Efficacy of mirror therapy on lower limb motor recovery, balance and gait in subacute and chronic stroke: A systematic review.

Objective: Mirror therapy (MT) has been proposed to be an effective therapeutic regimen for lower limb stroke rehabilitation. This review is the first to evaluate the efficacy of MT in subacute and chronic stroke for lower-limb motor functions, balance and gait focusing on particular stage of stroke with specific outcome measures.

Methods: According to PRISMA guidelines, all relevant sources were searched from 2005 to 2020 using "PIOD" framework. Search methods included electronic database, hand and citation searching. Screening and quality assessment was performed by two individual reviewers. Data was extracted and synthesised from 10 studies. Thematic analysis was considered, random-effect models were used and pooled analysis was performed using forest plots.

Results: For motor recovery, MT showed statistically significant effects compared to control group using Fugl-Meyer Assessment and Brunnstorm stages as outcome measures (SMD 0.59; 95% CI 0.29 to 0.88; p < 0.0001; I  = 0%). Statistical significant improvement was reported for balance in MT compared to control using Berg Balance Scale and Biodex in pooled analysis (SMD 0.47; 95% CI 0.04 to 0.90; p = 0.03; I  = 0%). When compared with electric stimulation and action-observation training MT showed no signifiant improvement for balance (SMD -0.21; 95% CI -0.91 to 0.50; p = 0.56; I  = 39%). For gait, MT showed statistical and clinical significant improvement compared to control group (SMD 1.13; 95% CI 0.27-2.00; p = 0.01; I  = 84%) and when compared to action-observation training and electrical stimulation, presented statistical improvement using 10-m walk test and Motion Capture system (SMD -0.65; 95% CI -1.15 to -0.15; p = 0.01; I  = 0%).

Conclusion: This review has shown that MT is effective in lower-limb motor recovery, balance and gait in subacute and chronic stroke in patients 18 years or above with no severe cognitive disorder, MMSE score ≥24 and FAC level ≥2. MT could be used for 30 min/day, 5 days/week for 4 weeks, as stand-alone for motor recovery and balance or as an adjunct with electric stimulation for gait for beneficial effects.