., 2009a; Dohle et al., 2009; Thieme et al., 2012; Kim, Lee & Song, 2014; Samuelkamaleshkumar et al., 2014; Lim et al., 2016) and eight fair quality RCTs (Yun et al., 2011; Lee, Cho & Song, 2012; Bae, Jeong & Kim, 2012; Radajewska et al., 2013, 2017; Mirela et al., 2015; Nagapattinam et al., 2015; Rehani, kumari & Midha, 2015; Gurbuz et al., 2016) investigated the effect of mirror therapy on upper extremity motor function in patients with subacute stroke.

The first high quality RCT (Cacchio et al., 2009a) randomized patients with subacute stroke and Complex Regional Pain Syndrome type 1 to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Wolf Motor Function Test – Functional Ability and Performance Time (WMFT-FA; WMFT-PT) at post-treatment (4 weeks) and follow-up (6 months). Significant between-group differences were found on both measures and at both time points, in favour of mirror therapy vs. sham mirror therapy.

The second high quality RCT (Dohle et al., 2009) randomized patients to receive mirror therapy or upper extremity training while watching the affected limb. Upper extremity motor function was measured by the Action Research Arm Test (ARAT – Grasp, Grip, Pinch, Gross movement scores) and the Fugl-Meyer Assessment (FMA – Proximal arm, Hand, Finger scores) at post-treatment (6 weeks). No significant between-group differences were found.

Note: However, in a subgroup of patients with distal plegia, a significant difference was seen in distal function (FMA – Finger score), in favour of mirror therapy vs. sham mirror therapy.

The third high quality RCT (Thieme et al., 2012) randomized patients to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Upper extremity motor function was measured by the ARAT and the FMA (Motor score) at post-treatment (5 weeks). No significant between-group differences on any of the measures were found.

The fourth high quality RCT (Kim, Lee & Song, 2014) randomized patients to receive mirror therapy and functional electrical stimulation (FES) or sham mirror therapy and FES; both groups received conventional rehabilitation. Upper extremity motor function was measured by the FMA (Shoulder/elbow/forearm, Wrist, Hand, Coordination subtests) and the Manual Function Test (MFT – Shoulder, Hand subtests) at post-treatment (4 weeks). Significant between-group differences in measures of distal function (FMA – Wrist, Hand subtests; MFT – Hand subtest) were seen, in favour of mirror therapy + FES vs. sham mirror therapy + FES.

The fifth high quality RCT (Samuelkamaleshkumar et al., 2014) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the FMA – Upper Extremity (FMA-UE) at post-treatment (3 weeks). A significant between-group difference was found, in favour of mirror therapy vs. no mirror therapy.

The sixth high quality RCT (Lim et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy. Upper extremity motor function was measured by the FMA at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

The first fair quality RCT (Yun et al., 2011) randomized patients to receive mirror therapy + neuromuscular electrical stimulation (NMES), mirror therapy, or NMES. Upper extremity motor function was measured by the FMA (Wrist, Hand, Coordination, combined scores) at post-treatment (3 weeks). There was no significant difference between mirror therapy vs. NMES.

Note: There were significant between-group differences in favour of mirror therapy + NMES vs. mirror therapy alone or NMES alone.

The second fair quality RCT (Lee, Cho & Song, 2012) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the FMA (Shoulder/elbow/forearm, Wrist, Hand, Coordination subtests) and the MFT (Upper limb, Hand subtests) at post-treatment (4 weeks). Significant between-group differences were found for most measures (FMA – Shoulder/elbow/forearm, Wrist, Hand subtests; MFT – Upper limb, Hand subtests), in favour of mirror therapy vs. no mirror therapy.

The third fair quality RCT (Bae, Jeong & Kim, 2012) randomized patients to receive mirror therapy or unilateral upper limb exercises while watching the non-paretic limb; both groups received conventional rehabilitation. Upper extremity motor function was measured by the MFT at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. unilateral upper limb exercises.

The fourth fair quality RCT (Radajewska et al., 2013, 2017) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional stroke rehabilitation. Upper extremity motor function was measured by the Frenchay Arm Test and Motor Status Score at post-treatment (3 weeks). A significant between-group difference in one measure of upper extremity motor function (Frenchay Arm Test) was found, in favour of mirror therapy vs. no mirror therapy.

The fifth fair quality RCT (Mirela et al., 2015) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE at post-treatment (6 weeks). A significant between-group difference was found, in favour of mirror therapy vs. no mirror therapy.

The sixth fair quality RCT (Nagapattinam et al., 2015) randomized patients to receive mirror therapy, FES, or mirror therapy + FES. Upper extremity motor function was measured by the ARAT (Grasp, Grip, Pinch, Gross movement, Total scores) at post-treatment (2 weeks). No significant between-group differences were found.

The seventh fair quality RCT (Rehani, kumari & Midha, 2015) randomized patients to receive mirror therapy or a Motor Relearning Principles exercise program; both groups received conventional physiotherapy. Upper extremity motor function was measured using the Chedoke Arm and Hand Activity Inventory at post-treatment (4 weeks). No significant between-group difference was found.

The eight fair quality RCT (Gurbuz et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is conflicting evidence (level 4) regarding the effect of mirror therapy on upper extremity motor function in patients with subacute stroke. Three high quality RCTs and five fair quality RCTs found that mirror therapy was more effective than no mirror therapy or comparison interventions (sham mirror therapy and unilateral upper limb exercises); however, two high quality RCTs and three fair quality RCTs found no difference between mirror therapy and comparison interventions (upper extremity training, sham group mirror therapy, neuromuscular electrical stimulation, functional electrical stimulation or Motor Relearning Principles exercise program).

Note: A high quality RCT found benefits were localised to distal function when mirror therapy was combined with FES. Another high quality RCT saw a significant difference in distal function of patients with distal plegia, in favour of mirror therapy vs. sham mirror therapy.

Motor recovery
Conflicting
4

Three high quality RCTs (Kim, Lee & Song, 2014; Samuelkamaleshkumar et al., 2014; Lim et al., 2016) and three fair quality RCTs (Lee, Cho & Song, 2012; Mirela et al., 2015; Gurbuz et al., 2016) investigated the effect of mirror therapy on upper extremity motor recovery in patients with subacute stroke.

The first high quality RCT (Kim, Lee & Song, 2014) randomized patients to receive mirror therapy and functional electrical stimulation (FES) or sham mirror therapy and FES; both groups received conventional rehabilitation. Upper extremity motor recovery was measured by Brunnstrom stages of motor recovery (Upper extremity, Hand scores) at post-treatment (4 weeks). A significant between-group difference in distal recovery (Hand score) was seen, in favour of mirror therapy + FES vs. sham mirror therapy + FES.

The second high quality RCT (Samuelkamaleshkumar et al., 2014) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor recovery was measured by Brunnstrom stages of motor recovery (Upper extremity, Hand scores) at post-treatment (3 weeks). Significant between-group differences were found in proximal and distal recovery, in favour of mirror therapy vs. no mirror therapy.

The third high quality RCT (Lim et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy. Upper extremity motor recovery was measured by Brunnstrom stages of motor recovery (Upper extremity, Hand scores) at post-treatment (4 weeks No significant between-group differences on any of the measures were found.

The first fair quality RCT (Lee, Cho & Song, 2012) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor recovery was measured by Brunnstrom stages of motor recovery (Upper extremity, Hand scores) at post-treatment (4 weeks). Significant between-group differences were found in proximal and distal recovery, in favour of mirror therapy vs. no mirror therapy.

The second fair quality RCT (Mirela et al., 2015) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor recovery was measured by Brunnstrom stages of motor recovery at post-treatment (6 weeks). No significant between-group difference was found.

The third fair quality RCT (Gurbuz et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Motor recovery was measured by Brunnstrom stages of motor recovery (Upper extremity, Hand scores) at post-treatment (4 weeks). No significant between-group differences on any of the measures were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mirror therapy on upper extremity motor recovery in patients with subacute stroke: One high quality RCT and one fair quality RCT found that mirror therapy was more effective than no mirror therapy, whereas one high quality RCT and two fair quality RCTs found no difference in outcomes between mirror therapy and sham/no mirror therapy.

Note: A third high quality RCT found that benefits were localised to distal motor recovery when mirror therapy was combined with FES.

Muscle power
Not effective
2a

One fair quality RCT (Yun et al., 2011) investigated the effect of mirror therapy on upper extremity muscle power in patients with subacute stroke. This fair quality RCT randomized patients to receive mirror therapy + neuromuscular electrical stimulation (NMES), mirror therapy, or NMES. Upper extremity muscle power (hand flexion/extension, wrist flexion/extension) was measured by manual muscle testing at post-treatment (3 weeks). There was no significant difference between mirror therapy and NMES.

Note: There were significant between-group differences in hand extension power only, in favour of mirror therapy + NMES vs. mirror therapy alone or NMES alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is not more effective than a comparison intervention (neuromuscular electrical stimulation) for improving muscle power in patients with subacute stroke.

Pain
Not effective
1a

Three high quality RCTs (Cacchio et al., 2009a; Dohle et al., 2009; Thieme et al., 2012) investigated the effect of mirror therapy on upper limb pain in patients with subacute stroke.

The first high quality RCT (Cacchio et al., 2009a) randomized patients with subacute stroke and Complex Regional Pain Syndrome type 1 to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity pain (at rest, on movement) and tactile allodynia were measured by visual analogue scale at post-treatment (4 weeks) and follow-up (6 months). Significant between-group differences in all measures were found at both time points, in favour of mirror therapy vs. sham mirror therapy.

The second high quality RCT (Dohle et al., 2009) randomized patients to receive mirror therapy or upper extremity training while watching the affected limb. Pain was measured by the Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (FMA – Pain score) at post-treatment (6 weeks). No significant between-group difference was found.

The third high quality RCT (Thieme et al., 2012) randomized patients to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Upper extremity pain was measured by the FMA (Pain score) at post-treatment (5 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is not more effective than comparison interventions (upper extremity training while watching the affected limb, sham group mirror therapy) for reducing upper limb pain in patients with subacute stroke.
Note:
However, one high quality RCT found that mirror therapy was more beneficial than sham mirror therapy for reducing pain and tactile allodynia in patients with subacute stroke and Complex Regional Pain Syndrome type 1, when measured using a visual analogue scale.

Range of motion
Not effective
1A

Two high quality RCTs (Dohle et al., 2009; Thieme et al., 2012) investigated the effect of mirror therapy on upper extremity range of motion (ROM) in patients with subacute stroke.

The first high quality RCT (Dohle et al., 2009) randomized patients to receive mirror therapy or upper extremity training while watching the affected limb. Upper extremity ROM was measured by the Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (FMA – ROM score) at post-treatment (6 weeks). No significant between-group difference was found.

The second high quality RCT (Thieme et al., 2012) randomized patients to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Upper extremity ROM was measured by the FMA (ROM score) at post-treatment (5 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is not more effective than comparison interventions (upper extremity training while watching the affected limb or sham group mirror therapy) for improving upper extremity range of motion in patients with subacute stroke.

Sensory function
Not effective
1A

Two high quality RCTs (Dohle et al., 2009; Thieme et al., 2012) investigated the effect of mirror therapy on upper limb sensorimotor function in patients with subacute stroke.

The first high quality RCT (Dohle et al., 2009) randomized patients to receive mirror therapy or upper extremity training while watching the affected limb. Upper extremity sensorimotor function was measured by the Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (FMA – Light touch, Proprioception scores) at post-treatment (6 weeks). A significant between-group difference in surface sensibility (FMA – Light touch) was found in favour of mirror therapy group vs. upper extremity training.

The second high quality RCT (Thieme et al., 2012) randomized patients with subacute stroke to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Upper extremity sensorimotor function was measured by the FMA (Sensory score) at post-treatment (5 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is not more effective than comparison interventions (upper extremity training, sham group mirror therapy) for improving upper extremity sensory function (proprioception only) in patients with subacute stroke.

Note: There was conflicting evidence between the two studies regarding the effect of mirror therapy on light touch – mirror therapy was more effective than upper extremity training but was no more effective than sham group mirror therapy.

Spasticity
Not effective
1A

Two high quality RCTs (Thieme et al., 2012; Samuelkamaleshkumar et al., 2014) and two fair quality RCTs (Yun et al., 2011; Mirela et al., 2015) investigated the effect of mirror therapy on upper extremity spasticity in patients with subacute stroke.

The first high quality RCT (Thieme et al., 2012) randomized patients to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Upper extremity spasticity was measured by the Modified Ashworth Scale (MAS – Finger flexors, Wrist flexors) at post-treatment (5 weeks). No significant differences between mirror therapy vs. sham group mirror therapy were found.

Note: A significant between-group difference in resistance to passive movement of finger flexors was found, in favour of individual mirror therapy vs. group mirror therapy.

The second high quality RCT (Samuelkamaleshkumar et al., 2014) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity spasticity was measured by the MAS at post-treatment (3 weeks). No significant between-group difference was found.

The first fair quality RCT (Yun et al., 2011) randomized patients to receive mirror therapy + neuromuscular electrical stimulation (NMES), mirror therapy, or NMES. Upper extremity spasticity was measured by the MAS at post-treatment (3 weeks). No significant between-group difference was found.

The second fair quality RCT (Mirela et al., 2015) randomized patients to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity spasticity was measured by the MAS (Shoulder, Elbow, Wrist scores) and the Bhakta Test (Finger flexion scale) at post-treatment (6 weeks). Significant between-group differences in distal spasticity (MAS – Wrist; Bhakta Test – Finger flexion scale) were found, in favour of mirror therapy vs. no mirror therapy.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one fair quality RCT that mirror therapy is not more effective than comparison interventions (group sham mirror therapy, no mirror therapy, neuromuscular electrical stimulation) for reducing upper extremity spasticity in patients with subacute stroke.

Note: One fair quality RCT found that mirror therapy was more effective than no mirror therapy for reducing distal spasticity.

Stroke outcomes
Not effective
1B

One high quality RCT (Thieme et al., 2012) investigated the effect of mirror therapy on stroke outcomes in patients with subacute stroke. This high quality RCT randomized patients to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Stroke outcomes were measured by the Stroke Impact Scale at post-treatment (5 weeks). There was no significant difference between groups.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mirror therapy is not more effective than a comparison intervention (sham group mirror therapy) for improving stroke outcomes in patients with subacute stroke.

Unilateral spatial neglect
Effective
1A

Two high quality RCTs (Dohle et al., 2009; Thieme et al., 2012) investigated the effect of mirror therapy on unilateral spatial neglect in patients with subacute stroke.

The first high quality RCT (Dohle et al., 2009) randomized patients to receive mirror therapy or upper extremity training while watching the affected limb. Unilateral spatial neglect was measured by a non-validated 5-point rating scale derived from the Behavioural Inattention Test and the Tests of Attentional Performance at post-treatment (6 weeks). A significant between-group difference was found, in favour of mirror therapy vs. upper extremity training watching the affected limb.

The second high quality RCT (Thieme et al., 2012) randomized patients to receive individual mirror therapy, group mirror therapy, or sham group mirror therapy. Unilateral spatial neglect was measured by the Star Cancellation Test at post-treatment (5 weeks). A significant between-group difference was found, in favour of individual mirror therapy vs. sham group mirror therapy.

Note: There were no significant differences between individual vs. group mirror therapy, nor between group mirror therapy vs. sham group mirror therapy.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is more effective than comparison interventions (upper extremity training while watching the affected limb, group sham mirror therapy) for improving unilateral spatial neglect in patients with subacute stroke.

Chronic phase

Dexterity
Conflicting
4

Two high quality RCTs (Ji, Cha & Kim, 2014; Lin et al., 2014), two fair quality RCTs (Cho & Cha, 2015; Kim et al., 2016) and one poor quality RCT (Park et al., 2015a) examined the effect of mirror therapy on dexterity in patients with chronic stroke.

The first high quality RCT (Ji, Cha & Kim, 2014) randomized patients to receive mirror therapy, mirror therapy + repetitive Transcranial Magnetic Stimulation (rTMS), or sham mirror therapy. Dexterity was measured by the Box and Block Test (BBT) at post-treatment (6 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.
Note: A significant between-group difference was also found in favour of mirror therapy + rTMS vs. mirror therapy.

The second high quality RCT (Lin et al., 2014) randomized patients to receive mirror therapy, mirror therapy + electrical stimulation, or conventional rehabilitation (task-oriented training). Manual dexterity was measured by the BBT at post-treatment (4 weeks). A significant between-group difference was found, in favour of task-oriented training vs. mirror therapy.
Note: A significant between-group difference was found in favour of mirror therapy + electrical stimulation vs. mirror therapy. There were no differences between mirror therapy + electrical stimulation vs. task-oriented training.

The first fair quality RCT (Cho & Cha, 2015) randomized patients to receive mirror therapy or sham mirror therapy; both groups received transcranial direct current stimulation. Dexterity was measured by the BBT at post-treatment (6 weeks). There was a significant between-group difference in favour of mirror therapy vs. sham mirror therapy.

The second fair quality RCT (Kim et al., 2016) randomized patients to receive mirror therapy or conventional rehabilitation. Dexterity was measured by the BBT at post-treatment (4 weeks). There was a significant between-group difference, favouring mirror therapy vs. conventional rehabilitation.

