In adult stroke patients, mirror therapy is more effective

than a control treatment on motor recovery measured with

the Fugl-Meyer motor assessment?
A systematic review
Sofoklis Karatzoglou,a Yvan Rolland,a Zhe Wang,a
a

International Physiotherapy Program, School of Health Studies, Hanze University of Applied Sciences,
Groningen, The Netherlands

ABSTRACT
Objective: To review the effect of mirror therapy compare to control treatment on motor
recovery for adult stroke patients.
Methods: Published articles from June 2011 to February 2014 were identified using the
databases Pubmed, PEDro and CINHAL. Three investigators selected randomized controlled
trials (RCTs) and assessed the methodogical quality according to the PEDro scale. The
research has been limited to English language.
Results: Three studies were included. Two studies showed no significant group differences
between the MT group and the CT group on the FMA. One study showed significant effects
favoring the MT group on the FMA total (P=.009) and distal part (P=.041) scores.
Conclusion: The results does not permit to draw a clear conclusion about the effect of MT
compare to control treatment on motor recovery for adult stroke patients. Two studies do not
showed significant group differences between the MT group and the CT group whereas one
study showed significant effects favoring the MT group on the FMA total and distal part
scores.

INTRODUCTION
Stroke is the third biggest cause of death
and the biggest cause of adult disability
including facial weakness, arm weakness,
leg weakness, sensory impairments and
speech problems and approximately 20%
of the patients who had a stroke are dead in
the next month. 1 In addition, of those who
live more than 6 months about one third
cannot serve themselves and need the help
of others to be able to perform activities of
daily living.1
Having said that, it is important to stress
the facts that one of the most important
predictor for long-termed recovery of
functional activities of daily living (ADL)
after stroke is the initial severity of upper
and lower extremity paresis and that

patients who survived 12 months after a

stroke
attack
experience
Complex
Regional Pain Syndrome Type I at 50%.2
Additionally, a great deal of patients of
acute right hemispheric and left
hemispheric stroke experience unilateral
neglect at 40% and 20% respectively.2
Therefore it is important to improve the
limitations presented above in order to
relieve stroke patients.
In the various forms of treatment
addressing the limitations in activity in
stroke patients, one alternative method,
especially for severe paresis, is mirror
therapy (MT). MT involves the reflection
and movement of the unaffected limb on a
mirror so that the reflection seems to the
patient as moving the affected limb.3 As a
form of therapy it has been used in

phantom limb pain and is currently used in

stroke patients to improve paresis, pain and
neglect.3 Although the way MT affects
human brain is not clearly understood two
theories are suggested: the primary motor
cortex hypothesis where there should be
facilitation for cortical reorganisation
appropriate for functional recovery and the
mirror neuron mechanisms where there
should be activation the motor cortex area
contralateral to the affected limb.3
MT has been researched so far to a certain
degree by several authors. When
overviewing the literature on MT we found
2 recent systematic reviews, Cochrane,
2012 with mean PEDro score of its 14
RCTs 5.5/10 and Fong Mei Toh & Fong,
2012 with mean PEDro score of its 6 RCTs
6.16/10.
Conclusions
of
the
aforementioned systematic reviews are a)
At the end of treatment, mirror therapy
improved movement of the affected limb
and the ability to carry out daily activities.
Mirror therapy reduced pain after stroke,
but only in patients with a complex
regional pain syndrome. The beneficial
effects on movement were maintained for
six months, but not in all study groups. No
adverse side effects were reported. Further
research is needed with larger studies in
natural clinical settings, and with a
comparison of mirror therapy with more
routine treatments2 and b) More research
is needed to determine the optimal dose of
therapy, optimal time to start this
intervention, and the right target group.
Accordingly, no firm conclusions can now
be drawn on the effectiveness of MT until
more evidence is present.3 Both suggest
that more research is needed to determine
the effectiveness of MT.
Taking into account that MT as a form of
therapy is simple, easy to perform and not
expensive to administer, it is valuable to
investigate the literature for further
research and see whether MT is more
effective than control treatment in adult
stroke patients in improving their condition
based on Fugl-Meyer motor Assessment

