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Meta-Analysis
. 2012 Mar 14;2012(3):CD008449.
doi: 10.1002/14651858.CD008449.pub2.

Mirror therapy for improving motor function after stroke

Holm Thieme  1 , Jan Mehrholz, Marcus Pohl, Johann Behrens, Christian Dohle
Affiliations
Meta-Analysis

Mirror therapy for improving motor function after stroke

Holm Thieme et al. Cochrane Database Syst Rev. .

Update in

  • Mirror therapy for improving motor function after stroke.
    Thieme H, Morkisch N, Mehrholz J, Pohl M, Behrens J, Borgetto B, Dohle C. Thieme H, et al. Cochrane Database Syst Rev. 2018 Jul 11;7(7):CD008449. doi: 10.1002/14651858.CD008449.pub3. Cochrane Database Syst Rev. 2018. PMID: 29993119 Free PMC article.

Abstract

Background: Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the patient's midsagittal plane, thus reflecting movements of the non-paretic side as if it were the affected side.

Objectives: To summarise the effectiveness of mirror therapy for improving motor function, activities of daily living, pain and visuospatial neglect in patients after stroke.

Search methods: We searched the Cochrane Stroke Group's Trials Register (June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), CINAHL (1982 to June 2011), AMED (1985 to June 2011), PsycINFO (1806 to June 2011) and PEDro (June 2011). We also handsearched relevant conference proceedings, trials and research registers, checked reference lists and contacted trialists, researchers and experts in our field of study.

Selection criteria: We included randomised controlled trials (RCTs) and randomised cross-over trials comparing mirror therapy with any control intervention for patients after stroke.

Data collection and analysis: Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality of studies and extracted data. We analysed the results as standardised mean differences (SMDs) for continuous variables.

Main results: We included 14 studies with a total of 567 participants that compared mirror therapy with other interventions. When compared with all other interventions, mirror therapy may have a significant effect on motor function (post-intervention data: SMD 0.61; 95% confidence interval (CI) 0.22 to 1.0; P = 0.002; change scores: SMD 1.04; 95% CI 0.57 to 1.51; P < 0.0001). However, effects on motor function are influenced by the type of control intervention. Additionally, mirror therapy may improve activities of daily living (SMD 0.33; 95% CI 0.05 to 0.60; P = 0.02). We found a significant positive effect on pain (SMD -1.10; 95% CI -2.10 to -0.09; P = 0.03) which is influenced by patient population. We found limited evidence for improving visuospatial neglect (SMD 1.22; 95% CI 0.24 to 2.19; P = 0.01). The effects on motor function were stable at follow-up assessment after six months.

Authors' conclusions: The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, activities of daily living and pain, at least as an adjunct to normal rehabilitation for patients after stroke. Limitations are due to small sample sizes of most included studies, control interventions that are not used routinely in stroke rehabilitation and some methodological limitations of the studies.

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Conflict of interest statement

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

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

Figures

Figure 1
Figure 1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 1 Motor function at the end of intervention phase.
Analysis 1.2
Analysis 1.2
Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 2 Activities of daily living at the end of intervention phase.
Analysis 1.3
Analysis 1.3
Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 3 Pain at the end of intervention phase.
Analysis 1.4
Analysis 1.4
Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 4 Visuospatial neglect at the end of intervention.
Analysis 1.5
Analysis 1.5
Comparison 1 Mirror therapy versus all other interventions: primary and secondary outcomes, Outcome 5 Motor function at follow‐up after 6 months.
Analysis 2.1
Analysis 2.1
Comparison 2 Subgroup analysis: upper versus lower extremity, Outcome 1 Motor function at the end of intervention.
Analysis 3.1
Analysis 3.1
Comparison 3 Subgroup analysis: sham intervention (covered mirror) versus other intervention (unrestricted view), Outcome 1 Motor function at the end of intervention phase.
Analysis 4.1
Analysis 4.1
Comparison 4 Sensitivity analysis by trial methodology, Outcome 1 Motor function at the end of intervention.
Analysis 5.1
Analysis 5.1
Comparison 5 Post‐hoc sensitivity analysis removing studies that only included patients with CRPS after stroke, Outcome 1 Motor function at the end of intervention.
Analysis 5.2
Analysis 5.2
Comparison 5 Post‐hoc sensitivity analysis removing studies that only included patients with CRPS after stroke, Outcome 2 Pain at the end of intervention phase.
Analysis 5.3
Analysis 5.3
Comparison 5 Post‐hoc sensitivity analysis removing studies that only included patients with CRPS after stroke, Outcome 3 Motor function at follow‐up after 6 months.
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References