The poor quality RCT (Park et al., 2015a) randomized patients to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Dexterity was measured by the BBT at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mirror therapy on dexterity in the chronic phase of stroke recovery. While one high quality RCT, two fair quality RCTs and one poor quality RCT found that mirror therapy was more effective than comparison interventions (sham mirror therapy, conventional rehabilitation), a second high quality RCTfound that mirror therapy was not more effective than task-oriented training.

Note: Two high quality RCTs found that mirror therapy and repetitive Transcranial Magnetic Stimulation / electrical stimulation are more effective than mirror therapy alone for improving dexterity in the chronic phase of stroke recovery.

Functional independence
Effective
2a

Two fair quality RCTs (Park et al., 2015b; Kim et al., 2016) and one poor quality RCT (Park et al., 2015a) investigated the effect of mirror therapy on functional independence in patients with chronic stroke.

The first fair quality RCT (Park et al., 2015b) randomized patients to receive mirror therapy or sham mirror therapy. Functional independence was measured by the Functional Independence Measure (FIM) at baseline and at post-treatment (6 weeks). A significant between-group difference in change scores from baseline to post-treatment was found, in favour of mirror therapy vs. sham mirror therapy.

The second fair quality RCT (Kim et al., 2016) randomized patients to receive mirror therapy or conventional rehabilitation. Functional independence was measured by the FIM at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. conventional rehabilitation.

The poor quality RCT (Park et al., 2015a) randomized patients to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (Total, Self-care, Sphincter control, Transfer, Locomotion, Communication, Social cognition scores) at post-treatment (4 weeks). Significant between-group differences were found (FIM: Total, Self-care scores), in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs and one poor quality RCT that mirror therapy is more effective than comparison interventions (sham mirror therapy, conventional rehabilitation) for improving functional independence in patients with chronic stroke.

Grip strength
Not effective
1b

One high quality RCT (Michielsen et al., 2010) and one fair quality RCT (Cho & Cha, 2015) investigated the effect of mirror therapy on grip strength in patients with chronic stroke.

The high quality RCT (Michielsen et al., 2010) randomized patients to receive mirror therapy or bimanual exercises with sight of both hands. Grip force was measured by Jamar handheld dynamometer at post-treatment (6 weeks) and follow-up (6 months). No significant between-group difference was found at either time point.

The fair quality RCT (Cho & Cha, 2015) randomized patients to receive mirror therapy or sham mirror therapy; both groups received transcranial direct current stimulation. Grip strength was measured by Jamar handheld dynamometer at post-treatment (6 weeks). There was a significant between-group difference, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mirror therapy is not more effective than a comparison intervention (bimanual exercises with sight of both hands) in improving grip strength among patients with chronic stroke.

Note: However, a fair quality RCT found that mirror therapy was more effective than sham mirror therapy. In this study, participants in the comparison group performed bilateral exercises without vision of the non-paretic arm; in the high quality RCT participants completed bilateral exercises with sight of both hands. Differences in treatment regime and intensity may also account for discrepancies between studies.

Hand function
Not effective
2a

One fair quality RCT (Cho & Cha, 2015) examined the effect of mirror therapy on hand function in patients with chronic stroke. This fair quality RCT randomized patients to receive mirror therapy or sham mirror therapy; both groups received transcranial direct current stimulation. Hand function was measured by the Jebsen Taylor Test of Hand Function at post-treatment (6 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is not more effective than a comparison therapy (sham mirror therapy) for improving hand function among patients with chronic stroke.

Kinematics
Effective
1a

Two high quality RCTs (Wu et al., 2013; Lin et al., 2014) investigated the effect of mirror therapy on upper extremity kinematics in patients with chronic stroke.

The first high quality RCT (Wu et al., 2013) randomized patients to receive mirror therapy or task-oriented training. Upper extremity kinematics (reaction time, normalized movement time, normalized total displacement, normalized shoulder flexion, normalized elbow extension, maximum shoulder abduction, maximum shoulder/elbow cross-correlation) were measured at post-treatment (4 weeks). Significant between-group differences in some kinematic variables (reaction time, normalized total displacement, maximum shoulder-elbow cross-correlation) were found, in favour of mirror therapy vs. task-oriented training.

The second high quality RCT (Lin et al., 2014) randomized patients to receive mirror therapy, mirror therapy + electrical stimulation, or conventional rehabilitation (task-oriented training). Upper extremity kinematics (wrist normalized movement time, wrist normalized movement units, normalized shoulder flexion, normalized elbow extension, maximum shoulder abduction) were measured at post-treatment (4 weeks). A significant between-group difference in maximum shoulder abduction was found in favour of mirror therapy vs. task-oriented training. Conversely, a significant difference in normalized shoulder flexion was found in favour of task-oriented training vs. mirror therapy.
Note: A significant between-group difference in maximum shoulder abduction was found in favour of mirror therapy + electrical stimulation vs. task-oriented training.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is more effective than a comparison intervention (task-oriented training) for improving some kinematic variables among patients with chronic stroke.

Mobility
Not effective
1b

One high quality RCT (Lin et al., 2014) investigated the effect of mirror therapy on mobility in patients with chronic stroke. This high quality RCT randomized patients to receive mirror therapy, mirror therapy + electrical stimulation, or conventional rehabilitation (task-oriented training). Mobility was measured by the 10-Minute Walk Test (velocity, stride length) performed at two speeds (self-paced, as quick as possible) at post-treatment (4 weeks). Significant between-group differences in most measures of mobility (self-paced – velocity, stride length; as quick as possible – velocity) were found, in favour of task-oriented training vs. mirror therapy.

Note: There were significant between-group differences in mobility (self-paced – velocity, stride length; as quick as possible – velocity), in favour of mirror therapy + electrical stimulation vs. mirror therapy. There were no differences between mirror therapy + electrical stimulation vs. task-oriented training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity mirror therapy is not more effective than a comparison intervention (task-oriented training) for improving mobility in patients with chronic stroke.

Motor activity
Not effective
1A

Three high quality RCTs (Wu et al., 2013; Lin et al., 2014; Rodrigues et al., 2016) investigated the effect of mirror therapy on upper extremity motor activity in patients with chronic stroke.

The first high quality RCT (Wu et al., 2013) randomized patients to receive mirror therapy or task-oriented training. Upper extremity motor activity was measured by the Motor Activity Log – Amount of Use (MAL-AOU) and – Quality of Movement (MAL-QOM) subtests at post-treatment (4 weeks) and follow-up (6 months). There were no significant between-group differences at either time point.

The second high quality RCT (Lin et al., 2014) randomized patients to receive mirror therapy, mirror therapy + electrical stimulation, or conventional rehabilitation (task-oriented training). Upper extremity motor activity was measured by the MAL-AOU and MAL-QOM at post-treatment (4 weeks). There were no significant differences between groups.

The third high quality RCT (Rodrigues et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy watching the paretic upper limb. Upper extremity motor activity was measured by the Brazilian version of the TEMPA (Total, Unilateral, Bilateral scores) at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mirror therapy is not more effective than comparison interventions (task-oriented training, sham mirror therapy watching the paretic upper limb) for improving upper extremity motor activity in patients with chronic stroke.

Motor function
Effective
1A

Eight high quality RCTs (Michielsen et al., 2010; Wu et al., 2013; Ji, Cha & Kim, 2014; Lin et al., 2014; Arya et al., 2015; Colomer, Noe & Llorens, 2016; Rodrigues et al., 2016; Arya et al., 2018), four fair quality RCTs (Altschuler et al., 1999; Cho & Cha, 2015; Park et al., 2015b; Kim et al., 2016) and one poor quality RCT (Park et al., 2015a) investigated the effect of mirror therapy on upper extremity motor function in the chronic phase of stroke recovery.

The first high quality RCT (Michielsen et al., 2010) randomized patients to receive mirror therapy or bimanual exercise training with sight of both hands. Upper extremity motor function was measured by the Action Research Arm Test (ARAT) and the Fugl-Meyer Assessment (FMA) at post-treatment (6 weeks) and follow-up (6 months). A significant between-group difference in one measure (FMA) was found at post-treatment, in favour of mirror therapy vs. bimanual exercises. Results did not remain significant at follow-up.

The second high quality RCT (Wu et al., 2013) randomized patients to receive mirror therapy or task-oriented training. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE – Total, Proximal, Distal scores) at post-treatment (4 weeks). Significant between-group differences (FMA-UE – Total, Distal scores) were found, in favour of mirror therapy vs. task-oriented training.

The third high quality RCT (Ji, Cha & Kim, 2014) randomized patients to receive mirror therapy, mirror therapy + repetitive Transcranial Magnetic Stimulation (rTMS), or sham mirror therapy. Upper extremity motor function was measured by the FMA at post-treatment (6 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

Note: A significant between-group difference was also found in favour of mirror therapy + rTMS vs. mirror therapy.

The fourth high quality RCT (Lin et al., 2014) randomized patients to receive mirror therapy, mirror therapy + electrical stimulation, or conventional rehabilitation (task-oriented training). Upper extremity motor function was measured by the FMA at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. task-oriented training.

Note: There was also a significant between-group difference in favour of mirror therapy + electrical stimulation vs. task-oriented training. There were no significant differences between mirror therapy vs. mirror therapy + electrical stimulation.

The fifth high quality RCT (Arya et al., 2015) randomized patients to receive mirror therapy or conventional occupational therapy. Upper extremity motor function was measured using the FMA-UE, Upper arm (FMA-UA) and Wrist/hand (FMA-W/H) scores at post-treatment (8 weeks). Significant between-group differences in two measures (FMA-UE, FMA-W/H) were found, in favour of mirror therapy vs. conventional occupational therapy.

The sixth high quality RCT (Colomer, Noe & Llorens, 2016) randomized patients to receive mirror therapy or passive mobilisation of the upper extremity. Upper extremity motor function was measured by the Wolf Motor Function Test – Performance time (WMFT-PT) and Functional ability (WMFT-FA) scores and the FMA-UE at post-treatment (8 weeks). No significant between-group differences on any of the measures were found.

The seventh high quality RCT (Rodrigues et al., 2016) randomized patients to receive mirror therapy or sham mirror therapy watching the paretic upper limb. Upper extremity motor function was measured by the FMA-UE (Total, Proximal, Distal scores) at post-treatment (4 weeks). No significant between-group differences on any of the measures were found.

The eighth high quality RCT (Arya et al., 2018) randomized patients to receive mirror therapy or time-matched standard motor and sensory rehabilitation. Upper extremity motor function was measured using the FMA/WH subscore at post-treatment (6 weeks). A significant between-group difference was found, in favour of mirror therapy vs. standard motor and sensory rehabilitation.

The first fair quality crossover study (Altschuler et al., 1999) randomized patients to receive mirror therapy or bilateral exercises with view of the affected arm. Upper extremity motor function (speed, accuracy of cardinal movement) was measured using a 7-point Likert scale at mid-treatment (2 weeks), post-treatment (4 weeks) and follow-up (6 weeks, 8 weeks). Patients demonstrated better outcomes following mirror therapy than the comparison intervention at all time points.

Note: Statistical data were not provided.

The second fair quality RCT (Cho & Cha, 2015) randomized patients to receive mirror therapy or sham mirror therapy; both groups received transcranial direct current stimulation. Upper extremity motor function was measured by the FMA at post-treatment (6 weeks). No significant between-group difference was found.

The third fair quality RCT (Park et al., 2015b) randomized patients to receive mirror therapy or sham mirror therapy. Upper extremity motor function was measured by the Manual Function Test at post-treatment (6 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

The fourth fair quality RCT (Kim et al., 2016) randomized patients to receive mirror therapy or conventional rehabilitation. Upper extremity motor function was measured by the ARAT and the FMA at post-treatment (4 weeks). Significant between-group differences were found on both measures, favouring mirror therapy vs. conventional rehabilitation.

The poor quality RCT (Park et al., 2015a) randomized patients to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the FMA at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is strong evidence (Level 1a) from six high quality RCTs, two fair quality RCTs and one poor quality RCT that mirror therapy is more effective than comparison interventions (bimanual exercises with sight of both hands, task-oriented training, sham mirror therapy, conventional occupational therapy, standard motor and sensory rehabilitation or conventional rehabilitation) for improving upper extremity motor function in patients with chronic stroke. A third fair quality RCT also reported improved motor function following mirror therapy.

Note: However, two high quality RCTs and one fair quality RCT reported no significant difference between mirror therapy and comparison interventions (passive mobilisation, sham mirror therapy). Differences in outcome measures used, as well as the intensity and duration of interventions, may account for discrepancies in results among studies.

Pain
Conflicting
4

Two high quality RCTs (Cacchio et al., 2009b; Michielsen et al., 2010) have investigated the effect of mirror therapy on pain in patients with chronic stroke.

The first high quality RCT (Cacchio et al., 2009b) randomized patients with chronic stroke and Complex Regional Pain Syndrome type 1 to receive mirror therapy, sham mirror therapy or mental imagery. Pain was measured by visual analogue scale (VAS) at post-treatment (4 weeks). Significant between-group differences in pain on movement were found, in favour of mirror therapy vs. sham mirror therapy and mental imagery.

The second high quality RCT (Michielsen et al., 2010) randomized patients to receive mirror therapy or bimanual exercises with sight of both hands. Pain was measured by VAS at post-treatment (6 weeks) and follow-up (6 months). No significant between-group difference was found at either time point.

Conclusion: There is conflicting evidence (Level 4) between two high quality RCTs regarding the effect of mirror therapy on pain in patients with chronic stroke. One high quality RCT found that mirror therapy was more effective than comparison interventions (sham mirror therapy, mental imagery) for improving pain in patients with chronic stroke and Complex Regional Pain Syndrome type 1, whereas a second high quality RCT found that mirror therapy is not more effective than a comparison therapy (bimanual exercises with sight of both hands).

Quality of life
Not effective
1B

One high quality RCT (Michielsen et al., 2010) investigated the effect of mirror therapy on quality of life in patients with chronic stroke. This high quality RCT randomized patients to receive mirror therapy or bimanual exercises with sight of both hands. Quality of life was measured by the EuroQol-5D at post-treatment (6 weeks) and follow-up (6 months). No significant difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mirror therapy is not more effective than a comparison intervention (bimanual exercises with sight of both hands) for improving quality of life in patients with chronic stroke.

Range of motion
Insufficient evidence
5

One fair quality (Altschuler et al., 1999) investigated the effect of mirror therapy on upper extremity range of motion in patients with chronic stroke. This fair quality crossover study randomized patients to receive mirror therapy or bilateral exercises with view of the affected arm. Upper extremity range of motion was measured using a 7-point Likert scale at mid-treatment (2 weeks), post-treatment (4 weeks) and follow-up (6 weeks, 8 weeks). Patients demonstrated better range of motion following mirror therapy than the comparison intervention at all time points.

Note: Statistical data were not provided.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of mirror therapy on range of motion in patients with chronic stroke. One fair quality RCT found improvements in range of motion following mirror therapy in comparison to bilateral exercises with view of the affected arm.

Self-perceived upper extremity function
Not effective
1a

Three high quality RCTs (Michielsen et al., 2010; Wu et al., 2013; Lin et al., 2014) investigated the effect of mirror therapy on self-perceived upper extremity function in patients with chronic stroke.

The first high quality RCT (Michielsen et al., 2010) randomized patients to receive mirror therapy or bimanual exercise training with sight of both hands. Self-perceived upper extremity function was measured by the ABILHAND at post-treatment (6 weeks) and follow-up (6 months). No significant between-group difference was found at either time point.

The second high quality RCT (Wu et al., 2013) randomized patients to receive mirror therapy or task-oriented training. Self-perceived upper extremity motor function was measured by the ABILHAND at post-treatment (4 weeks) and follow-up (6 months). No significant between-group difference was found at either time point.

The third high quality RCT (Lin et al., 2014) randomized patients to receive mirror therapy, mirror therapy + electrical stimulation, or conventional rehabilitation (task-oriented training). Self-report of upper extremity motor function was measured by the ABILHAND at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mirror therapy is not more effective than comparison interventions (bimanual exercises with sight of both hands, task-oriented training, mirror therapy + electrical stimulation) in improving self-perceived upper extremity function in patients with chronic stroke.

Sensory function
Not effective
1A

Three high quality RCTs (Wu et al., 2013; Colomer, Noe & Llorens, 2016; Arya et al., 2018) investigated the effect of mirror therapy on upper extremity sensory function in patients with chronic stroke.

The first high quality RCT (Wu et al., 2013) randomized patients to receive mirror therapy or task-oriented training. Upper extremity sensory function was measured by the revised Nottingham Sensory Assessment – Tactile subtest (Light touch, Temperature, Pinprick, Pressure, Tactile localization, Bilateral simultaneous touch, Tactile total score) at post-treatment (4 weeks). A significant between-group difference was found on only one measure of sensory function (Temperature), in favour of mirror therapy vs. task-oriented training.

The second high quality RCT (Colomer, Noe & Llorens, 2016) randomized patients to receive mirror therapy or passive mobilisation of the upper extremity. Upper extremity sensation was measured by the Nottingham Sensory Assessment – Tactile (Light touch, Pressure, Pinprick, Temperature, Tactile localisation, Bilateral simultaneous touch), Kinaesthetic and Stereognosis scores at post-treatment (8 weeks). A significant between-group difference was found on one measure of upper extremity sensation (Light touch), in favour of mirror therapy vs. passive mobilisation.

