Leanne Loranger, PT, Manager Policy and Practice August 2, 2018
Li Y, Wei Q, Gou W, He C. Effects of mirror therapy on walking ability, balance and lower limb recovery after stroke: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation 2018; DOI: 10.1177/0269215518766642.1
“Stroke is the leading cause of death and disability in Canada.”2 Up to half of people with stroke-related hemiplegia cannot walk independently after rehabilitation;1 however, independent mobility is often a priority for people following stroke.
Mirror therapy involves the use of a mirror placed in the mid-sagittal plane to create the illusion that the affected limb is performing the movements that the unaffected limb is performing. It has been theorized that the visual feedback can help to prevent or reduce learned non-use of the affected limb. Mirror therapy first became common in the rehabilitation of stroke-related upper extremity dysfunction, but more recently has been used in the rehabilitation of lower limbs.
The authors conducted a systematic review and meta-analysis of randomized controlled trials of the use of mirror therapy in the rehabilitation of stroke-related lower-limb impairments.
- Systematic search of MEDLINE, EMBASE, Web of Science, CENTRAL, Physiotherapy Evidence Database, CNKI, VIP, Wan Fang, ClinicalTrials.gov, and Current Controlled Trials, conducted according to PRISMA guidelines.
- Study Inclusion Criteria:
- Randomized Controlled Trials
- Patients > 18 years of age with stroke
- More than five subjects in the study
- Compared mirror to no intervention, a different intervention, or a control group with the same therapeutic intervention minus mirror therapy
- Provided original data or sufficient information about at least one outcome to allow inclusion in Meta-analysis
- Published in English or Chinese
- The PEDro Scale was used to assess quality of included studies.
- Scores ranged from five to eight points
- Six studies were rated “good quality” while seven were rated “fair quality”
- Meta-analysis was conducted using RevMan 5.3.
- Subgroup analysis was conducted to establish the effectiveness of treatment depending on recovery stage (acute, subacute, or chronic) and nature of the treatment intervention (movement of unaffected limb only, or bilateral movement).
- A total of 13 studies, representing 572 patients were included in the meta-analysis.
- Timing of interventions ranged from six days to 16 months post-stroke.
- Six studies involved bilateral movements, while in seven only the unaffected side was moved.
- Frequency ranged from three to six days per week.
- Duration of treatment ranged from two weeks to three months.
- Significant improvement in walking speed compared with control group, measured by 10-meter walk test.
- Both bilateral and unilateral movements led to improved walking speed.
- No significant improvement in mobility, measured by Timed Up and Go or Functional Ambulatory Category.
- Significant treatment effect for balance, measured by the Berg Balance Scale or Brunnel Balance Assessment.
- Significant effect on lower limb motor recovery, measured by the Fugl-Meyer or Brunnstrom Scale.
- No significant effect on spasticity of ankle muscles.
- Significant improvement in PROM of ankle dorsiflexion.
The main finding of this systematic review and meta-analysis was that “patients with stroke who received mirror therapy had significant improvements in walking speed, balance, lower limb motor recovery and passive range of motion of ankle dorsiflexion.”1 However, although the findings were statistically significant, they “seemed to have little clinical significance.” For example, the average improvement in walking speed after mirror therapy treatment would not lead to a change in patient categorization from “house-hold ambulator” to “limited community ambulator.”
- Considerable study heterogeneity regarding treatment frequency and duration may have impacted on the strength of the study findings.
- Relatively small number of studies and total patients included.
Relevance to physiotherapy practice in Alberta
Mirror therapy shows some promise for lower limb rehabilitation of people who have experienced a stroke, leading to statistically significant changes in gait speed, balance, motor recovery and range of motion. However, current research findings show that effects may have limited clinically significance. More research is needed to determine the frequency, duration, timing and parameters of mirror therapy that may result in clinically significant effects, and the patient populations that derive greatest benefit from the intervention, if any.
The purpose of this summary is to highlight recently published research findings that are not openly accessible. Every effort is made to ensure accuracy and clarity of the summary. Readers are encouraged to review the published article in full for further information.
- Li Y, Wei Q, Gou W, He C. Effects of mirror therapy on walking ability, balance and lower limb recovery after stroke: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation 2018; DOI: 10.1177/0269215518766642
- Physiotherapy Alberta – College + Association. Physiotherapy Works for Stroke. Available at https://www.physiotherapyalberta.ca/files/physioworks_stroke.pdf. Accessed July 13, 2018.