(FMA). The FMA has a high intrarater and

interrater reliability.4 FMA index have
been chosen because it is stroke-specific
and assess a wide variety of motor
functions.
METHODS
Search strategy
Firstly, we define several search terms
from our PICO question through MeSH
and Google:
- Adult stroke patients: acute, subacute,
chronic, CVA, cerebral infarction,
- Mirror therapy: Mirror box therapy,
mirror box training, mirror visual feedback
- Control treatment,
- Recovery of motor function: Limb
function, Fugl-Meyer motor assessment.
Then, these terms were searched in
databases including Pubmed, PEDro and
CINHAL. We combined these terms with
the search operators OR and AND
respectively. We found a similar review
article which was published in January
2012 and included studies realised before
June 2011, so this review focus on studies
released from June 2011 to February 2014.
The research has been limited to English
language.
Selection process
Inclusion criteria
Types of studies: we included RCTs with
a longitudinal design as this study design
allows
the
comparison
of
two
interventions.
Types of participants: we included
studies with participants aged over 18
years, affected by a stroke, in the acute,
sub-acute or chronic stage.
Types of interventions: we included
studies where the intervention by MT can
be isolated.
Types of outcome measures: The primary
outcome of interest was the motor
performance items on the FMA. Scores

regarding upper extremities (UE) or lower

extremities (LE) were included.
Exclusion criteria
Studies where MT was combined with
another intervention were excluded.
Evaluation of the studies
We used the PEDro scale as a valid
measure of the methodological quality of
clinical trials. In the stroke rehabilitation
literature, where double-blinding studies
are often not possible due to the nature of
the interventions, breaking down the levels
of blinding and accounting for concealed
allocation, intention-to-treat, and attrition
is important. Accordingly, the PEDro scale
provides a more comprehensive measure of
methodological quality of the stroke
literature.5
RESULTS
Selection of articles
After searching through these search terms
in three different databases, 574 articles
were found. Amongst them 15 articles
were selected after titles screening. 13
articles were eligible after reading the
abstracts. After de-duplication and
accessibility to the full-text, 3 articles were
retained for review. The search results
appear in table 1.
Quality assessment
Table 3 summarizes the three articles
retained for this review. The level of
evidence has been assessed by using the
Pedro scale. The results appear in the table
2. Eligibility criteria item does not
contribute to total score.
External validity
The subjects asked to participate in the
studies have been recruited either in four
different hospitals, or referred by their
physicians or physiotherapists, or in an
inpatient stroke rehabilitation unit. The
mean age of the participants is 62,09 years
old (SD=6,59). Stroke risk increases with

age. Nearly three-quarters of strokes occur

in people aged over 65 years. For each
decade after age 55, the risk of stroke
doubles.6
Theses factors are in favour to be
representative of the entire population.
Internal validity
Through these studies we have no
information about the compliance to the
treatment.
Moreover
information
concerning the extend to which the
participant focused on the mirror image
during the treatment is not known.
Table 2 Application of the PEDro scale
PEDro Quality
Criteria
Eligibility
criteria
Random
allocation
Concealed
allocation
Baseline
comparability
Blind subjects
Blind
therapists
Blind assessors
Adequate
follow-up
Intention-totreat analysis
Between-group
comparisons
Point estimates
and variability
Grade

Thieme &
al.

Wu &
al.

Mohan &
al.

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

No

No

No

No

No

No

Yes

Yes

Yes

Yes

No

No

Yes

No

No

Yes

Yes

Yes

Yes

Yes

No

8/10

6/10

4/10

Outcomes
The outcome measures and the results
appear in table 4. Two studies (Thieme &
al., Mohan & al.) showed no significant
group differences between the MT group
and the CT group on the FMA. The study
of Wu & all showed significant effects
favoring the MT group on the FMA total
(P=.009) and distal part (P=.041) scores.
None of the studies followed-up their
participants concerning the FMA.

Table 1 Search results

Search terms
((((stroke) AND mirror therapy) OR "mirror box training") OR
"mirror visual feedback")
((((CVA) AND mirror therapy) OR "mirror box training") OR
"mirror visual feedback")
((((cerebral infarction) AND mirror therapy) OR "mirror box
training") OR "mirror visual feedback")
(((((CVA) AND mirror therapy) OR "mirror box training") OR
"mirror visual feedback") AND Fugl-Meyer motor assessment)
(((((CVA) AND mirror therapy) OR "mirror box training") OR
"mirror visual feedback") AND "limb function")
Stroke AND mirror therapy
CVA AND mirror therapy
cerebral infarction AND mirror therapy
Stroke AND mirror box training
Stroke AND mirror visual feedback
Amount of results after selection based on titles
Amount of results after selection based on abstracts
Amount of results full text available on internet/library
DISCUSSION
This systematic review investigated 3
RCTs to compare MT and control
treatment in adult stroke patients to
improve their condition based on FMA.
The results of our study show some
heterogeneity amongst the results. Two
studies do not showed significant group
differences between the MT group and the
CT group whereas the study of Wu & al.
showed significant effects favoring the MT
group on the FMA total and distal part
scores. When attempting to explain theses
results, it can be mentioned the difference
in terms of intensity and frequency of
treatment. If the sum of the number and
length of the sessions is made, it can be
noticed that in total, the MT group in the
study of Wu & al. performed 30 hours of
MT. Whereas in the studies of Thieme &
al., and Mohan & al., the participants
performed 9,5 hours and 18 hours of MT
respectively. These differences in terms of
dose of treatment could explain the
different results. Further studies may
investigate the effectiveness of prolonged
MT and the use of a home exercises