The third high quality RCT (Arya et al., 2018) randomized patients to receive mirror therapy or time-matched standard motor and sensory rehabilitation. Sensory function was measured at post-treatment (6 weeks) using the Semmes-Weinstein Monofilaments to assess cutaneous thresholds of the palm and fingers, and the 2-Point Discrimination Test to measure touch discrimination. No significant between-group difference in mean change in cutaneous thresholds for the affected fingers and palm were found. An increase in the number of positive responses for the finger quadrants and palm was found, in favour of mirror therapy vs. motor and sensory rehabilitation.

Note: A reliable assessment of touch discrimination was not achieved as only 26% of participants (n=17, 4 respectively) responded to touch discrimination testing on the affected side.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mirror therapy is not more effective than comparison interventions (task-oriented training, passive mobilisation or motor and sensory rehabilitation) for improving upper extremity sensory function in patients with chronic stroke.

Spasticity/tone
Not effective
1A

Two high quality RCTs (Michielsen et al., 2010; Lin et al., 2014) investigated the effect of mirror therapy on upper extremity spasticity in patients with chronic stroke.

The first high quality RCT (Michielsen et al., 2010) randomized patients to receive mirror therapy or bimanual exercise training with sight of both hands. Upper extremity spasticity was measured by the Tardieu Scale at post-treatment (6 weeks) and follow-up (6 months). There was no significant between-group difference at either time point.

The second high quality RCT (Lin et al., 2014) randomized patients to receive mirror therapy, mirror therapy + electrical stimulation, or conventional rehabilitation (task-oriented training). Upper extremity tone in the biceps, flexor carpi radialis and flexor carpi ulnaris was measured by Myoton-3 myometer at post-treatment (4 weeks). There were no significant between-group differences.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is not more effective than comparison interventions (bimanual exercises with sight of both hands, task-oriented training, mirror therapy + electrical stimulation) in reducing upper extremity spasticity/tone in patients with chronic stroke.

Upper extremity usage
Not effective
1B

One high quality RCT (Michielsen et al., 2010) investigated the effect of mirror therapy on amount of upper extremity use in patients with chronic stroke. This high quality RCT randomized patients to receive mirror therapy or bimanual exercises with sight of both hands. Upper extremity use was measured by the Stroke Upper Limb Activity Monitor at post-treatment (6 weeks). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mirror therapy is not more effective than a comparison therapy (bimanual exercises with sight of both hands) in improving upper extremity usage in patients with chronic stroke.

Phase not specific to one period

Dexterity
Ineffective
2A

One fair quality RCT (Amasyali & Yaliman, 2016) investigated the effect of mirror therapy on dexterity in patients with stroke. This fair quality RCT randomized patients with subacute / chronic stroke to receive mirror therapy, electrostimulation or no additional treatment; all participants received conventional rehabilitation. Dexterity was measured by the Box and Block Test at post-treatment (3 weeks) and follow-up (3 months). Significant between-group differences were found at follow-up only, in favour of mirror therapy vs. electrostimulation and no additional treatment.

Note: There was no significant difference between electrostimulation and no additional treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is not more effective than comparison interventions (electrostimulation, no additional treatment) for improving dexterity in patients with stroke.

Note: However, significant between-group differences were found at follow up, in favour of mirror therapy vs. electrostimulation and no additional treatment.

Functional independence
Conflicting
4

Two high quality RCTs (Yavuzer et al., 2008; Purvane Vural et al., 2016) investigated the effect of mirror therapy on functional independence in patients with stroke.

The first high quality RCT (Yavuzer et al., 2008) randomized patients with subacute / chronic stroke to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM – Self-care score) at post-treatment (4 weeks) and follow-up (6 months). A significant between-group difference was found at both time points, in favour of mirror therapy vs. sham mirror therapy.

The second high quality RCT (Purvane Vural et al., 2016) randomized patients with subacute/chronic stroke to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Functional independence was measured by the FIM – Motor score at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mirror therapy on functional independence following stroke. While one high quality RCT found that mirror therapy was more effective than sham mirror therapy, a second high quality RCT reported no significant difference between mirror therapy vs. no mirror therapy.

Note: The two studies used different measures of functional independence (FIM Self Care items vs. FIM Motor score), which may account for discrepancies in results.

Grip strength
Not effective
2A

One fair quality RCT (Amasyali & Yaliman, 2016) investigated the effect of mirror therapy on grip strength in patients with stroke. This fair quality RCT randomized patients with subacute / chronic stroke to receive mirror therapy, electrostimulation or no additional treatment; all participants received conventional rehabilitation. Grip strength was measured by handheld dynamometer at post-treatment (3 weeks) and follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is not more effective than a comparison intervention (electrostimulation) or no treatment for improving grip strength in patients with stroke.

Motor function
Effective
1B

One high quality RCT (Purvane Vural et al., 2016), one fair quality RCT (Amasyali & Yaliman, 2016) and one poor quality RCT (Rajappan et al., 2015) investigated the effect of mirror therapy on upper extremity motor function in patients with stroke.

The high quality RCT (Purvane Vural et al., 2016) randomized patients with subacute / chronic stroke to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE – Wrist, Hand scores) at post-treatment (4 weeks). Significant between-group differences were found on both scores, in favour of mirror therapy vs. no mirror therapy.

The fair quality RCT (Amasyali & Yaliman, 2016) randomized patients with subacute / chronic stroke to receive mirror therapy, electrostimulation or no additional treatment; all participants received conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE at post-treatment (3 weeks) and follow-up (3 months). A significant between-group difference was found at post-treatment only, in favour of mirror therapy vs. no additional treatment.

Note: There were no significant differences between mirror therapy vs. electrostimulation, or between electrostimulation vs. no additional treatment at either time point.

The poor quality RCT (Rajappan et al., 2015) randomized patients with subacute / chronic stroke to receive mirror therapy or sham mirror therapy; all participants received conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE (Total, Wrist, Hand, Speed scores) and the Upper Extremity Functional Index at post-treatment (4 weeks). Significant between-group differences were found on all scores, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT, one fair quality RCT and one poor quality RCT that mirror therapy is more effective than comparison interventions (no mirror therapy, sham mirror therapy) for improving upper extremity motor function in patients with stroke.

Motor recovery
Conflicting
4

Two high quality RCTs (Yavuzer et al., 2008; Purvane Vural et al., 2016) investigated the effect of mirror therapy on upper extremity motor recovery in patients with stroke.

The first high quality RCT (Yavuzer et al., 2008) randomized patients with subacute / chronic stroke to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity motor recovery was measured by the Brunnstrom stages of motor recovery (Upper extremity, Hand change scores) at post-treatment (4 weeks) and follow-up (6 months). Significant between-group differences were found at both time points, in favour of mirror therapy vs. sham mirror therapy.

The second high quality RCT (Purvane Vural et al., 2016) randomized patients with subacute/chronic stroke to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity motor recovery was measured by the Brunnstrom stages of motor recovery (Upper Extremity, Hand scores) at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mirror therapy on upper extremity motor recovery following stroke. While one high quality RCT found that mirror therapy was more effective than sham mirror therapy, a second high quality RCT reported no significant difference between mirror therapy vs. no mirror therapy.

Pain
Effective
1b

One high quality RCT (Purvane Vural et al., 2016) investigated the effect of mirror therapy on pain in patients with stroke. This high quality RCT randomized patients with subacute / chronic stroke to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Pain was measured by a visual analogue scale at post-treatment (4 weeks). A significant between-group difference was found, in favour of mirror therapy vs. no mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mirror therapy is more effective than no mirror therapy for reducing pain in patients with stroke.

Range of motion
Not effective
2A

One fair quality RCT (Amasyali & Yaliman, 2016) investigated the effect of mirror therapy on range of motion in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive mirror therapy, electrostimulation or no additional treatment; all participants received conventional rehabilitation. Wrist range of motion was measured by goniometer at post-treatment (3 weeks) and follow-up (3 months). A significant between-group difference was found at follow-up only, in favour of mirror therapy vs. no additional treatment.

Note: A significant between-group difference was found at follow-up in favour of electrostimulation vs. no additional therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mirror therapy is not more effective than a comparison intervention (electrostimulation) or no additional treatment for improving range of motion (wrist) in patients with stroke.

Spasticity
Not effective
1A

Two high quality RCTs (Yavuzer et al., 2008; Purvane Vural et al., 2016) investigated the effect of mirror therapy on upper extremity spasticity in patients with stroke.

The first high quality RCT (Yavuzer et al., 2008) randomized patients with subacute / chronic stroke to receive mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Upper extremity spasticity was measured by the Modified Ashworth Scale (MAS) at post-treatment (4 weeks) and follow-up (6 months). No significant between-group difference was found at either time point.

The second high quality RCT (Purvane Vural et al., 2016) randomized patients with subacute / chronic stroke to receive mirror therapy or no mirror therapy; both groups received conventional rehabilitation. Upper extremity spasticity was measured by the MAS at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is not more effective than a comparison intervention (sham mirror therapy) or no mirror therapy for reducing upper extrremity spasticity in patients with stroke.

Clinician How-To

What is mirror therapy?

In mirror therapy, a mirror is placed in the client’s sagittal plane so the client cannot see the affected upper limb. The client watches in the mirror the movements made with the healthy limb and simultaneously tries to move the affected limb on the other side of the mirror. To explain why the reflection of the healthy limb in the mirror helps with the motor recovery of the affected limb, the current hypothesis is that the mirror neurons in the brain are activated during the imitation movements and interact simultaneously with the motor neurons.

Who should have mirror therapy?

Regarding the affective dimension , one of the main elements to consider is the client’s motivation to commit to the treatment process since it requires an almost daily investment of time. Mirror therapy is not recommended for clients who have a recent history of alcohol or drug abuse, severe depression or claustrophobia because these elements could interfere with the treatment.

Regarding the cognitive dimension , the key element is that the client must be able to follow instructions. Clients with cognitive disorders, aphasia, dementia, a mental health problem or attention deficit could have the therapy as long as these problems do not interfere with their understanding of the instructions and thus with the treatment for 30 minutes each day.

It is even more important to consider cognitive difficulties for clients who wish to have the therapy at home since they must be able to participate in self-directed treatment. This means they must not only be able to administer the therapy themselves, they must also be able to manage the treatment schedule, manage the material and how it is set up, keep their attention on the mirror without being reminded, self-correct, etc.

Clients with hemispatial neglect can have mirror therapy. Some studies exclude them from their research protocol but this is because their research objectives focus more specifically on the motor or functional recovery of the affected upper limb. Hemispatial neglect is excluded from their sample so that it cannot interfere with the expected results. Furthermore, clients who present severe hemispatial neglect and cannot turn their head on the contralateral side of the lesion upon request cannot have the therapy since they would not be able to keep their attention on the mirror.

Regarding the physical dimension , studies include both men and women, right- or left-handed, regardless of whether the affected side is the dominant side or not. The stroke may be ischemic or hemorrhagic with a cortical or subcortical lesion. Clients may present mild to severe hemiparesis as well as sensory deficits (paresthesia). They must be medically stable and able to maintain a sitting position throughout the treatment. Clients with vision impairments, apraxia and neurological disorders are usually excluded from studies for research purposes. Therefore, it is not known if mirror therapy is effective in the presence of these problems.

Who can give the therapy?

Mirror therapy is often given by occupational therapists and physiotherapists but any health professional can administer it.

It can also be given by a family caregiver or be self-administered following a brief explanation of how to do it and after receiving tools to do the therapy at home (user guide, written explanations, photos or videos of the movements to be done). It is important to do a regular follow-up (once a week) with clients doing the therapy at home, with or without the help of a family caregiver. The aim is to verify that the client is following instructions, understands the exercises and applies them correctly, is not making any compensating movements or taking the wrong position. The aim is also to vary the degree of difficulty, answer the client’s questions, etc. The follow-up can be done on the phone, at personal meetings, in a journal, etc. If the mirror therapy is done at home, it is important to consider the motivation of carers and the client to commit to the treatment.

If the hemiparesis is too severe and the client cannot reproduce with the affected side, simultaneously and as accurately as possible, the movements made with the healthy side, a therapist may be needed to guide or control the movements on the affected side passively. Hence it would be more difficult for such clients to do the therapy at home.

How is mirror therapy administered?

The person who administers the mirror therapy can stand in front of the client on the other side of the table. This person supervises the movements made on each side of the mirror and ensures that the client is really looking at the reflection of his/her healthy limb in the mirror.

How many weeks should mirror therapy last?

Between 3 and 6 weeks but most studies have a 4-week protocol.

How many times per week?

A minimum of 5 days per week.

How long does a mirror therapy session last?

A minimum of 30 minutes per day. This can be split into two shorter periods during the day.

What can be done in front of the mirror?

What voluntary movements are done in front of the mirror?

  • Flexion and extension of the shoulder
  • Flexion and extension of the elbow
  • Flexion and extension of the wrist
  • Flexion and extension of the fingers
  • Abduction and adduction of the shoulder
  • Abduction and adduction of the fingers
  • Internal and external rotation of the shoulder
  • Pronation and supination of the forearm
  • Ulnar and radial deviation of the wrist
  • Circumduction of the wrist

What actions can be done in front of the mirror?

Some examples of actions:

  • Squeeze and release the fist
  • Open and close the hand
  • Tap the fingers on the table
  • Oppose (touch) each finger to the thumb one by one
  • With the hand closed, try to lift each finger, including the thumb, one at a time

What tasks can be done in front of the mirror?

Some examples of tasks:

  • Handle objects using different types of grips, for example, make small balls of theraplast or modeling clay with the fingers, turn a cylindrical object in the hand (complex rotation), pick up beads or paper clips, put clothes pegs on the lip of a mug, insert pegs in a board, etc.
  • Grasp and release objects with different textures (balls, sponges, etc.)
  • Pick up and move various objects (balls, sticks, cubes, mug, glass, etc.) in different directions, for example, move an object following a sequence of movements forming a square or an ‘X’, put a ball in a glass and take it out, lift a glass, lift a rectangular object, place beads or pegs in a container with a small opening, insert pegs in holes in a piece of wood, transfer grains of rice from one pot to another, manipulate rings, etc.
  • Turn over playing cards
  • Color, connect the dots to make a drawing, copy shapes on a piece of paper
  • Use different shaped stamps with an ink pad
  • Handle utensils
  • Wipe, clean and dust the table with cloths with different textures (scouring pad, soft sponge, silk cloth, etc.)

How must the movements be done?

The movements in front of the mirror must be done simultaneouly on the affected and the non-affected side. This encourages bilateral use of the upper limbs. If the mirror therapy involves use of an object by the healthy upper limb, the affected upper limb must try to reproduce the movement as accurately as possible but without the object.

At what speed must the movements be done?

  • The client can choose the speed of the movements.
  • Some studies combining the mirror with electrical stimuli suggest that the voluntary movements are done in 5 or 10 seconds. The time the movements take must match the duration of the electrical stimuli.

What assistance is offered during the sessions?

  • The emphasis should be on active movements in front of the mirror. Clients must try their best to make the same movements with their affected upper limb. According to some studies, assistance can be offered to make the movements with the affected upper limb passively, especially if the hemiparesis is severe. To date, there is no consensus regarding whether physical assistance interferes with the mirror therapy treatment.
  • The desired movement may be demonstrated.
  • The client can be given an instruction booklet containing written instructions, photos or videos of the movements, actions and tasks to be done, especially if the mirror therapy is done at home. A toolbox containing the material needed to use the mirror may also be offered or loaned to the client.
  • The client can use a journal, especially if the therapy is done at home, as a tool to help with follow-up and to inform the therapists of the progress of the therapy (mirror therapy schedule, client’s experiences, exercises done, etc.).

What assessments and other intervention can be done with mirror therapy?

Studies exploring mirror therapy have used different assessments to measure participants’ progress, including:

  • Fugl-Meyer Assessment to measure motor recovery of the upper limb
  • Brunnstrom Scale to measure the type of movement done
  • Demeurisse Motricity Index for the upper limb to assess motor function
  • Action Research Arm Test (ARAT) to measure specific changes in upper limb activity
  • Functional Independence Measure (FIM)

There are no contraindications to using mirror therapy at the same time as other therapies. In fact, some studies combine training on specific tasks, bilateral use of the upper limbs and electrical stimuli with the use of mirror therapy.

What are the side effects of mirror therapy?

Study participants have not reported any side effects. However, one study reported that some participants got bored during the therapy.

What important features must the mirror have?

  • The mirror is placed in the client’s midsagittal plane. The client must watch the reflection of his/her healthy limb in the mirror in order to simulate that the image is actually of the affected upper limb.
  • Different materials can be used to build the structure of the mirror (wood, corrugated cardboard, plastic, etc.).
  • The size of the mirror can vary between 12 in x 12 in and 28 in x 48 in. Its size depends on the types of movements to be done in front of the mirror.
  • To ensure that the client cannot see it behind the mirror, the affected upper limb can be inserted in an enclosed box or the affected hand can be covered by a screen.
  • One study designed a folding mirror that is easy to carry. The angle of the mirror is supported by velcro strips.