References to studies included in this review

    1. Acerra NE. Is early post‐stroke upper limb mirror therapy associated with improved sensation and motor recovery? A randomised‐controlled trial [PhD thesis] In: Sensorimotor Dysfunction in CRPS1 and Stroke: Characteristics, Prediction and Intervention. Brisbane, Australia: University of Queensland, 2007.
    1. Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, et al. Rehabilitation of hemiparesis after stroke with a mirror. Lancet 1999;353(9169):2035‐6. [PUBMED: 10376620] - PubMed
    1. Cacchio A, Blasis E, Blasis V, Santilli V, Spacca G. Mirror therapy in complex regional pain syndrome type 1 of the upper limb in stroke patients. Neurorehabilitation and Neural Repair 2009;23(8):792‐9. [PUBMED: 19465507] - PubMed
    1. Cacchio A, Blasis E, Necozione S, Orio F, Santilli V. Mirror therapy for chronic complex regional pain syndrome type 1 and stroke. New England Journal of Medicine2009; Vol. 361, issue 6:634‐6. [PUBMED: 19657134] - PubMed
    1. Dohle C, Pullen J, Nakaten A, Kust J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabilitation and Neural Repair 2009;23(3):209‐17. [PUBMED: 19074686] - PubMed

References to studies excluded from this review

    1. Adamovich SV, August K, Merians A, Tunik E. A virtual reality‐based system integrated with fmri to study neural mechanisms of action observation‐execution: a proof of concept study. Restorative Neurology and Neuroscience 2009;27(3):209‐23. [PUBMED: 19531876] - PMC - PubMed
    1. Altschuler EL. Interaction of vision and movement via a mirror. Perception 2005;34:1153‐5. [PUBMED: 16245491] - PubMed
    1. Dohle C, Kaick S, Görtner H, Schnellenbach I. [Kombination von funktioneller Elektrostimulation und Spiegeltherapie]. Gemeinsame Jahrestagung der DGNR/DGNKN. Berlin, 2009.
    1. Eng K, Siekierka E, Pyk P, Chevrier E, Hauser Y, Cameirao M, et al. Interactive visuo‐motor therapy system for stroke rehabilitation. Medical and Biological Engineering and Computing 2007;45(9):901‐7. [PUBMED: 17687578] - PubMed
    1. Ezendam D, Bongers RM, Jannink MJA. Systematic review of the effectiveness of mirror therapy in upper extremity function. Disability and Rehabilitation 2009;31:2135‐49. [PUBMED: 19903124] - PubMed

References to studies awaiting assessment

    1. Amimoto K, Matsuda T, Watanabe S. The effect of mirror therapy on the lower limb function of chronic hemiplegic patients. International Journal of Stroke 2008;3 Suppl 1:336‐7 (Abstract PO02‐274).

References to ongoing studies

    1. Dheeraj KV, Arora R, Pandian JD. Therapy in unilateral neglect after stoke ‐ MUST. International Journal of Stroke 2010;5 Suppl 2:288.
    1. DRKS00000732. Mirror therapy as group intervention after stroke ‐ a randomised controlled trial [Spiegeltherapie als Gruppenintervention nach einem Schlaganfall ‐ eine randomisierte kontrollierte Studie]. www.germanctr.de (accessed 6 February 2011).
    1. NCT01010607. Use of tendon vibration and mirror for the improvement of upper limb function and pain reduction. clinicaltrials.gov/show/NCT01010607 (accessed 6 February 2011).
    1. Thomas N. Mirror arm exercises for stroke. http://www.controlled‐trials.com (accessed 6 February 2011).

Additional references

    1. Barker WH, Mullooly JP. Stroke in a defined elderly population, 1967‐1985. A less lethal and disabling but no less common disease. Stroke 1997;28(2):284‐90. [PUBMED: 9040676] - PubMed
    1. Bruehl S, Harden RN, Galer BS, Saltz S, Bertram M, Backonja M, et al. External validation of IASP diagnostic criteria for Complex Regional Pain Syndrome and proposed research diagnostic criteria. International Association for the Study of Pain. Pain 1999;81(1‐2):147‐54. [PUBMED: 10353502 ] - PubMed
    1. Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Physical Therapy 1966;46:357‐75. [PUBMED: 590725] - PubMed
    1. Carr J, Shepherd R. Investigation of a new Motor Assessment Scale. Physical Therapy 1985;65:175‐80. [PUBMED: 3969398] - PubMed
    1. Collen FM, Wade DT, Robb GF, Bradshaw CM. The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment. International Disability Studies 1991;13(2):50‐4. - PubMed

References to other published versions of this review

    1. Thieme H, Mehrholz J, Pohl M, Dohle C. Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews 2010, Issue 4. [DOI: 10.1002/14651858.CD008449] - DOI - PMC - PubMed

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