Mirror Therapy - upper extremity

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, 2 poor quality RCTs and 1 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.

Please click here to see the Authors’ Results Table.

Acute phase

Functional independenceEffective2a

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 functionEffective2a

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 integrationNot effective2b

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.

StrengthEffective2a

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 neglectEffective1b

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

DexterityConflicting4

Two high quality RCTs (Kim, Lee & Song, 2014Samuelkamaleshkumar 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 independenceNot effective1a

Three high quality RCTs (Dohle et al., 2009Thieme et al., 2012Lim et al., 2016) and two fair quality RCTs (Radajewska et al., 20132017Gurbuz 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., 20132017) 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 activityEffective1b

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 functionConflicting4

Six high quality RCTs (Cacchio et al., 2009a; Dohle et al., 2009; Thieme et al., 2012Kim, Lee & Song, 2014Samuelkamaleshkumar et al., 2014; Lim et al., 2016) and eight fair quality RCTs (Yun et al., 2011Lee, Cho & Song, 2012Bae, Jeong & Kim, 2012Radajewska et al., 20132017; Mirela et al., 2015Nagapattinam et al., 2015Rehani, kumari & Midha, 2015Gurbuz 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., 20132017) 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:
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 recoveryConflicting4

Three high quality RCTs (Kim, Lee & Song, 2014; Samuelkamaleshkumar et al., 2014; Lim et al., 2016) and three fair quality RCTs (Lee, Cho & Song, 2012Mirela 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 powerNot effective2a

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.

PainNot effective1a

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 motionNot effective1a

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 functionNot effetive1a

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.

SpasticityNot effective1a

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 outcomesNot effective1b

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 neglectEffective1a

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

DexterityConflicting4

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 RCT found 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 independenceEffective2a

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 strengthNot effective1b

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 functionNot effective2a

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.

KinematicsEffective1a

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.

MobilityNot effective1b

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 activityNot effective1a

Three high quality RCTs (Wu et al., 2013; Lin et al., 2014Rodrigues 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 functionEffective1a

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, 2015Park 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.

PainConflicting4

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 lifeNot effective1b

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 motionInsufficient evidence5

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 functionNot effective1a

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 functionNot effective1a

Three high quality RCTs (Wu et al., 2013Colomer, Noe & Llorens, 2016Arya 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/toneNot effective1a

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 usageNot effective1b

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

DexterityIneffective2a

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 independenceConflicting4

Two high quality RCTs (Yavuzer et al., 2008Purvane 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 strengthNot effective2a

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 functionEffective1b

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 recoveryConflicting4

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.

PainEffective1b

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 motionNot effective2a

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.

SpasticityNot effective1a

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.


Reference list:

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.