What else is important to remember before using the mirror?

All jewelry and watches must be removed so that the illusion of the reflection is as credible as possible.

When and in what settings can mirror therapy be used?

When is the best time to have mirror therapy?

Mirror therapy has positive results in the acute, subacute and chronic phase post-stroke. Most studies advocate early intervention (as soon as possible) up to 14 months post-stroke.

In what settings can mirror therapy be used?

Mirror therapy can be used in different settings, including in the hospital (acute care), in-patient rehabilitation, out-patient rehabilitation and at home. The treatment setting varies with the client’s level of functional and socio-residential autonomy.

Mirror therapy can be done at home, self-administered or supervised by a family caregiver. However, clinical reasoning must be used before determining if a client is eligible.

Can mirror therapy be given in a group?

Mirror therapy can be given individually or in a group. However, including clients with attention deficits or hemispatial neglect in a group is not recommended because there is less progress in a group with respect to reducing hemispatial neglect.

References used in this section

Altschuler, E. L., et al. (1999). “Rehabilitation of hemiparesis after stroke with a mirror.” The Lancet 353(9169): 2035-2036.

Arya, K. N. and S. Pandian (2013). “Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study.” Topics in Stroke Rehabilitation 20(3): 210-217.

Cacchio, A., et al. (2009). “Mirror therapy for chronic complex regional pain syndrome type 1 and stroke.” New England Journal of Medicine 361(6): 634-636.

Cacchio, A., et al. (2009). “Mirror therapy in complex regional pain syndrome type 1 of the upper limb in stroke patients.” Neurorehabilitation & Neural Repair 23(8): 792-799.

de Almeida Oliveira, R., et al. (2014). “Mental practice and mirror therapy associated with conventional physical therapy training on the hemiparetic upper limb in poststroke rehabilitation: a preliminary study.” Topics in Stroke Rehabilitation 21(6): 484-494.

Dohle, C., et al. (2009). “Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial.” Neurorehabilitation & Neural Repair 23(3): 209-217.

Ezendam, D., et al. (2009). “Systematic review of the effectiveness of mirror therapy in upper extremity function.” Disability & Rehabilitation 31(26): 2135-2149.

Faralli, A., et al. (2013). “Noninvasive strategies to promote functional recovery after stroke.” Neural Plasticity 2013: 854597.

Invernizzi, M., et al. (2013). “The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial.” European journal of physical & rehabilitation medicine. 49(3): 311-317.

Kim, H., et al. (2014). “Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients.” Journal of Stroke & Cerebrovascular Diseases 23(4): 655-661.

Kojima, K., et al. (2014). “Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: a randomized crossover trial.” Neurorehabilitation 34(2): 235-244.

Lee, M. M., et al. (2012). “The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients.” American Journal of Physical Medicine & Rehabilitation 91(8): 689-696, quiz 697-700.

Lin, K. C., et al. (2014). “Combining afferent stimulation and mirror therapy for rehabilitating motor function, motor control, ambulation, and daily functions after stroke.” Neurorehabilitation & Neural Repair 28(2): 153-162.

Lisa, L. P., et al. (2013). “The effectiveness of different treatment modalities for the rehabilitation of unilateral neglect in stroke patients: a systematic review.” Neurorehabilitation 33(4): 611-620.

Michielsen, M. E., et al. (2011). “Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial.” Neurorehabilitation & Neural Repair 25(3): 223-233.

Nilsen, D. M. and T. DiRusso (2014). “Using mirror therapy in the home environment: a case report.” American Journal of Occupational Therapy 68(3): e84-89.

Pandian, J. D., et al. (2014). “Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial.” Neurology 83(11): 1012-1017.

Pollock, A., et al. (2014). “Interventions for improving upper limb function after stroke.” Cochrane Database of Systematic Reviews 11: CD010820.

Radajewska, A., et al. (2013). “The effects of mirror therapy on arm and hand function in subacute stroke in patients.” International Journal of Rehabilitation Research 36(3): 268-274.

Rothgangel, A. S., et al. (2011). “The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature.” International Journal of Rehabilitation Research 34(1): 1-13.

Samuelkamaleshkumar, S., et al. (2014). “Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial.” Archives of Physical Medicine & Rehabilitation 95(11): 2000-2005.

Sathian, K., et al. (2000). “Doing it with mirrors: a case study of a novel approach to neurorehabilitation.” Neurorehabilitation & Neural Repair 14(1): 73-76.

Shinoura, N., et al. (2008). “Mirror therapy activates outside of cerebellum and ipsilateral M1.” Neurorehabilitation 23(3): 245-252.

Stevens, J. A. and M. E. P. Stoykov (2003). “Using motor imagery in the rehabilitation of hemiparesis.” Archives of physical medicine and rehabilitation 84(7): 1090-1092.

Thieme, H., et al. (2012). “Mirror therapy for improving motor function after stroke.” Cochrane Database of Systematic Reviews 3: CD008449.

Thieme, H., et al. (2013). “Mirror therapy for patients with severe arm paresis after stroke–a randomized controlled trial.” Clinical Rehabilitation 27(4): 314-324.

Wang, J., et al. (2013). “Cerebral activation evoked by the mirror illusion of the hand in stroke patients compared to normal subjects.” Neurorehabilitation 33(4): 593-603.

Wu, C. Y., et al. (2013). “Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial.” Archives of Physical Medicine & Rehabilitation 94(6): 1023-1030.

Yavuzer, G., et al. (2008). “Mirror therapy improves hand function in subacute stroke: a randomized controlled trial.” Archives of Physical Medicine & Rehabilitation 89(3): 393-398.

Yun, G. J., et al. (2011). “The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients.” Annals of Rehabilitation Medicine 35(3): 316-321.

Info Pocket Booklet

Pocket Card for mirror therapy

References

Altschuler, E.L., Wisdom, S.B., Stone, L., Foster, C., Galasko, D., Llewellyn, M.E., & Ramachandran, V.S. (1999). Rehabilitation of hemiparesis after stroke with a mirror. The Lancet, 353, 2035-2036. doi: 10.1016/S0140-6736(99)00920-4

Amasyali, S.Y. & Yaliman, A. (2016). Comparison of the effects of mirror therapy and electromyography-triggered neuromuscular stimulation on hand functions in stroke patients: a pilot study. International Journal of Rehabilitation Research, 39, 302-7. doi: 10.1097/MRR.0000000000000186

Arya, K.N., Pandian, S., Kumar, D., & Puri, V. (2015). Task-based mirror therapy augmenting motor recovery in poststroke hemiparesis: a randomized controlled trial. Journal of Stroke & Cerebrovascular Diseases, 24(8), 1738-48. doi: 10.1016/j.jstrokecerebrovasdis.2015.03.026

Bae, S.H., Jeong, W.S., & Kim, K.Y. (2012). Effects of mirror therapy on subacute stroke patients’ brain waves and upper extremity functions. Journal of Physical Therapy Science, 24(11), 1119-22. doi: 10.1589/jpts.24.1119

Cacchio, A., De Blasis, E., De Blasis, V., Santilli, V., & Spacca, G. (2009a). Mirror therapy in Complex Regional Pain Syndrome type 1 of the upper limb in stroke patients. Neurorehabilitation and Neural Repair, 23, 792-799. doi: 10.1177/1545968309335977

Cacchio, A., De Blasis, E., Necozione, S., di Orio, F., & Santilli, V. (2009b). Mirror therapy for Chronic Complex Regional Pain Syndrome type 1 and stroke. New England Journal of Medicine, 361(6), 634-636. doi: 10.1056/NEJMc0902799

Cho, H.-S. & Cha, H.-G. (2015). Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. Journal of Physical Therapy Science, 27, 1045-7. doi: 10.1589/jpts.27.1045

Colomer, C., Noe, E., & Llorens, R. (2016). Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. European Journal of Physical and Rehabilitation Medicine, 52(3), 271-8. Retrieved from: http://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y2016N03A0271

Costa, V.S, Silveira, J.C.C., Clementino, T.C.A., Borges, L.R.D.M., & Melo, L.P. (2016). Effects of mirror therapy on the motor and functional recovery of post-stroke paretic upper limbs: a systematic review. Fisioterapia e Pesquisa, 23(4), 431-8. doi: 10.1590/1809-2950/15809523042016

Dohle, C., Püllen, J., Nakaten, A., Küst, J., Rietz, C., & Karbe, H. (2009). Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabilitation and Neural Repair, 23, 209-217. doi: 10.1177/1545968308324786

Ezendam, D., Bongers, R. M., Jannink, M. J. A. (2009). Systematic review of the effectiveness of mirror therapy in upper extremity function. Disability and Rehabilitation, 31, 2135-2149. doi: 10.3109/09638280902887768

Gurbuz, N., Afsar, S.I., Ayas, S., & Cosar, S.N.S. (2016). Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial. The Journal of Physical Therapy Science, 28(9), 2501-6. DOI: 10.1589/jpts.28.2501

Invernizzi, M., Negrini, S., Cara, S., Lanzotti, L., Cisari, C., & Baricich, A. (2013). The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. European Journal of Physical and Rehabilitation Medicine, 49(3), 311-7. Retrieved from: https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y2013N03A0311

Ji, S.-G., Cha, H.-G., & Kim, M.-K. (2014). Stroke recovery can be enhanced by using repetitive transcranial magnetic stimulation combined with mirror therapy. Journal of Magnetics, 19(1), 28-31. doi: 10.4283/JMAG.2014.19.1.028

Kim, K., Lee, S., Kim, D., Lee, K., & Kim, Y. (2016). Effects of mirror therapy combined with motor tasks on upper extremity function and activities daily living of stroke patients. Journal of Physical Therapy Science, 28(2), 483-7. doi: 10.1589/jpts.28.483

Kim, H.J., Lee, G.C., & Song, C.H. (2014). Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. Journal of Stroke and Cerebrovascular Diseases, 23(4), 655-61. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.017

Lee, M.M., Cho, H., & Song, C.H. (2012). The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. American Journal of Physical Medicine & Rehabilitation, 91(8), 689-700. doi: 10.1097/PHM.0b013e31824fa86d

Lim, K.-B., Lee, H.-J., Yoo, J., Yun, H.-J., & Hwang, H.-J. (2016). Efficacy of mirror therapy containing functional tasks in poststroke patients. Annals of Rehabilitation Medicine, 40(4), 629-36. doi: 10.5535/arm.2016.40.4.629

Lin, K.-C., Huang, P.-C., Chen, Y.-T., Wu, C.-Y., & Huang, W.-L. (2014). Combining afferent stimulation and mirror therapy for rehabilitating motor function, motor control, ambulation, and daily functions after stroke. Neurorehabilitation and Neural Repair, 28(2), 153-62. doi: 10.1177/1545968313508468

Michielsen, M. E., Selles, R. W., van der Geest, J. N., Eckhardt, M., Yavuzer, G., Stam, H. J., Smits, M., Ribbers, G. M., & Bussmann, J. B. J. (2010). Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabilitaiton and Neural Repair, 4, 1-11. doi: 10.1177/1545968310385127

Mirela, C.L., Matei, D., Ignat, B., & Popescu, C.D. (2015). Mirror therapy enhances upper extremity motor recovery in stroke patients. Acta Neurologica Belgica, 115, 597-603. doi: 10.1007/s13760-015-0465-5

Nagapattinam, S., Vinod Babu, K., Sai Kumar, N., & Ayyappan, V.R. (2015). Effect of task specific mirror therapy with functional electrical stimulation on upper limb function for subacute hemiplegia. International Journal of Physiotherapy, 2(5), 840-9. doi: 10.15621/ijphy/2015/v2i5/78243

Pandian, J.D., Arora, R., Kaur, P., Sharma, D., Vishwambaran, D.K., & Arima, H. (2014). Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology, 83, 1012-7. doi: 10.1212/WNL.0000000000000773

Park, J.-Y., Chang, M., Kim, K.-M., & Kim, H.J. (2015a). The effect of mirror therapy on upper-extremity function and activities of daily living in stroke patients. Journal of Physical Therapy Science, 27, 1681-3. doi: 10.1589/jpts.27.1681

Park, Y., Chang, M., Kim, K.-M., & An, D.-H. (2015b). The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients. Journal of Physical Therapy Science, 27, 1499-501. doi: 10.1589/jpts.27.1499

Purvane Vural, S., Yuzer, G.F.N., Ozcan, D.S., Ozbudak, S.D., & Ozgirgin, N. (2016). Effects of mirror therapy in stroke patients with complex regional pain syndrome type 1: a randomized controlled study. Archives of Physical Medicine and Rehabilitation, 97, 575-81. doi: 10.1016/j.apmr.2015.12.008

Radajewska, A., Opara, J.A., Kucio, C., Blaszczyszyn, M., Mehlich, K., Szczygiel, J. (2013). The effects of mirror therapy on arm and hand function in subacute stroke in patients. International Journal of Rehabilitation Research, 36(3), 268-74. doi: 10.1097/MRR.0b013e3283606218

Radajewska, A., Opara, J., Bilinski, G., Kaczorowska, A., Nawrat-Szoltysik, A., Kucinsak, A., &. Lepsy, E. (2017). Effectiveness of mirror therapy for subacute stroke in relation to chosen factors. Rehabilitation Nursing, 42(4), 223-9. doi: 10.1002/rnj.275

Rajappan, R., Abudaheer, S., Selvaganapathy, K., & Gokanadason, D. (2015). Effect of mirror therapy on hemiparetic upper extremity in subacute stroke patients. International Journal of Physiotherapy, 2(6), 1041-6. doi: 10.15621/ijphy/2015/v2i6/80766

Rehani, P., Kumari, R., & Midha, D. (2015). Effectiveness of motor relearning programme and mirror therapy on hand functions in patients with stroke – a randomized clinical trial. International Journal of Therapies and Rehabilitation Research, 4(3), 20-4. doi: 10.5455/ijtrr.00000058

Rodrigues, L.C., Farias, N.C., Gomes, R.P., & Michaelsen, S.M. (2016). Feasibility and effectiveness of adding object-related bilateral symmetrical training to mirror therapy in chronic stroke: a randomized controlled pilot study. Physiotherapy Theory and Practice, 32(2), 83-91. doi: 10.3109/09593985.2015.1091872

Rothgangel, A. S., Braun, S. M., Beurskens, A. J., Seitz, R. J., & Wade, D. T. (2011). The clinical aspects of mirror therapy in rehabilitation: A systematic review of the literature. International Journal of Rehabilitation Research, 34, 1-13. doi: 10.1097/MRR.0b013e3283441e98

Samuelkamaleshkumar, S., Reethajanetsureka, S., Pauljebaraj, P., Benshamir, B., Padankatti, S.M., David, J.A. (2014). Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 95(11), 2000-5. doi: 10.1016/j.apmr.2014.06.020

Thieme, H., Bayn, M., Wurg, M., Zange, C., Pohl, M., & Behrens, J. (2012). Mirror therapy for patients with severe arm paresis after stroke – a randomized controlled trial. Clinical Rehabilitation, 27(4), 314-24. doi: 10.1177/0269215512455651

Wu, C.-Y., Huang, P.-C., Chen, Y.-T., Lin, K.-C., & Yang, H.-W. (2013). Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 1023-30. doi: 10.1016/j.apmr.2013.02.007

Yavuzer G., Selles R., Sezer N., Sütbeyaz S., Bussmann J.B., Köseoglu F., Atay M.B., Stam H.J.(2008). Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial. Archive of Physical Medicine, 89, 393-398. doi: 10.1016/j.apmr.2007.08.162

Yeldan, I., Huseyinsinoglu, B.E., Akinci, B., Tarakci, E., Baybas, S., & Ozdincler, A.R. (2015). The effects of very early mirror therapy on functional improvement of the upper extremity in acute stroke patients. Journal of Physical Therapy Science, 27, 3519-24. doi: 10.1589/jpts.27.3519

Yun, G.J., Chun, M.H., Park, J.Y., & Kim, B.R. (2011). The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients. Annals of Rehabilitation Medicine, 35, 316-21. doi: 10.5535/arm.2011.35.3.316

Excluded Studies

Arya, K.N. & Pandian, S. (2013). Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study. Topics in Stroke Rehabilitation, 20(3), 210-7. doi: 10.1310/tsr2003-210
Reason for exclusion: not a randomized controlled trial.

Dalla Libera, D., Regazzi, S., Fasoletti, C., Dinacci Ruggieri, D., & Rossi Hildebrand, P. (2015). Beneficial effect of transcranial magnetic stimulation combined with mirror therapy in stroke patients: a pilot study in neurorehabilitative setting. Brain Stimulation, 8, 360-77. doi: 10.1016/j.brs.2015.01.206
Reason for exclusion: abstract only – statistical data of clinical outcome measures not provided.

Geller, D., Nilsen, D., Van Lew, S., Gillen, G., & Bernardo, M. (2016). Home mirror therapy: a randomized controlled pilot study comparing unimanual and bimanual mirror therapy for improved upper limb function post-stroke. Archives of Physical Medicine and Rehabilitation, 97(10), e4. doi: 10.1016/j.apmr.2016.08.008
Reason for exclusion: oral presentation – no statistical data provided for clinical outcome measures.