Amount of results
PEDro Pubmed CINHAL
/
75
19
/

219

218

20
0
0
0
0
6
4
3

4
4
2

5
5
1

protocol.
The goal of this study focused on motor
control improvements measured according
to the FMA. However it can be observed
that even if the participants increased their
scores on the FMA after MT intervention
in the study of Wu & al., these
improvements were not transferred in
ADL activities performances measured
with
the
Motor
Activity
Log
semistructured interview (MAL) and the
ABILHAND questionnaire. However the
results of others studies noticed
improvements
in
ADL
activities
7
performances. It has been noted that the
living situation during the intervention
could be the cause of this disagreement:
Participants improved their ADL activities
performances when they lived in a
rehabilitation center. In the study of Wu &
al., participants were in an outpatients
living at home. These participants might
have established a stable ADL routine that
was less likely to change over time.8

Table 3 Quality assessment of the articles

Authors

Title

Problem
(knowledge gap)

Purpose

Research question /
hypotheses

Level of evidence:
A1/A2/B/C/D
General study
design

Population, sample

Holm Thieme, Maria Bayn, Marco Wurg,

Christian Zange, Marcus Pohl, Johann Behrens
Mirror therapy for patients with severe arm paresis
after stroke - a randomized controlled trial (2013)

Ching-Yi Wu, Pai-Chuan Huang, ScD, Yu-Ting Chen,

Keh-Chung Lin, Hsiu-Wen Yang,
Effects of Mirror Therapy on Motor and Sensory
Recovery in Chronic Stroke: A Randomized Controlled
Trial (2013)

There is not enough evidence to support the

effective use of MT in stroke patients with
sensorimotor impairments in and after the subacute
phase. Additionally, there are no studies to support
any improvements in stroke patients in activities of
daily life (ADL) and quality of life (QOL) in the
subacute stroke phase.

Few studies have reported that MT has prolonged

effects after 6 months. The limited evidence that
exists suggests that further studies are needed regarding
the effects of MT on sensory recovery and ADL
immediately after an intervention and at follow-up.

Whether MT as group and/or individual therapy is

more effective in improving upper limb
sensorimotor function, ADL, QOL and
visuospatial neglect than a control intervention in
stroke patients with severe arm paresis in subacute
stage and if the effects of a group training
protocol of MT are different from those of an
individual treatment
MT as group and/or individual therapy is more
effective in improving upper limb sensorimotor
function, ADL, QOL and visuospatial neglect than
a control intervention in patients with severe arm
paresis in subacute stroke patients
The effects of a group training protocol of MT are
different from those of an individual treatment.

To compare the effects of MT versus CT on movement

performance, motor control, sensory recovery, and
performance of ADL in people with chronic stroke.

Uthra Mohan, S Karthik babu, K Vijaya Kumar1, BV

Suresh, ZK Misri, M Chakrapani
Effectiveness of mirror therapy on lower extremity
motor recovery, balance and mobility in patients with
acute stroke: A randomized sham-controlled pilot trial
(2013)
The recovery mechanism after stroke is known to be
most prominent within the first three months.
Furthermore, the level of recovery achieved in the
first month of stroke determines the functional
outcome in the chronic phase. Thus, implementation
of intensive therapy within the first month of stroke
can lead to enhanced and faster improvement in
performance of activities.
To evaluate the effectiveness of MT on lower
extremity motor recovery, balance and mobility in
patients with acute stroke.

MT would improve motor performance, motor control

strategies, sensory recovery, and daily function more
than the CT.
We also hypothesized that the positive effects on ADL
would be retained at 6 months after MT.

The practice of functional movement synergies of the

non-paretic lower extremity with MT in addition to
convention stroke rehabilitation would show more
extensive recovery in function compared to the
convention stroke rehabilitation alone.