Harmsen, W., Bussmann, J.B.J., Selles, R.W., Hurkmans, H.L.P., & Ribbers, G.M. (2015). A mirror therapy-based action observation protocol to improve motor learning after stroke. Neurorehabilitation and Neural Repair, 29(6), 509-16. doi: 10.1177/1545968314558598
Reason for exclusion: observational study; intervention provided over one session.

Ju, Y. & Yoon, I.-J. (2018). The effects of modified constraint-induced movement therapy and mirror therapy on upper extremity function and its influence on activities of daily living. The Journal of Physical Therapy Science, 30, 77-81. doi: 10.1589/jpts.30.77
Reason for exclusion: no between-group comparisons.

Kim, H. & Shim, J. (2015). Investigation of the effects of mirror therapy on the upper extremity functions of stroke patients using the manual function test. The Journal of Physical Therapy Science, 27, 227-9. doi: 10.1589/jpts.27.227
Reason for exclusion: not a randomized controlled trial; results do not add strength to current evidence.

Kojima, K., Ikuno, K., Morii, Y., Tokuhisa, K., Morimoto, S., & Shomoto, K. (2014). Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: a randomized crossover trial. NeuroRehabilitation, 34, 235-44. doi: 10.3233/NRE-131038
Reason for exclusion: combined therapy (mirror therapy + electromyography-triggered neuromuscular stimulation) impacts on ability to determine effects of mirror therapy alone.

Lee, D., Lee, G. & Jeong, J. (2016). Mirror therapy with neuromuscular electrical stimulation for improving motor function of stroke survivors: a pilot randomized clinical study. Technology and Health Care, 24(4), 503-11. doi: 10.3233/THC-161144
Reason for exclusion: combined therapy (mirror therapy + neuromuscular electrical stimulation) impacts on ability to determine effects of mirror therapy alone.

Medeiros, C.S., Fernandes, S.G., Lopes, J.M., Cacho, E.N., & Cacho, R.O. (2014). Effects of mirror therapy through functional activities and motor standards in motor function of the upper limb after stroke. Fisioterapia & Pesquisa, 21(3), 264-70. doi: 10.590/1809-2950/87821032014.
Reason for exclusion: both groups received mirror therapy (mirror therapy using functional activities vs. mirror therapy using isolated motor patterns).

Moustapha, A. & Rousseaux, M. (2012). Immediate effects of mirror therapy on spatial neglect. Annals of Physical and Rehabilitation Medicine, 55(S1), e197. doi: 10.1016/j.rehab.2012.07.501
Reason for exclusion: abstract, insufficient information.

Paik, Y.-R., Kim, S.-K., Lee, J.-S., & Jeon, B.-Y. (2014). Simple and task-oriented mirror therapy for upper extremity function in stroke patients: a pilot study. Hong Kong Journal of Occupational Therapy, 24, 6-12. doi: 1016/j.hkjot.2014.01.002
Reason for exclusion: non-randomized study with no between-group comparisons; results do not add strength to current evidence.

Rothgangel, A.S., Morton, A.R., van den Hout, J.W.E., Beurkens, A.J.H.M. (2004). Phantoms in the brain: spiegeltherapie bij chronische CVA-patienten; een pilot-study. Nederlands Tijdschrift voor Fysiotherapie, 114, 36-40. Accessed from: https://www.researchgate.net/profile/Andreas_Rothgangel/publication/290130135_Phantoms_in_the_brain_Mirror_therapy_in_chronic_stroke_patients_a_pilot_study/links/56a0b3ec08aee4d26ad74c6a/Phantoms-in-the-brain-Mirror-therapy-in-chronic-stroke-patients-a-pi
Reason for exclusion: language other than English/French.

Selles, R.W., Michielsen, M.E., Bussmann, J.B.J., Stam, H.J., Hurkmans, H.L., Heijnen, I., Groot, D.d., Ribbers, G.M. (2014). Effects of a mirror-induced visual illusion on a reachgin task in stroke patients: implications for mirror therapy training. Neurorehabilitation and Neural Repair, 28(7), 652-9. doi: 10.1177/1545968314521005
Reason for exclusion: not an intervention.

Salhab, G., Sarraj, A.R., & Saleh, S. (2016). Mirror therapy combined with functional electrical stimulation for rehabilitation of stroke survivors’ ankle dorsiflexion. IEEE xplore digital library, 38th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC). doi: 10.1109/EMBC.2016.7591776
Reason for exclusion: combined therapy (mirror therapy + electrical stimulation) impacts on ability to determine effect of mirror therapy alone.

Sathian K., Greenspan A.I. & Wolf S.L. (2000). Doing It with Mirrors: A Case Study of a Novel Approach to Neurorehabilitation. Neurorehabilitation and Neural Repair, 14(1), 73-76. doi: 10.1177/154596830001400109
Reason for exclusion: not a randomized controlled trial; results do not add to strength to current evidence.

Seok, H., Kim, S.H., Jang, Y.W., Lee, J.B., & Kim, S.W. (2010). Effect of mirror therapy on recovery of upper limb function and strength in subacute hemiplegia after stroke. Journal of Korean Academy of Rehabilitation Medicine, 34, 508-12. Accessed from: http://www.koreascience.or.kr/article/ArticleFullRecord.jsp?cn=DJHOB7_2010_v34n5_508
Reason for exclusion: language other than English/French.

Stevens J.A., Stoykov P.M.E. (2003). Using motor imagery in the rehabilitation of hemiparesis. Archives of Physical Medicine, 84(7), 1090-2. doi: 10.1016/S0003-9993(03)00042-X
Reason for exclusion: not a randomized controlled trial; results do not add to strength to current evidence.

Yoon, J.A., Koo, B.I., Shin, M.J., Shin, Y.B., Ko, H.-Y., & Shin, Y.-I. (2014). Effect of constraint-induced movement therapy and mirror therapy for patients with subacute stroke. Annals of Rehabilitation Medicine, 38(4), 458-66. doi: 10.5535/arm.2014.38.4.458
Reason for exclusion: combined therapy (mirror therapy + CIMT) impacts on ability to determine effects of mirror therapy alone.

Zacharis, D., Moumtzi, E., Terzis, N., Roussos, N., & Patatoukas, D. (2014). The use of mirror therapy in stroke patients with hemiplegic upper limb: a randomized controlled trial. Annals of Physical and Rehabilitation Medicine, 57S, e27. doi: 10.1016/j.rehab.2014.03.101
Reason for exclusion: abstract, insufficient information.

Motor Imagery / Mental Practice

Evidence Reviewed as of before: 01-06-2017
Author(s)*: Tatiana Ogourtsova, MSc BSc OT; Annabel McDermott, OT; Angela Kim, B.Sc.; Adam Kagan, B.Sc.; Emilie Belley B.A. Psychology, B.Sc PT; Mathilde Parent-Vachon Bsc PT; Josee-Anne Filion; Alison Nutter; Marie Saulnier; Stephanie Shedleur, Bsc PT; Tsz Ting Wan, BSc PT; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Stephen Page, PhD (C)
Patient/Family Information Table of contents

Introduction

Motor imagery or mental practice/mental imagery/mental rehearsal involves activation of the neural system while a person imagines performing a task or body movement without actually physically performing the movement. Motor imagery has been used after a stroke to attempt to treat loss of arm, hand and lower extremity movement, to help improve performance in activities of daily living, to help improve gait, and to minimize the effects of unilateral spatial neglect. Motor imagery can be used in the acute phase, subacute phase or chronic phase of rehabilitation. It has been shown that while motor imagery is beneficial by itself, it is most effective when used in addition to physical practice. In fact, many of the first studies on motor imagery were designed to investigate whether motor imagery improved motor performance in athletes. Brain scanning techniques have shown that similar areas of the brain are activated during motor imagery and physical movement. In addition, motor imagery has been shown in one study to help the brain reorganize its neural pathways, which may help promote learning of motor tasks after a stroke.

Patient/Family Information

Authors: Tatiana Ogourtsova, MSc BSc OT, Annabel McDermott, OT, Erica Kader; Emilie Belley, BA Psychology, BSc PT; Josee-Anne Filion; Alison Nutter; Mathilde Parent-Vachon; Marie Saulnier; Stephanie Shedleur, Bsc PT; Tsz Ting Wan, BSc PT; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT

What is motor imagery?

Motor imagery is a form of therapy that can be used to strengthen the arms, hands, feet and legs which may be weakened by stroke. In motor imagery, we mentally rehearse the movement of the affected body parts, without ever actually attempting to perform the movement. In other words, you imagine doing the motion in your mind. For example, you may imagine hitting a golf ball or drinking a cup of tea. Researchers have shown that this “mental rehearsal” actually works, as it stimulates the brain areas responsible for making the weaker arm or leg move.

Courtesy of Dr. Stephen Page and his team at Drake Center and University of Cincinnati

What is motor imagery used for?

It has been used to improve strength, increase hip movements, and improve postural control in the elderly, as well as treat people who have health problems, including injury to the spinal cord, Parkinson’s disease, or fibromyalgia (general muscle pain). It is especially useful for people with problems with the arms, legs, and hands.

Are there different types of motor imagery?

There are two distinct types of motor imagery:

  • Kinaesthetic motor imagery – imagining the feeling associated with performing a movement.
  • Visual motor imagery – imagining the movement itself.

What can I expect from a motor imagery session?

An example of a motor imagery session for a person with a weakened arm might include:

  • 5 minutes of listening to a tape recording of relaxation techniques
  • 20 minutes of exercises related to motor imagery. In week one the mental imagery training involves using computer images and movies to analyze steps and sequences required to successfully complete a task ie. reaching for a cup or turning a page in a book. In week two, patients are trained to identify problems they are having with the tasks and correct them using mental imagery. In the third week, they practice the corrected tasks mentally as well as perform the actual tasks.
  • The session concludes with time given to the individual to refocus on the room around them.

Does it Work for Stroke?

Experts have done experiments to compare mental imagery with other treatments, to see if mental imagery helps people who have had a stroke.

In individuals with ACUTE stroke (up to 1 month after stroke), 1 high quality study and one fair quality study found that mental imagery:

  • Was more helpful than the usual treatment alone for improving self-care skills (e.g. dressing and shopping);
  • Was as helpful as other treatments for improving thinking skills (e.g. attention) and motor function of the arms and legs.

In individuals with SUBACUTE stroke (1 month to 6 months after stroke), 2 high quality studies and 1 fair quality study found that mental imagery:

  • Was more helpful than the usual treatment alone for improving walking speed;
  • Was as helpful as other treatments for improving self-care skills (e.g. dressing) and physical skills of the arms and legs, including mobility, dexterity and grip strength.

In individuals with CHRONIC stroke (more than 6 months after stroke), 10 high quality studies, 6 fair quality studies in 1 poor quality study found that mental imagery:

  • Was more helpful than the usual treatment alone for improving balance, walking speed, and motor function of the arms and legs;
  • Was as helpful as other treatments for improving self-care skills (e.g. dressing and shopping) and spasticity.

When can motor imagery be used after stroke?

Motor imagery techniques can be started at any time following a stroke. However, it is believed that the treatments would be most useful in the first 6 to 18 months after a stroke when the majority of post-stroke recovery occurs.

Are there any risks to me?

There are no specific risks involved in participating in motor imagery. Motor imagery is actually quite easy to do at home, and many people find it a fun and relaxing way of having additional therapy.

How do I begin?

Your rehabilitation therapist should be able to provide you with a program to meet your individual needs. She/He can guide you as to:

  • how many times a week you should do motor imagery exercises,
  • what specific activities and movements you should do,
  • what activities you should not do,
  • how long each motor imagery session should be,
  • how to change activities as you improve.

How much does it cost? Do I need special equipment?

Motor imagery is inexpensive and accessible. Insurance will cover the services that you will receive in the hospital or rehabilitation centre. Once you are home you can continue this treatment on your own. No special equipment is required.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The present module compiled results from 30 RCTs – 16 high quality RCTs, 12 fair quality RCTs and two low quality RCTs – and one non-randomized quasi experimental study. A Cochrane review by Barclay-Goddard et al. (2011) and three systematic reviews by Harris & Hebert (2015), Nilsen, Gillen & Gordon (2010), and Braun et al. (2006) were also reviewed to ensure completeness of results.

Studies were excluded if: (1) they were not RCTs and outcomes within those studies could be found in RCTs; (2) both groups were receiving a form of mental imagery training; and/or (3) no between-group analyses were performed.

Studies included in this review used mental imagery across all stages of stroke recovery, although most studies included individuals in the chronic phase or mixed phases of recovery (acute/subacute/chronic). Overall, mental imagery was often provided in combination with other interventions (e.g. conventional rehabilitation, physical therapy, occupational therapy, electrical stimulation or modified-Constraint Induced Movement Therapy – mCIMT). While in many instances it was found to achieve similar results to other interventions, mental imagery was shown to be more effective than comparison interventions in improving outcomes such as:

  • Acute stroke – functional independence and instrumental activities of daily living;
  • Subacute strokegait speed;
  • Chronic stroke – balance, gait speed, lower extremity motor function, mobility and stroke outcomes.

Note: Mental imagery, motor imagery or mental rehearsal are used interchangeably in this module.

Results Table

View results table

Outcomes

Acute phase

Functional independence
Effective
1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Functional independence of trained and untrained tasks was measured by a 7-point Likert Scale at post-treatment (3 weeks) and at follow-up (1 month). Significant between-group differences in functional independence (trained and untrained tasks) were found at post-treatment, favoring mental imagery + ADL training vs. ADL training alone. Significant between-group differences in functional independence (trained tasks only) were found at follow-up, favoring mental imagery + ADL training vs. ADL training alone.
Note: In this study, mental imagery training was aimed at creating a strategy to correct ADLs in general, rather than to improve a particular movement.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is more effective than a comparison intervention (ADL training alone) in improving functional independence in patients with acute stroke.

Instrumental activities of daily living (IADLs)
Effective
2a

One fair quality RCT (Liu et al., 2009) investigated the effect of mental imagery on instrumental activities of daily living (IADLs) in patients with acute stroke. This fair quality RCT randomized patients to receive mental imagery training or conventional functional rehabilitation. IADLs (trained: sweeping, tidying, cooking, going outdoors, going to a shop; untrained: cooking, cleaning, visiting a resource center) were measured at post-treatment (3 weeks). There were significant between-group differences in performance of 3/5 trained tasks (tidying, cooking, going outdoors) and 2/3 untrained tasks (cleaning, visiting a resource center) at post-treatment, favoring mental imagery training vs. conventional functional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mental imagery training is more effective than a comparison intervention (conventional functional rehabilitation) in improving IADLs in patients with acute stroke.

Motor function (lower extremity)
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on lower extremity motor function in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving lower extremity motor function in patients with acute stroke.

Motor function (upper extremity)
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effects of mental imagery on upper extremity motor function in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving upper extremity motor function in patients with acute stroke.

Sensation
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on sensation in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Sensation was measured by the Fugl-Meyer Assessment – Sensation subtest at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training) in improving sensation in patients with acute stroke.

Sustained visual attention
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effects of mental imagery on sustained visual attention in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Sustained attention was measured by the Color Trails Test at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving sustained attention in patients with acute stroke.

Subacute phase

Dexterity
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on dexterity in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Dexterity was measured by a timed manual dexterity task at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving dexterity in patients with subacute stroke.

Functional independence
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on functional independence in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Functional independence was measured by the Barthel Index and the Modified Functional Limitations Profile at post-treatment (4 weeks). No significant between-group differences were found on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving functional independence in patients with subacute stroke.

Gait speed
Effective
1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on gait speed in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Gait speed was measured by the 10 Meter Walking Test at post-treatment (6 weeks). Significant between-group differences were found at post-treatment, favoring lower extremity mental imagery practice vs. muscle relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is more effective than a comparison intervention (muscle relaxation) in improving gait speed in patients with subacute stroke.

Grip strength
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on grip strength in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Grip strength was measured with a dynamometer at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving grip strength in patients with subacute stroke.

Motor function (lower extremity)
Not effective
1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on lower extremity motor function in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity (far transfer) at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is not more effective than a comparison intervention (muscle relaxation) in improving lower extremity motor function in patients with subacute stroke.

Motor function (upper extremity)
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) and one fair quality RCT (Riccio et al., 2010) investigated the effect of mental imagery on upper extremity motor function in patients with subacute stroke.

The high quality RCT (Ietswaart et al., 2011) randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Upper extremity motor function was measured by the Action Research Arm Test at post-treatment (4 weeks). No significant between-group differences were found.

The fair quality RCT (Riccio et al., 2010) randomized patients to receive mental rehearsal training + conventional rehabilitation or conventional rehabilitation alone, in a cross-over design study. Upper extremity motor function was measured by the Motricity Index – Upper Extremity subscale (MI-UE) and the Arm Functional Test – Functional Ability Scale and Time score (AFT-FAS, AFT-T) score at post-treatment of Phase 1 (3 weeks) and post-treatment of Phase 2 (6 weeks). Significant between-group differences were found on all measures of upper extremity motor function at both time points, in favour of the group that had just undergone mental rehearsal training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving upper extremity motor function in patients with subacute stroke.
Note:
However, one cross-over fair quality RCT found that mental rehearsal training + conventional rehabilitation was more effective than conventional rehabilitation alone in improving upper extremity motor function in patients with subacute stroke.

Motor imagery ability
Not effective
1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on motor imagery ability in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Motor imagery ability was measured by the Movement Imagery Questionnaire Revised – Visual and Kinesthetic scales, and the Walking Trajectory Test (imagery/actual walking time) at post-treatment (6 weeks). There was a significant between-group difference on only one measure (Movement Imagery Questionnaire Revised – kinesthetic scale) at post-treatment, favoring lower extremity mental imagery practice vs. muscle relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is not more effective than a comparison intervention (muscle relaxation) in improving motor imagery ability in patients with subacute stroke.
Note:
However, there was a significant difference in kinaesthetic motor imagery, in favour of lower extremity mental imagery practice vs. muscle relaxation.

Chronic phase

Balance
Effective
1a

Four high quality RCTs (Hwang et al., 2010; Cho et al., 2012; Hosseini et al., 2012; Kim & Lee, 2013) investigated the effect of mental imagery on balance in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Balance was measure by the Berg Balance Scale (BBS) at post-treatment (4 weeks). Significant between-group differences were found in balance, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. Balance was measured by the Functional Reach Test (FRT) at post-treatment (6 weeks). Significant between-group differences were found in balance, favoring mental imagery + gait training vs. gait training alone.

The third high quality RCT (Hosseini et al., 2012) randomized patients to receive mental imagery + occupational therapy or occupational therapy alone. Balance was measured by the BBS at post-treatment (5 weeks) and at follow-up (7 weeks). Significant between-group differences were found in balance at post-treatment, favoring mental imagery + occupational therapy vs. occupational therapy alone. Differences did not remain significant at follow-up.

The forth high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Balance was measured by the FRT at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mental imagery training is more effective than comparison interventions (sham imagery training, gait training alone, occupational therapy alone) in improving balance in patients with chronic stroke. However, a fourth high quality RCT reported no significant between-group differences when comparing mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone in improving balance in patients with chronic stroke.

Balance confidence
Conflicting
4

Two high quality RCTs (Hwang et al., 2010 Dickstein et al., 2013) investigated the effect of mental imagery on balance confidence in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Balance confidence was measure by the Activities Specific Balance Confidence Scale at post-treatment (4 weeks). Significant between-group differences were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Balance confidence was measured by the Falls Efficacy Scale at post-treatment (4 weeks) and at follow-up (6 weeks). No significant between-group differences were found at either time point.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on balance confidence in patients with chronic stroke. While one high quality RCT found that videotape-based locomotor imagery training was more effective than sham mental imagery training, one second high quality RCT found that mental imagery training was not more effective than physical therapy in improving balance confidence in patients with chronic stroke.
Note:
Studies used different measures of balance confidence.

Functional independence
Not effective
1a

Two high quality RCTs (Bovend’Eerdt et al., 2010; Hong et al., 2012) investigated the effect of mental imagery on functional independence in patients with chronic stroke.

The first high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the Barthel Index (BI) at post-treatment (6 weeks). No significant between-group differences were found.

The second high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery with electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Functional independence was measured by the modified BI at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, functional electric stimulation) in improving functional independence in patients with chronic stroke.

Gait parameters
Conflicting
4

Two high quality RCTs (Hwang et al., 2010 Kim & Lee, 2013) and one fair quality RCT (Lee et al., 2011) investigated the effect of mental imagery on gait parameters in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Gait parameters (cadence, joint motion, stride length) were measured by a 3D motion capture system at post-treatment (4 weeks). Significant between-group differences in some gait parameters (joint motion, stride length) were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Gait parameters (cadence, speed, single/double limb support, step/stride length) were measured by the GAITRite system at post-treatment (4 weeks). There were significant between-group differences in three gait parameters (cadence, speed, single limb support) at post-treatment, favoring action observation training + physical therapy vs. physical therapy alone.

The fair quality RCT (Lee et al., 2011) randomized patients to receive mental imagery + treadmill training or treadmill training alone. Gait parameters (cadence, speed, single/double limb support, step/stride length) were measured at post-treatment (2 weeks following a 6-week treatment block). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery training on gait parameters in patients with chronic stroke. While one high quality RCT found that videotape-based locomotor imagery training is more effective than a comparison intervention (sham mental imagery training) in improving some gait parameters in patients with chronic stroke, another high quality RCT and one fair quality RCT found that mental imagery training is not more effective than comparison interventions (action observation training with physical therapy, physical therapy alone, treadmill training alone) in improving gait parameters in patients with chronic stroke.

Gait speed
Effective
1a

Three high quality RCTs (Hwang et al., 2010; Cho et al., 2012;Dickstein et al., 2013) investigated the effect of mental imagery on gait speed in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Gait speed was measured by the 10 Meter Walk Test (10MWT) at post-treatment (4 weeks). Significant between-group differences were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. Gait speed was measured by the 10MWT at post-treatment (6 weeks). Significant between-group differences were found in gait speed at post-treatment, favoring mental imagery + gait training vs. gait training alone.

The third high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Gait speed was measured by the 10MWT at post-treatment (4 weeks) and at follow-up (6 weeks). Significant between-group differences were found at both time points, favoring mental imagery training vs. physical therapy.
Note: Further, all participants who received physical therapy crossed-over to receive mental imagery training for 4 weeks. A significant improvement in gait speed was reported among those participants at both time points.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mental imagery training is more effective than comparison interventions (sham imagery training, gait training alone, physical therapy) in improving gait speed in patients with chronic stroke.

Goal attainment
Not effective
1b

One high quality RCT (Bovend’Eerdt et al., 2010) investigated the effect of mental imagery training on goal attainment in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Goal attainment was measured by the Goal Attainment Scale at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving goal attainment in patients with chronic stroke.

Instrumental activities of daily living (IADLs)
Not effective
1b

One high quality RCT (Bovend’Eerdt et al., 2010) investigated the effect of mental imagery training on instrumental activities of daily living (IADLs) in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. IADLs were measured by the Nottingham Extended Activities of Daily Living at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving IADLs in patients with chronic stroke.

Mobility
Conflicting
4

Seven high quality RCTs (Malouin et al., 2009Bovend’Eerdt et al., 2010Hwang et al., 2010; Cho et al., 2012Hosseini et al., 2012Dickstein et al., 2013Kim & Lee, 2013) investigated the effect of mental imagery training on mobility in patients with chronic stroke.

The first high quality RCT (Malouin et al., 2009) randomized patients to receive mental imagery + physical practice, cognitive training + physical practice, or no training. Mobility was measured by the change scores in leg loading of the affected leg as a percent of body weight during the rising-to-sitting action at baseline, post-treatment (4 weeks) and follow-up (7 weeks). Significant between-group differences in change scores from baseline to post-treatment were found, favoring mental imagery training + physical practice vs. cognitive training + physical practice; and favoring mental imagery training + physical practice vs. no training. Significant between-group differences were not maintained at follow-up.

The second high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Mobility was measured by the Timed Up and Go Test (TUGT) and the Rivermead Mobility Index at post-treatment (6 weeks). No significant between-group differences were found on any of the measures.

The third high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Mobility was measured by the Dynamic Gait Index and the Modified Emory Functional Ambulation Profile at post-treatment (4 weeks). Significant between-group differences in both measures of mobility were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The forth high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. Mobility was measured by the TUGT at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery + gait training vs. gait training alone.

The fifth high quality RCT (Hosseini et al., 2012) randomized patients to receive mental imagery + occupational therapy or occupational therapy alone. Mobility was measured by the TUGT at post-treatment (5 weeks) and at follow-up (7 weeks). Significant between-group differences were found at post-treatment, favoring mental imagery + occupational therapy vs. occupational therapy alone. Significant between-group differences were not maintained at follow-up.

The sixth high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Mobility was measured by step activity monitor (community ambulation) and number of steps/minute at post-treatment (4 weeks) and at follow-up (6 weeks). There were no significant between-group differences in both measures of mobility at either time point.

The seventh high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Mobility was measured by the TUGT, Walking Ability Questionnaire, and Functional Ambulation Category at post-treatment (4 weeks). A significant between-group difference in one measure of mobility (TUGT) was found at post-treatment, favoring action observation training + physical therapy vs. physical therapy alone.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on mobility in patients with chronic stroke. While four high quality RCTs found that mental imagery training is more effective than comparison interventions (cognitive training + physical practice, no training, sham imagery training, gait training alone, occupational therapy alone) in improving mobility in patients with chronic stroke; three other high quality RCTs found that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, physical therapy, action observation training + physical therapy) in improving mobility in patients with chronic stroke.

Motor activity (upper extremity)
Not effective
1b

One high quality RCT (Hong et al., 2012) and one fair quality RCT (Page et al., 2005) investigated the effect of mental imagery on upper extremity motor activity among patients with chronic stroke.

The high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Upper extremity motor activity was measured by the Motor Activity Log – Amount of Use and Quality of Movement (MAL-AOU, MAL-QOM) at post-treatment (4 weeks). No significant between-group differences were found.

The fair quality RCT (Page et al., 2005) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor activity was measured by the MAL at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that mental imagery training is not more effective than comparison interventions (functional electrical stimulation to the affected forearm, relaxation training) in improving upper extremity motor activity in patients with chronic stroke.

Motor function (lower extremity)
Effective
1b

One high quality RCT (Cho et al., 2012) investigated the effect of mental imagery on lower extremity motor function in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + gait training or gait training alone. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery + gait training vs. gait training alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + gait training is more effective than a comparison intervention (gait training alone) in improving lower extremity motor function in patients with chronic stroke.

Motor function (upper extremity)
Conflicting
4

Four high quality RCTs (Bovend’Eerdt et al., 2010Page et al., 2011;Hong et al., 2012Nilsen et al., 2012) and five fair quality RCTs (Page, 2000Page et al., 2005Ertelt et al., 2007Page et al., 2007Page et al., 2009) investigated the effect of mental imagery on upper extremity motor function in patients with chronic stroke.

The first high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Upper extremity motor function was measured by the Action Research Arm Test (ARAT) at post-treatment (6 weeks). No significant between-group differences were found.

The second high quality RCT (Page et al., 2011) randomized patients to receive mental imagery or sham audio therapy. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE) and the ARAT at post-treatment (10 weeks). No significant between-group differences were found on any of the measures.

The third high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). Significant between-group differences in upper extremity motor function were found at post-treatment, favoring mental imagery + electromyogram-triggered electric stimulation vs. functional electric stimulation to the affected forearm.

The forth high quality RCT (Nilsen et al., 2012) randomized patients to receive mental imagery training using an internal perspective (internal group), mental imagery training using an external perspective (external group), or relaxation imagery; all groups received occupational therapy. Upper extremity motor function was measured by the FMA-UE and the Jebsen-Taylor Test of Hand Function at post-treatment (6 weeks). Significant between-group differences were found on both measures, favoring both styles of mental imagery training (internal group, external group) vs. relaxation imagery.

The first fair quality RCT (Page, 2000) randomized patients to receive mental imagery training + occupational therapy or occupational therapy alone. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). Significant between-group differences were found at post-treatment, favoring mental imagery training + occupational therapy vs. occupational therapy alone.

The second fair quality RCT (Page et al., 2005) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor function was measured by the ARAT at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery training vs. relaxation training.

The third fair quality RCT (Ertelt et al., 2007) randomized patients to receive action observation therapy or conventional rehabilitation. Upper extremity motor function was measured by the Frenchay Arm Test and the Wolf Motor Function Test at post-treatment (18 days); participants in the action observation group were reassessed 8 weeks later (follow-up). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring action observation therapy vs. conventional rehabilitation. Significant within-group gains were maintained at follow-up.

The forth fair quality RCT (Page et al., 2007) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (1 week following a 6-week treatment). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring mental imagery training vs. relaxation training.

The fifth fair quality RCT (Page et al., 2009) randomized patients to receive mental imagery + modified-constraint induced therapy (mCIMT) or mCIMT alone. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (10 weeks) and follow-up (3 months). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment and at follow-up, favoring mental imagery training + mCIMT vs. mCIMT alone.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on upper extremity motor function. While two high quality RCTs found that mental imagery was not more effective than comparison interventions (conventional rehabilitation alone, sham audio therapy) in improving upper extremity motor function in patients with chronic stroke; two other high quality RCTs found that mental imagery was more effective than comparison interventions (functional electric stimulation to the affected forearm, relaxation imagery) in improving upper extremity motor function in patients with chronic stroke.
Note:
Five fair quality RCTs found that mental imagery training is more effective than comparison interventions (occupational therapy alone, relaxation training, conventional rehabilitation, mCIMT alone) in improving upper extremity motor function in patients with chronic stroke.

Occupational performance
Not effective
1b

One high quality RCT (Nilsen et al., 2012) investigated the effect of mental imagery on occupational performance in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery training using an internal perspective (internal group), mental imagery training using an external perspective (external group), or relaxation imagery; all groups received occupational therapy. Occupational performance was measure by the Canadian Occupational Performance Measure at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery training using an internal or external perspective is not more effective than a comparison intervention (relaxation imagery) in improving occupational performance in patients with chronic stroke.

Pain
Not effective
2b

One poor quality RCT (Cacchio et al., 2009) investigated the effect of mental imagery on pain in patients with chronic stroke. This poor quality RCT randomized patients with Complex Regional Pain Syndrome (CRPS) to receive mental imagery, mirror therapy or covered mirror practice. Pain was measured by Visual Analogue Scale at post-treatment (4 weeks). Significant between-group differences were found, favoring mirror therapy vs. mental imagery and favouring mirror therapy vs. covered mirror practice.
Note: Following 4 weeks, some participants crossed-over to the mirror therapy group. A significant reduction in pain was reported among participants who crossed-over from the mental imagery and covered mirror practice groups to the mirror therapy group.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that mental imagery is not more effective than comparison interventions (mirror therapy, covered mirror practice) in improving pain in patients with chronic stroke and CRPS. In fact, mirror therapy was more effective than mental imagery in reducing pain.

Spasticity
Not effective
1b

One high quality RCT (Hong et al., 2012) investigated the effect of mental imagery training on spasticity in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Spasticity was measured by the Modified Ashworth Scale at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + electromyogram-triggered electric stimulation is not more effective than a comparison intervention (functional electric stimulation to the affected forearm) in improving spasticity in patients with chronic stroke.

Stroke outcomes
Effective
2a

One fair quality RCT (Ertelt et al., 2007) investigated the effect of mental imagery on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive action observation therapy or conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale at post-treatment (18 days); participants in the action observation group were reassessed 8 weeks later (follow-up). Significant between-group differences were found at post-treatment, favoring action observation therapy vs. conventional rehabilitation. Significant within-group gains were maintained at follow-up.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that action observation training is more effective than a comparison intervention (conventional rehabilitation) in improving stroke outcomes in patients with chronic stroke.

Phase not specific to one period

Balance
Not effective
1a

Two high quality RCTs (Braun et al., 2012; Schuster et al., 2012) investigated the effect of mental imagery on balance in patients with stroke.

The first high quality RCT (Braun et al., 2012) randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

The second high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training or time-matched stroke education tapes; all groups received physical therapy. Balance was measured by the BBS at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, time-matched stroke education tapes) in improving balance in patients with stroke.

Balance confidence
Not effective
1b

One high quality RCT (Schuster et al., 2012) investigated the effect of mental imagery training on balance confidence in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive embedded mental imagery training or added mental imagery training or time-matched stroke education tapes; all groups received physical therapy. Balance confidence was measured by the Activities-Specific Balance Confidence Scale at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that embedded or added mental imagery is not more effective than a comparison intervention (time-matched stroke education tapes) in improving balance confidence in patients with subacute/chronic stroke.

Dexterity
Not effective
1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on dexterity in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Nine Hole Peg Test at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving dexterity in patients with acute/subacute stroke.

Functional independence
Not effective
1a

Three high quality RCTs (Braun et al., 2012Schuster et al., 2012Timmermans et al., 2013), one fair quality RCT (Ferreira et al., 2011) and one poor quality RCT (Park et al., 2015) investigated the effect of mental imagery on functional independence in patients with stroke.

The first high quality RCT (Braun et al., 2012) randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the Barthel Index (BI); patients’ and therapists’ perception of performance of daily activities (e.g. drinking, walking) was measured by a 10-point numeric rating scale at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found on either measure at either time point.

The second high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Functional independence was measured by the BI at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

The third high quality RCT (Timmermans et al., 2013) randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. Functional independence was measured by the BI at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found at any time point.

The fair quality RCT (Ferreira et al., 2011) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation, visual scanning training + conventional rehabilitation, or conventional rehabilitation alone. Functional independence was measured by the Functional Independence Measure (FIM) at post-treatment (5 weeks) and at follow-up (3 months). There were no significant differences between mental imagery + conventional rehabilitation and other treatment groups at either time point.
Note: Significant between-group differences in functional independence (FIM – self-care items only) were found at post-treatment, favoring visual scanning + conventional rehabilitation vs. conventional rehabilitation alone. Differences did not remain significant at follow-up.