A2

Longitudinal experimental - RCT

Longitudinal experimental - RCT

Longitudinal experimental - RCT

60 people from 18-80 years old, 35 males and 15

females

33 persons, 23 males and 10 females

22 persons, 12 males and 10 females

Inclusion
(1) they had to have had a first supratentorial
stroke within the previous three months, ensured
through the diagnosis of the primary care hospital,
(2) be aged between 18 and 80 years and (3) be
clinically diagnosed with a severe distal
hemiparesis of the arm (Medical Research Council
grading of 0 or 1 for wrist and finger extensors).
in- and exclusion
criteria

Sample size

Blinding
Randomisation
Validity, specificity
and reliability of
the measurement
instruments that
are used in the
article
Which outcome
variables of effect
measures are used?
What kind of

Inclusion
(1) a first-ever unilateral ischemic or hemorrhagic
cerebrovascular accident with onset of more than 6
months; (2) mild to moderate motor impairment (total
FMA-UE scores of 26e56); (3) mild spasticity in all
joints of the affected limb (Modified
Ashworth Scale score<3); and (4) sufficient cognitive
ability to follow instructions (Mini-Mental State
Examination score >24)

Inclusion
(1) First episode of unilateral stroke with hemiparesis
(onset < 2 weeks) (2) able to understand and follow
simple verbal instructions (3) Brunnstrom recovery
stage 2 and above, (4) no severe cognitive disorders
that would interfere with the study's purpose (MiniMental State Examination score > 23) (5) stable
medical condition to allow participation in the study
(6) ambulatory before stroke

Exclusion
(1) participation in another drug or experimental
rehabilitation project within 6 months; (2) serious
vision or visual perception impairments (eg, neglect
and poor visual field) as assessed by the National
Institutes of Health Stroke Subscales; and (3) severe
neuropsychologic, neuromuscular, or orthopedic
disease.
33 participants.
MT, n=16
CT, n=17

Exclusion
Patients with neglect, pusher syndrome, visual
deficits, and history of multiple stroke, or
comorbidities that influenced lower extremity usage

Blind subjects: No; Blind therapists: No; Blind

assessors: Yes

Blind subjects: No; Blind therapists: No; Blind

assessors: Yes

Blind subjects: No; Blind therapists: No; Blind

assessors: Yes

Random allocation: Yes; Concealed allocation:Yes

Random allocation: Yes; Concealed allocation: Yes

Random allocation: Yes; Concealed allocation: No

- FMA: high intrarater and interrater reliability

- Action Research Arm Test: Excellent intrarater
and interrater reliability

- FMA: high intrarater and interrater reliability

- rNSA: good intrarater and interrater reliability
- MAL: goog internal consistency, onterrater reliability
and construct validity
- ABILHAND: reliability, responsiveness and
construct validity are high in people with stroke

- FMA: high intrarater and interrater reliability

- Brunnel Balance assessment (BBA): Excellent
intrarater and interrater reliability
- Mobility (functional ambulation categories (FAC):
Excellent intrarater and interrater reliability

- Sensorymotor improvements
- Visual neglect improvements

- Motor performance
- Sensory and ADL functions

Both descriptive and inferential statistics are used.

Both descriptive and inferential statistics are used. Data

- Motor performance
- Balance
- Mobility
Descriptive statistics is used. SPSS software, t test,

Exclusion
(1) visual impairments which may limit the
participation in MT, (2) severe cognitive and/or
language deficits that could prevent them from
following instructions, (3) other neurological or
musculoskeletal impairments of the upper
extremity unrelated to stroke and (4) a severe
visuospatial neglect.
60 participants.
MT in individual, n=18
MT in group, n=21
CT, n=21

22 participants
MT, n= 11
CT, n= 11

statistics is used,
descriptive or
inferential or both?
Which statistical
analyses are used?
Description of the
results (clear?)
Is the research
question answered /
are the hypotheses
tested?
Is there a clear and
consistent
conclusion?
Opinion about the
discussion (clear,
complete)?

For the statistical analysis ANOVA, Kruskal

Wallis test, chi-square test and PASW 19 software
were used.

were analyzed with IBM SPSS 19.0 software

Chi-square test, Mann Whitney test and Wilcoxon test

are used for statistical analysis

The description of the results is clear, the research

question was answered and the hypothesis tested.
No significant difference between groups in the
sensorymotor part, only in visuospatial neglect

The description of the results is clear, the research

question was answered and the hypothesis tested.

The description of the results is clear, the research

question was answered and the hypothesis tested.

The conclusion is clear but it takes into account so

many preconditions that makes it very narrow with
low clinical significance and low external validity.

The conclusion is clear and emphasises the limitation

of the study (e.g. number of participant).

This study did not show a significant difference

between two groups, but it does not mean mirror
therapy with functional movement synergies is not
beneficial. It is believed that applying this
intervention for a longer time is necessary.