The poor quality RCT (Park et al., 2015) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the modified BI at post-treatment (2 weeks). Significant between-group differences were found, favoring mental imagery + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs and one fair quality RCT that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, time-matched stroke education tapes, neurodevelopmental therapy, visual scanning training + conventional rehabilitation) in improving functional independence in patients with stroke.
Note
: One poor quality RCT found that mental imagery training + conventional rehabilitation is more effective than a comparison intervention (conventional rehabilitation alone) in improving functional independence in patients with subacute/chronic stroke.

Gait speed
Not effective
1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on gait speed in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Gait speed was measured by the 10 Meter Walk Test at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) in improving gait speed in patients with acute/subacute stroke.

Grip strength
Effective
2a

One fair quality RCT (Muller et al., 2007) investigated the effect of mental imagery on grip strength in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive mental imagery training, motor practice training or conventional physical therapy. Grip strength was measured by a force transducer at post-treatment (4 weeks). Significant between-group differences were found, favoring mental imagery vs. physical therapy l rehabilitation and favoring motor practice vs. physical therapy rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mental imagery training is more effective than a comparison intervention (conventional physical therapy) in improving grip strength in patients with acute/subacute stroke.

Instrumental activities of daily living (IADLs)
Not effective
1b

One high quality RCT (Timmermans et al., 2013) investigated the effect of mental imagery on instrumental activities of daily living (IADLs) in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. IADLs were measured by the Frenchay Activity Index at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found at any time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (neurodevelopmental therapy) in improving IADLs in patients with acute/subacute stroke.

Mobility
Not effective
1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on mobility in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Mobility was measured by the Rivermead Mobility Index at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) in improving mobility in patients with acute/subacute stroke.

Motor activity
Not effective
1b

One high quality RCT (Schuster et al., 2012) investigated the effect of mental imagery on motor activity in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Motor activity was measured by (i) time taken to complete a motor task; (ii) the Chedoke McMaster Stroke Assessment (activity scale); and (iii) stage of motor task as per Adams & Tyson classification, at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found on any measure at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that embedded or added mental imagery training is not more effective than a comparison (time-matched stroke education tapes) in improving motor activity in patients with subacute/chronic stroke.

Motor activity (upper extremity)
Not effective
1b

One high quality RCT (Timmermans et al., 2013) and one quasi-experimental design study (Rajesh, 2015) investigated the effect of motor imagery on upper extremity motor activity among patients with stroke.

The high quality RCT (Timmermans et al., 2013) randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. Upper extremity motor activity was measured by accelerometry (total activity, activity/hour, activity ratio of affected/unaffected arm) at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found at either time point.

The quasi-experimental design study (Rajesh, 2015) assigned patients with stroke (stage of recovery not specified) to receive mental imagery + occupational therapy or occupational therapy alone. Upper extremity motor activity was measured by the Motor Activity Log at post-treatment (3 weeks). Significant between-group differences were found, favoring mental imagery + conventional occupational therapy vs. conventional occupational therapy alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (neurodevelopmental therapy) in improving upper extremity motor activity in patients with acute/subacute stroke.
Note:
However, one quasi-experimental study found that mental imagery was more effective than a comparison intervention (conventional occupational therapy alone) in improving upper extremity motor activity in patients with stroke. Discrepancies could result from differences in employed measurement scales and treatment duration (6 vs. 3 weeks).

Motor function (upper extremity)
Not effective
1a

Two high quality RCTs (Welfringer et al., 2011Timmermans et al., 2013), two fair quality RCTs (Page et al., 2001Muller et al., 2007), and one poor quality RCT (Park et al., 2015) investigated the effect of mental imagery on upper extremity motor function in patients with stroke.

The first high quality RCT (Welfringer et al., 2011) randomized patients with acute/subacute stroke to receive visuomotor imagery + conventional rehabilitation or conventional rehabilitation alone. Upper extremity motor function was measured by the Action Research Arm Test (ARAT) at post-treatment (3 weeks). No significant between-group differences were found.

The second high quality RCT (Timmermans et al., 2013) randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Wolf Motor Function Test, Frenchay Arm Test and Fugl-Meyer Assessment – Upper Extremity (FMA-UE) at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found on any measure at any time point. 

The first fair quality RCT (Page et al., 2001) randomized patients with acute/subacute/chronic stroke to receive mental imagery training or stroke education; both groups received time-matched occupational therapy. Upper extremity motor function was measured by the FMA-UE and the ARAT at post-treatment (6 weeks). Differences in both measures of upper extremity motor function were found at post-treatment, favoring mental imagery training vs. stroke education.

The second fair quality RCT (Muller et al., 2007) randomized patients with acute/subacute stroke to receive mental imagery training, motor practice or conventional physical therapy. Upper extremity motor function was measured by the Jebsen Hand Function Test (JHFT – writing, turning over card, picking up small objects, simulated feeding, stacking checkers, picking up large light cans, picking up large heavy cans) at post-treatment (4 weeks). Significant between-group differences were found in some aspect of upper extremity motor function (JHFT – writing, simulated feeding), favoring mental imagery training vs. conventional physical therapy and favoring motor practice vs. conventional physical therapy.

The poor quality RCT (Park et al., 2015) randomized patients with subacute/chronic stroke to receive mental imagery training + conventional rehabilitation or conventional rehabilitation alone. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (2 weeks). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring mental imagery training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, neurodevelopmental therapy) in improving upper extremity motor function in patients with stroke.
Note: 
However, two fair quality RCTs and one poor quality RCT found that mental imagery is more effective than comparison interventions (stroke education, conventional physical therapy, conventional rehabilitation alone) in improving upper extremity motor function in patients with stroke.

Motor imagery ability
Not effective
1b

One high quality RCT (Schuster et al., 2012) investigated the effect of mental imagery on motor imagery ability in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Motor imagery ability was measured by the Imaprax Questionnaire and the Kinesthetic and Visual Imagery Questionnaire at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found on either measure at either time point.

Conclusion: There is moderate evidence (Level 1a) from one high quality RCT that embedded or added mental imagery is not more effective than a comparison intervention (time-matched stroke education tapes) in improving motor imagery ability in patients with stroke.

Unilateral spatial neglect
Not effective
1b

One high quality RCT (Welfringer et al., 2011) and one fair quality RCT (Ferreira et al., 2011) investigated the effect of mental imagery on unilateral spatial neglect (USN) in patients with stroke.

The high quality RCT (Welfringer et al., 2011) randomized patients with acute/subacute stroke to receive visuomotor imagery + conventional rehabilitation or conventional rehabilitation alone. USN was measured by the Bells Cancellation Test, Reading Test, Flower Copying Test, Clock Drawing Test and Representation Test (body touching, visual arm imagery, kinesthetic arm imagery) at post-treatment (3 weeks). No significant between-group differences were found on any measure.

The fair quality RCT (Ferreira et al., 2011) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation, visual scanning training + conventional rehabilitation, or conventional rehabilitation alone. USN was measured by the Behavioral Inattention Test at post-treatment (5 weeks) and at follow-up (3 months). There were no significant differences between mental imagery + conventional rehabilitation and other groups at either time point.
Note: Significant between-group differences favoring visual scanning + conventional rehabilitation vs. conventional rehabilitation alone were found at post-treatment and at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that mental imagery + conventional rehabilitation is not more effective than comparison interventions (conventional rehabilitation alone, visual scanning training + conventional rehabilitation) in improving USN in patients with stroke.

Quality of life
Not effective
1b

One high quality RCT (Schuster et al., 2012) and one quasi-experimental design study (Rajesh, 2015) investigated the effect of mental imagery on quality of life in patients with stroke.

The high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Quality of life was measured by Visual Analogue Scale at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

The quasi-experimental design study (Rajesh, 2015) assigned patients with stroke (stage of recovery not specified) to receive mental imagery + conventional occupational therapy or conventional occupational therapy alone. Quality of life was measured by the Stroke-Specific Quality of Life scale at post-treatment (3 weeks). Significant between-group differences were found, favoring mental imagery practice + conventional occupational therapy vs. conventional occupational therapy alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that embedded or added mental imagery training is not more effective than a comparison intervention (time-matched stroke education tapes) in improving quality of life in patients with subacute/chronic stroke.
Note
: One quasi-experimental study found that mental imagery training + conventional occupational therapy is more effective than a comparison intervention (conventional occupational therapy alone) in improving quality of life in patients with stroke. Discrepancies could result from differences in employed measurement scales and treatment duration (2 vs. 3 weeks).

Sensation
Not effective
1b

One high quality RCT (Welfringer et al., 2011) investigated the effect of visual imagery on sensation in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive visuomotor imagery with conventional rehabilitation or conventional rehabilitation alone. Upper extremity sensation was measured by the Arm Function Test – Sensation score at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that visual imagery + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) for improving sensation in patients with acute/subacute stroke.

Strength
Not effective
1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery training on strength in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Strength was measured by the Motricity Index at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery training + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) in improving strength in patients with acute/subacute stroke.

References

Bovend’Eerdt, T.J., Dawes, H., Sackley, C., Hooshang, I., & Wade, D.T. (2010). An Integrated Motor Imagery Program to Improve Functional Task Performance in Neurorehabilitation: A Single-Blind Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 91, 939-946.
https://www.ncbi.nlm.nih.gov/pubmed/20510987

Braun, S.M., Beurskens, A.J., Kleynen, M., Oudelaar, B., Schols, J.M., & Wade, D.T. (2012). A multicenter randomized controlled trial to compare subacute “treatment as usual” with and without mental practice among persons with stroke in Dutch Nursing Homes. JAMDA, 13, 1-7.
https://www.ncbi.nlm.nih.gov/pubmed/21450196

Cacchio, A., De Blasis, E., Necozione, S., di Orio, F., & Santilli, V. (2009). Mirror therapy for Chronic Complex Regional Pain Syndrome type 1 and stroke. New England Journal of Medicine, 361(6), 634-636.
http://www.nejm.org/doi/full/10.1056/nejmc0902799#t=article

Cho, H. Y., Kim, J. S., & Lee, G. C. (2012). Effects of motor imagery training on balance and gait abilities in post-stroke patients: a randomized controlled trial. Clinical rehabilitation27(8), 675-680.
http://journals.sagepub.com/doi/abs/10.1177/0269215512464702

Dickstein, R., Deutsch, J.E., Yoeli, Y., Kafri, M., Falash, F., Dunsky, A., Eshet, A., & Alexander, N. (2013). Effects of integrated motor imagery practice on gait of individuals with chronic stroke: a half-crossover randomized study. Archives of Physical Medicine and Rehabilitation, 94, 2119-25.
https://www.ncbi.nlm.nih.gov/pubmed/23872048

Ertelt, D., Small, S., Solodkin, A., Dettmers, C., McNamara, A., Binkofsk,i F.,&  Buccino G. (2007). Action observation has a positive impact on rehabilitation of motor deficits after stroke. Neuroimage, 36,164-173.
https://www.ncbi.nlm.nih.gov/pubmed/17499164

Ferreira, H.P., Lopes, M.A.L., Luiz, R.R., Cardoso, L., & Andre, S. (2011). Is visual scanning better than mental practice in hemispatial neglect? Results from a pilot study. Topics in Stroke Rehabilitation, 18(2), 155-61.
https://www.ncbi.nlm.nih.gov/pubmed/21447465

Hong, I.K., Choi, J.B., & Lee, J.H. (2012). Cortical changes after mental imagery training combined with electromyography-triggered electrical stimulation in patients with chronic stroke. Stroke, 43, 2506-09.
https://www.ncbi.nlm.nih.gov/pubmed/22798329

Hosseini, S.A., Fallahpour, M., Sayadi, M., Gharib, M., & Haghgoo, H. (2012). The impact of mental practice on stroke patients’ postural balance. Journal of Neurological Sciences, 322 (1-2), 263-7.
https://www.ncbi.nlm.nih.gov/pubmed/22857987

Hwang, S, Jeon, H, Yi, C, Kwon, O, et al. (2010). Locomotor imagery training improves gait performance in people with chronic hemiparetic stroke: a controlled clinical trial. Clinical Rehabilitation, 24, 514-522.
https://www.ncbi.nlm.nih.gov/pubmed/20392784

Ietswaart, M., Johnston, M., Kijkerman, C., Joice, S., Scott, C. L., MacWalter, R. S., & Hamilton, S. J. C. (2011). Mental practice with motor imagery in stroke recovery: Randomized controlled trial of efficacy. Brain, 134, 1373-1386.
https://www.ncbi.nlm.nih.gov/pubmed/21515905

Kim, J. H., & Lee, B. H. (2013). Action observation training for functional activities after stroke: a pilot randomized controlled trial. NeuroRehabilitation33(4), 565-574.
http://content.iospress.com/articles/neurorehabilitation/nre991

Lee, G.C., Song, C.H., Lee, Y.W., Cho, H.Y., & Lee, S.W. (2011). Effects of motor imagery training on gait ability of patients with chronic stroke. Journal of Physical Therapy Science, 23, 197-200.
https://www.jstage.jst.go.jp/article/jpts/23/2/23_2_197/_pdf

Liu, K.P., Chan, C.C., Lee, T.M., Hui-Chan, C.W. et al. (2004). Mental imagery for promoting relearning for people after stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 85(9), 1403-1408.
https://www.ncbi.nlm.nih.gov/pubmed/15375808

Liu, K.P., Chan, C.C., Wong, R.S., Kwan, I.W., Yau, C.S., Li, L.S., Lee, T.M. (2009). A randomized controlled trial of mental imagery augment generalization of learning in acute poststroke patients. Stroke, 40(6), 2222-5.
https://www.ncbi.nlm.nih.gov/pubmed/19390069

Malouin, F., Richards, C. L., Durand, A., & Doyon, J. (2009). Added value of mental practice combined with a small amount of physical practice on the relearning of rising and sitting post-stroke: A pilot study. Journal of Neurologic Physical Therapy, 33, 195-202.
https://www.ncbi.nlm.nih.gov/pubmed/20208464

Müller, K., Bütefisch, C. M., Seitz, R., J. & Hömberg, V. (2007). Mental practice improves hand function after hemiparetic stroke. Restorative Neurology and Neuroscience, 25, 501-11.
https://www.ncbi.nlm.nih.gov/pubmed/18334768

Nilsen, D.M., Gillen, G., DiRusso, T., & Gordon, A.M. (2012). Effect of imagery perspective on occupational performance after stroke: a randomized controlled trial. The American Journal of Occupational Therapy, 66(3), 320-9.
https://www.ncbi.nlm.nih.gov/pubmed/22549597

Oostra, K.M., Oomen, A., Vanderstraeten, G., & Vingerhoets, G. (2015). Influence of motor imagery training on gait rehabilitation in sub-acute stroke: a randomized controlled trial. Journal of Rehabilitation Medicine, 47, 204-9.
https://www.ncbi.nlm.nih.gov/pubmed/25403275

Page, S.J. (2000). Imagery improves upper extremity motor function in chronic stroke patients: A pilot study. The Occupational Therapy Journal of Research, 20(3), 200-213.
http://psycnet.apa.org/psycinfo/2000-00370-003

Page, J.S., Levine, P., Sisto, S., & Johnston, M.V. (2001). A randomized efficacy and feasibility study of imagery in acute stroke. Clinical Rehabilitation, 15, 233-240.
https://www.ncbi.nlm.nih.gov/pubmed/11386392

Page, S. J., Levine, D., & Leonard, A.C. (2005). Effects of mental practice on affected limb use and function in chronic stroke. Archives of Physical Medicine & Rehabilitation, 86(3), 399-402.
https://www.ncbi.nlm.nih.gov/pubmed/15759218

Page, J.S., Laine, D., & Leonard, A.C. (2007). Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Stroke, 38(4), 1293-7.
https://www.ncbi.nlm.nih.gov/pubmed/17332444

Page, S., Levine, P., & Khoury, J. (2009). Modified Constraint-Induced Therapy Combined With Mental Practice: Thinking Through Better Motor Outcomes. Stroke, 40(2), 551-554.
https://www.ncbi.nlm.nih.gov/pubmed/19109542

Page, S.J., Dunning, K., Hermann, V., Leonard, A., & Levine, P. (2011). Longer versus shorter mental practice sessions for affected upper extremity movement after stroke: a randomized controlled trial. Clinical Rehabilitation, 25(7), 627-637.
https://www.ncbi.nlm.nih.gov/pubmed/21427151

Park, J., Lee, N., Cho, M., Kim, D., & Yang, Y. (2015). Effects of mental practice on stroke patients’ upper extremity function and daily activity performance. Journal of physical therapy science27(4), 1075-1077.
https://www.jstage.jst.go.jp/article/jpts/27/4/27_jpts-2014-664/_article

Rajesh, T. (2015). Effects of Motor Imagery on Upper Extremity Functional Task Performance and Quality of Life among Stroke Survivors. Disability, CBR & Inclusive Development26(1), 109-124.
http://dcidj.org/article/view/225

Riccio, I., Iolascon, G., Barillari, M.R., Gimigliano, R., Gimigliano, F. (2010) Mental Practice is effective in upper limb recovery after stroke: a randomized single-blind cross-over study. European Journal of Physical Rehabilitation Medicine,46 (1): 19-25.
https://www.ncbi.nlm.nih.gov/pubmed/20332722

Schuster, C., Butler, J., Andrews, B., Kischka, U., & Ettlin, T. (2012). Comparison of embedded and added motor imagery training in patients after stroke: results of a randomised controlled pilot trial. Trials13(1), 11.
https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-13-11

Timmermans, A.A.A., Verbunt, J.A., van Woerden, R., Moennekens, M., Pernot, D.H., & Seelen, H.A.M. (2013). Effect of mental practice on the improvement of function and daily activity performance of the upper extremity in patients with subacute stroke: a randomized clinical trial. JAMDA, 14, 204-12.
https://www.ncbi.nlm.nih.gov/pubmed/23273853

Welfringer, A., Leifert-Fiebach, G., Babinsky, R., & Brant, T. (2011). Visuomotor imagery as a new tool in the rehabilitation of neglect: a randomized controlled study of feasibility and efficacy. Disability and Rehabilitation, 33 (21-22), 2033-43.
https://www.ncbi.nlm.nih.gov/pubmed/21348577

Excluded references and reasons for exclusion:

Arulmozhe, A. & Sivakumar, V.P.R. (2016). Comparison of embedded versus added motor imagery training for improving balance and gait in individuals with stroke. International Journal of Pharmaceutical and Clinical Research, 8(9), 1331-8.
Reason for exclusion: both groups received a type of motor imagery training (added vs. embedded).