Table 4 Results of the articles

Article

Author(s),year of
publication

Aim/ purpose of
study

Description of the
intervention that is
used

Duration, intensity
and frequency of
the intervention
that is used
Amount of
participants

Mirror therapy for patients with severe arm paresis

after stroke- A randomized control trial

Effects of mirror therapy on motor and sensory

recovery in chronic stroke: a randomized controlled
trial

Holm Thieme, Maria Bayn, Marco Wurg,

Christian Zange, Marcus Pohl and Johann
Behrens, 2013
(1) To see whether MT as group and/or individual
therapy is more effective in improving upper limb
sensorimotor function, ADL, QOL and
visuospatial neglect than a control intervention in
stroke patients with severe arm paresis in subacute
stage and (2) if the effects of a group training
protocol of mirror therapy are different from those
of an individual treatment.

Ching-Yi Wu, Pai-Chuan Huang, Yu-Ting Chen, KehChung Lin, Hsiu-Wen Yang, 2013

Effectiveness of mirror therapy on lower extremity

motor recovery, balance and mobility in patients
with acute stroke: A
randomized sham-controlled pilot trial
Uthra Mohan, S Karthik babu, K Vijaya Kumar,
BV Suresh, ZK Misri, M Chakrapani, 2013

To compare the effects of MT versus CT on movement

performance, motor control, sensory recovery, and
performance of ADL in people with chronic stroke.

To evaluate the effectiveness of MT on lower

extremity motor recovery, balance and mobility in
patients with acute stroke.

Mirror therapy for the upper limb (individual and

group):
In the first week isolated movements of fingers,
wrist, lower arm, elbow and shoulder joints were
performed in all degrees of freedom. In each
direction up to 50 repetitions per series and up to
four series were possible. In the second and third
week additional movements were used. Therapists
were instructed to include object-related
movements, such as putting a ball or bigger
squares in different directions, moving sticks or
wipe-like movements with a cloth.
5 weeks, 19 sessions, 30 minutes max. (total
duration of intervention=9,5h)

Mirror therapy through 3 exercises:

(1) transitive movements, such as fine motor tasks
of squeezing sponges, placing pegs in holes, or flipping
a card;
(2) gross motor tasks of reaching out to touch a switch
or keyboard; and (3) intransitive movements, including
the distal part movement of wrist repetitive extensionflexion or finger opponent and the proximal part
movement of forearm pronation supination.

Mirror therapy group performed 30 minutes of

functional synergy movements of non-paretic lower
extremity, whereas control group underwent sham
therapy with similar duration. In addition, both
groups were administered with conventional stroke
rehabilitation regime.

4 weeks, 20 sessions, 90 min (total duration of

intervention=30h)

2 weeks, 12 sessions, MT:90 min and CT: 60min

(total duration of intervention=18h)

60

33

22

Outcome measures

Results of the
intervention (FMA)
Follow-up

- FMA
- Action Research Arm Test

FMA: There were no significant group differences

(F = 0.8, P = 0.44). Fugl-Meyer Test motor scores
for the upper limb for all participants increased
over time (F = 18.0, P < 0.001) with no
differences between groups (F = 0.4, P = 0.71).
No follow-up measurement

- FMA
- rNSA
- MAL
- ABILHAND
FMA: The results of the FMA and kinematic variables
showed significant and large to moderate effects
favouring the MT group on the FMA total (F 2,31=6.32,
P=.009, 2=.17) and distal part (F 2,31=3.25, P=.041,
2=.10) scores.
6 months later

- FMA
- Brunnel Balance assessment (BBA)
- Functional ambulation categories (FAC)
FMA: no statistical difference between groups (P =
0.894)

No follow-up measurement

Our study has been limited by the amount

of studies available in full-text. 13 studies
were selected based on the abstracts, and
we achieved to obtain 3 studies after deduplication and accessibility to the fulltext. Due to the short time allowed to our
study (8 weeks) we did not contact the
authors of the studies to have access to the
full-text.
CONCLUSION
The heterogeneity of the results does not
permit to draw a clear conclusion about the
effect of MT compare to control treatment
on motor recovery for adult stroke patients.
With aging of the population, the number
of older stroke survivors is likely to
increase substantially.9 A variety of
techniques are available to physiotherapists
in order to improve neurological
conditions. However, for some of these
techniques there is a clear lack of evidence.
To the contrary some interventions (e.g.
robotic-assisted training, improve motor
recovery10, but the cost of these devices is
the main limitation for a large
implementation.
Therefore MT is an interesting intervention
due to its accessibility. We noticed in this
study the importance of the frequency and
intensity of the treatment. Studies are
needed to define efficient protocols. Home
exercises protocols could be of great value
to add efficiency to physiotherapists
interventions.

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