Barclay-Goddard, R. E., Stevenson, T. J., Poluha, W. & Thalman, L. (2011). Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke. Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD005950. DOI: 10.1002/14651858.CD005950.pub4.
Reason for exclusion: systematic review

Braun, S. M., Beurskens, A. J., Borm, P. J., Schack, T., & Wade, D. T. (2006). The effects of mental practice in stroke rehabilitation: A systematic review. Archives of Physical Medicine and Rehabilitation, 87, 842-852.
Reason for exclusion: systematic review

Butler A.J., & Page S.J. (2006). Mental practice with motor imagery: evidence for motor recovery and cortical reorganization after stroke. Archives of Physical Medicine & Rehabilitation, 87(12 Suppl 2), S2-11.
Reason for exclusion: not RCT

Chan, K.Y. & Cameron, L.D. (2012). Promoting physical activity with goal-oriented mental imagery: a randomized controlled trial. Journal of Behavioral Medicine, 35, 347-63.
Reason for exclusion: no stroke population studied

Dickstein, R., Dunsky, A., & Marcovitz, E. (2005). Motor imagery for gait rehabilitation in post-stroke hemiparesis. Physical Therapy, 84(12), 1167-1175.
Reason for exclusion: not RCT

Dijkerman H.C. (2004). Does motor imagery training improve hand function in chronic stroke patients? A pilot study. Clinical Rehabilitation, 18(5), 538-49.
Reason for exclusion: not RCT

Dunsky, A., Dickstein, R., Ariav, C., Deutsch, J., & Marcovitz E. (2006) Motor imagery practice in gait rehabilitation of chronic post-stroke hemiparesis: four case studies. International Journal of Rehabilitation Studies, 29, 351-356.
Reason for exclusion: not RCT

Grabherr, L., Jola, C., Berra, G., Theiler, R., & Mast, F.W. (2015). Motor imagery training improves precision of an upper limb movement in patients with hemiparesis. Neurorehabilitation, 36, 157-66.
Reason for exclusion: not RCT; outcomes available in RCTs.

Guttman, A., Burstin, A., Brown, R., Bril, S., & Dickstein, R. (2012). Motor imagery practice for improving sit to stand and reaching to grasp in individuals with poststroke hemiparesis. Topics in Stroke Rehabilitation, 19(4), 306-19.
Reason for exclusion: not RCT

Harris, J.E. & Hebert, A. (2015). Utilization of motor imagery in upper limb rehabilitation: a systematic scoping review. Clinical Rehabilitation, 29(11), 1092-1107.
Reason for exclusion: systematic review

Hewett, T.E., Ford, K.R., Levine, P., & Page, S.J. (2007). Reaching kinematics to measure motor changes after mental practice in stroke. Topics in Stroke Rehabilitation, 14(4), 23-9.
Reason for exclusion: not RCT

Jackson, P.L., Doyon, J., Richards, C.L., & Malouin F. (2004). The efficacy of combined physical and mental practice in the learning of a foot-sequence task after stroke: A case report. NeuroRehabilitation and Neural Repair, 18(2), 106-111.
Reason for exclusion: not RCT

Kim, J.S., Oh, D.W., Kim, S.Y. & Choi, J.D. (2011). Visual and kinesthetic locomotor imagery training integrated with auditory step rhythm for walking performance of patients with chronic stroke. Clinical Rehabilitation, 25(2): 134-45.
Reason for exclusion: mental imagery provided to all groups with varying intensities.

Leifert-Fierbach, G., Welfringer., Babinsky, R., & Brandt, T. (2013). Motor imagery training in patietns with chronic neglect: a pilot study. NeuroRehabilitation, 32, 43-58.
Reason for exclusion: not RCT

Liu, K.P., Chan, C.C., Lee, T.M., & Hui-Chan, C.W. (2004b). Mental imagery for relearning of people after brain injury. Brain Injury, 18(11), 1163-72.
Reason for exclusion: not RCT

Liu, H., Song, L., & Zhang, T. (2014). Mental practice combined with physical practice to enhance hand recovery in stroke patients. Behavioral Neurology, 1-9.
Reason for exclusion: not RCT

Malouin, F., Belleville, S., Richards, C.L., Desrosiers, J., & Doyon J. (2004). Working memory and mental practice outcomes after stroke. Archives of Physical Medicine and Rehabilitation, 5, 177-83.
Reason for exclusion: not RCT

Page, J.S., Levine, P., Sisto, S., & Johnston, M.V. (2001b). Mental practice combined with physical practice for upper-limb motor deficit in sub-acute stroke. Physical Therapy, 81(8), 1455-1462.
Reason for exclusion: not RCT

Page, S.J., Levine, P., & Hill, V. (2007b). Mental practice as a gateway to modified Constraint-Induced Movement Therapy: A promising combination to improve function. American Journal of Occupational Therapy, 61, 321-327.
Reason for exclusion: not RCT

Stevens, J.A. & Stoykov, P.M.E. (2003). Using motor imagery in the rehabilitation of hemiparesis.Archives of Physical Medicine and Rehabilitation, 84(7), 1090-2.
Reason for exclusion: not RCT

Yoo, E., Park E., & Chung B. (2001). Mental practice effect on line-tracing accuracy in persons with hemiparetic stroke: A preliminary study. Archives of Physical Medicine and Rehabilitation, 82, 1213-8.
Reason for exclusion: not RCT

Music Therapy

Evidence Reviewed as of before: 19-07-2017
Author(s)*: Tatiana Ogourtsova, PhD Candidate MSc BSc OT; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Music interventions are used to optimize an individual’s emotional well-being, physical health, social functioning, communication abilities, and cognitive skills. This module reviews studies that incorporate music as the primary type of intervention.

Patient/Family Information

Authors*: Erica Kader; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Nicol Korner-Bitensky, PhD OT

What is music therapy?

Music therapy is a specific form of rehabilitation that is typically facilitated by an accredited music therapist and uses music in a variety of ways to help achieve therapeutic goals. Music therapy has been found to be helpful for people who have had a stroke. Since music is emotionally and intellectually stimulating, this form of therapy can help to maintain or improve one’s physical and mental health, quality of life, and well-being.

Are there different kinds of music therapy?

Music therapy can be provided in different forms, depending on your needs and preferences. Various ways of conducting music therapy and its benefits include:

  • Active listening – develops attention, memory, and awareness to your environment.
  • Composing/songwriting – can be a way of sharing your feelings and being able to express yourself.
  • Improvising movements to music – a creative, non-verbal way of expressing feelings. Since improvisation does not require any previous musical training anyone can participate.
  • Rhythmic movements and dancing – improves movement, speed, balance, breathing, stamina, relaxation of muscles, and walking.
  • Playing instruments – increases coordination, balance, and strength. As an example, hitting a tambourine with a stick is a good exercise to improve your hand-eye coordination and develop strength in your arms and hands. This is a great activity whether or not you have previous experience playing instruments.
  • Singing – improves communication, speech, language skills, articulation, and breathing control. Singing is particularly useful after a stroke for those who are unable to speak, because sometimes even though speech is affected, the individual is still able to sing. This happens because the speech center located in the brain is in a different location than the brain area used for singing. So, someone may have damage to the brain area responsible for speech, but no damage to the area responsible for singing.
With permission of the Music Therapy Association of British Columbia

Is music therapy offered individually or in a group?

Music therapy can be offered either way, so it is your choice. You and your music therapist can plan your music therapy sessions together. Benefits to participating in a group includes improving communication and social skills, making new friends, and the opportunity to share feelings and experiences. Playing instruments in a group can help develop cooperation and attention, as well as improve self-esteem and well-being. Composing and songwriting is another activity that works well in a group, as it allows you to communicate and work along with others. If you are not comfortable working in a group, music therapy sessions can also be offered on an individual basis. Individual sessions may lead to group sessions later on in the rehabilitation process, or the treatment plan may involve a combination of both. For people who are restricted to bed, music therapy can even be offered at their bedside with portable instruments.

Why use music therapy after a stroke?

Music therapy has the ability to help in the rehabilitation of individuals who have had a stroke. The research on the effects of this intervention is still quite new. There is some limited evidence suggesting that music therapy can help improve the movement of the arms, walking, pain perception, mood, and behaviour after stroke.

Courtesy of the Institute for Music and Neurologic Function

Do music-based treatments work in post-stroke rehabilitation?

Researchers have studied how different music-based treatments can help patients with stroke:

In individuals with ACUTE stroke (up to 1 month after stroke), studies found that:

  • Listening to music is MORE helpful than comparison treatment(s) in improving attention, memory, mood and affect. It is AS helpful as comparison treatment(s) in improving executive functions (cognitive processes that assist in managing oneself and one’s resources in order to achieve a goal), language, music cognition, quality of life, and the ability to identify visual and spatial relationships among objects.
  • Music-movement therapy is MORE helpful than comparison treatment(s) in improving mood and affect, and range of motion. It is AS helpful as comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), and muscle strength.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving walking ability.

In individuals with SUBACUTE stroke (1 month to 6 months after stroke), studies found that:

  • Music training is MORE helpful than a comparison treatment in improving hand and arm function.

In individuals with CHRONIC stroke (more than 6 months after stroke), studies found that:

  • Music therapy + occupational therapy is MORE helpful than comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), quality of life, sensation, and arm function. It is AS helpful as comparison treatment(s) in improving consequences of stroke, and arm movement quality.
  • Melodic intonation therapy is AS helpful as a comparison treatment in improving language.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, behavior, walking ability, grip strength, interpersonal relationships, quality of life, legs range of movement, consequences of stroke, and mood and affect. They are AS helpful as comparison treatment(s) in improving cognitive functions (e.g. attention), dexterity, language, musical behavior, occupational performance, arm function, memory, and walking endurance.

In individuals with stroke (acute, subacute and/or chronic), studies found that:

  • Melodic intonation therapy is MORE helpful than a comparison treatment in improving language.
  • Music performance is AS helpful as comparison treatment(s) in improving dexterity and arm range of motion and function.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, and walking ability. They are AS helpful as comparison treatment(s) in improving dexterity, sensation, strength, stroke consequences, arm function and activity.

Who provides the treatment?

Many hospitals and rehabilitation centers have music therapy programs that are conducted by accredited music therapists. The music therapist will meet with you to assess your needs and discuss preferences, so that he or she can design a program specific to your needs. In some centers it may be a recreational therapist or leisure therapist who provides music therapy. Ask your health professional or family members to help you find out more about the music therapy services offered in your hospital, rehabilitation center or community.

Are there any side effects or risks?

You do not face any risks when participating in music therapy after a stroke, as long as activities are practiced in a manner that fits your abilities. Consult your physician or rehabilitation healthcare professional for the best advice on how to participate safely. This is especially important if you are going to incorporate dancing or rhythmic movements into your music sessions and have some balance difficulties. *Family members/friends: it is important to help the person who has had a stroke seek out new activities such as music therapy that may be both pleasant and therapeutic.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

This module reviews 24 studies that use music as a primary means of rehabilitation; of these, 12 are high quality RCTs, seven are fair quality RCTs, one is a poor quality RCT and four are non-randomized studies.

This module reviews the following types of music-based interventions:

Listening to music: participants listening to music.

Music therapy + occupational therapy: participants playing instruments (e.g. drums, bells, shakers, mallets, chimes, piano, harp) with the affected upper limb to encourage proximal and distal upper limb movements, with attention to positioning and movement quality.

Melodic intonation therapy: participants singing phrases and tap to the rhythm of the phrases; this intervention has been shown to improve outcomes related to language/aphasia.

Music-movement therapy: participants performing movements of lower and upper extremities while listening to music.

Music performance: participants playing acoustic musical instruments and/or iPads with touchscreen musical instruments as part of fine/distal exercise.

Music training: participants are taught to play a musical instrument.

Rhythmic music interventions: participants performing matching upper and/or lower extremity movements or gait patters to musical rhythm.

Results Table

View results table

Outcomes

Acute phase - Listening to music

Attention
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on attention in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of attention were taken at 3 and 6 months post-stroke, and outcomes included: (1) attention, measured by the CogniSpeed reaction time software; (2) focused attention, measured by the mental subtraction and Stroop subtests (number correct and reaction time); and (3) sustained attention, measured by the vigilance (number correct, reaction time) and simple reaction time subtests. Significant between-group differences in focused attention were found at 3 months post-stroke, favoring the music group vs. the control group. Significant between-group differences in focused attention were found at 6 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. There were no significant between-group differences in other measures of attention at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving focused attention in patients with acute stroke. However, no between-group differences were found on measures of attention or sustained attention.

Auditory sensory memory
Not effective
1b

One high quality RCT (Sarkamo et al., 2010) investigated the effect of music interventions on auditory sensory memory in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Auditory sensory memory was evaluated by the magnetically-measured mismatch negativity (MMNm) responses to change in sound frequency and duration from baseline to 3 and 6 months post-stroke. There were no significant differences between groups at 3 months post-stroke. At 6 months post-stroke, there were significant between-group differences in auditory sensory memory (frequency MMNm only), favoring the music group vs. the control group.
Note: Comparison of the audio book group vs. the control group revealed significant differences favoring the audio book group in frequency MMNm (left and right lesions) and duration MMNm (right lesions only) at 6 months post-stroke.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving auditory sensory memory among patients with acute stroke in the short term.
Note:
However, this high quality RCT showed that patients who listened to music demonstrated significantly better auditory sensory memory several months following treatment than patients who received conventional rehabilitation alone.

Executive function
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on executive function in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Executive function was measured by the Frontal Assessment Battery at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving executive function in patients with acute stroke.

Language
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on language in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Language was measured by the Finnish version of the Boston Diagnostic Aphasia Examination (word repetition, sentencing repetition, reading subtests), the CERAD battery (verbal fluency, naming subtests) and the Token Test at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving language in patients with acute stroke.

Memory
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on memory in patients with acute stroke. This high quality RCT randomized patients to a music group that listened to music for a minimum 1 hour/day, a language group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of memory were taken at 3 and 6 months post-stroke and outcomes included: (1) verbal memory, measured by the Rivermead Behavioral Memory Test (story recall subtests) and an auditory list learning task; and (2) short-term working memory, measured by the Wechsler Memory Scale – Revised (digit span subtest) and a memory interference task. Significant between-group differences in verbal memory were found at 3 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. Similarly, significant between-group differences in verbal memory were found at 6 months post-stroke, favoring the music group vs. the audio book group. There were no significant between-group differences in short-term working memory at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving verbal memory in patients with acute stroke. However, no between-group differences were found on measures of short-term working memory.

Mood
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on mood in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Mood was measured by a shortened Finnish Version of the Profile of Mood States at 3 and 6 months post-stroke. Significant between-group differences in mood (depression score only) were found at 3 months post-stroke favoring the music group vs. the control group.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving mood in patients with acute stroke.

Music cognition
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on music cognition in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Music cognition was measured by the Montreal Battery of Evaluation of Amusia (scale and rhythm subtests) at 3 months post-stroke. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving music cognition in patients with acute stroke.

Quality of life
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on quality of life in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Quality of life was measured by the Stroke and Aphasia Quality of Life Scale – 39 (self-rated, proxy rated) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (audio therapy, no training) in improving quality of life in patients with acute stroke.

Visuospatial skills
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on visuospatial skills in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Visuospatial skills were measured by the Clock Drawing Test, Figure Copying Test, Benton Visual Retention Test (short version), and Balloons Test (subtest B) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving visuospatial skills in patients with acute stroke.

Acute phase - Music-movement therapy

Behavioral outcomes
Effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on mood and affect in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Behavioral outcomes were assessed according to: 1) mood measured by the Korean version of the Profile of Mood States Brief Instrument; and 2) depression, measured by the Center for Epidemiologic Studies Depression Scale at post-treatment (8 weeks). Significant between-group differences were found for mood favoring music-movement therapy vs. no training.  

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is more effective than no training in improving behavioral outcomes (mood) in patients with acute