Methods

RCT

Participants

Country: Australia

Setting: inpatient

Age: adults (mean age: 68 years)

Sample size: 40 participants (20 in each group)

Sex: 22 women, 18 men

Inclusion criteria: acute stroke (< 2 weeks)

Exclusion criteria: previous stroke; vision or hearing impairment; acute trauma or impairment of the limbs; inability to sit supported in a high‐backed chair for < 1 hour; MMSE < 22/30; major comorbidities

Interventions

2 arms

1. MT: participants were instructed to move both arms while looking in the mirror box, sensory stimulation

2. Sham therapy: participants performed the same treatment protocol as in group 1 but only viewing the unaffected arm

1 and 2: 5 days a week, 20 to 30 minutes for 2 weeks; additional usual rehabilitation programme

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline, after 2 weeks of treatment and 1 month after treatment

1. mAS (item 7 and 8, each 0 to 6)

2. Resting pain intensity (NRS 0 to 10); differential CRPS‐type 1 diagnosis

3. grip strength (handheld dynamometer)

4. sensory detection (synchiria yes/no, QST)

5. adverse events

Notes

Unpublished data

We used means and SDs of Item 7 of the mAS, and combined the scores on pain intensity of shoulder and hand

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random number sequence

Allocation concealment (selection bias)

Low risk

Generated list was used by an independent person for group allocation

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Results were analysed on an ITT basis

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Iran

Setting: inpatient hospital

Age: adults (mean age: 50.9 years)

Sample size: 24 participants (12 in each group, no dropouts published)

Sex: 9 women, 15 men

Inclusion criteria: stroke > 6 months, ability to understand treatment guidelines

Exclusion criteria: any structural abnormalities that prevent the execution, any cognitive or perceptual deficit that can affect the implementation of treatment, visual deficits

Interventions

2 arms

1. Bilateral MT

2. Bilateral arm training without mirror

1 and 2: 3 weeks, 5 days a week, 30 minutes a day

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline, immediately after treatment and 1 month after treatment

1. FM‐UE motor (0 ‐ 66 points)

2. BBT

3. Jamar Dynamometer for grip strength

Notes

Published and unpublished information

Funding source: Neuromuscular Rehabilitation Research Centre ‐ Semnan University of Medical Sciences

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomisation with odd‐ and even‐numbered cards

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

Randomised cross‐over trial

Participants

Country: USA

Setting: not stated

Age: adults (mean age: 58.2 years)

Sample size: 9 participants (9 in each group)

Sex: 4 women, 5 men

Inclusion criteria: at least 6 months post‐stroke

Exclusion criteria: not stated

Interventions

2 arms

1. 4 weeks of mirror therapy: participants were instructed to move the non‐paretic arm while looking in the mirror and moving the paretic arm as best they could; followed by 4 weeks of control therapy, using transparent plastic instead of a mirror

2. Vice versa

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline, after 2, 4, 6 and 8 weeks

1. Self‐developed scale (‐3 to +3); assessing changes in participants' movement ability in terms of range of motion, speed and accuracy by video analysis

Notes

Data not included in the analysis

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Participants were randomly assigned (authors' statement)

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Turkey

Setting: inpatient rehablitation centre

Age: adults (mean age: 58.8 years)

Sample size: 24 participants (9 in experimental group (2 dropped out at follow‐up assessment); 8 in control group 1; 7 in control group 2 (1 dropped out at follow‐up assessment)

Sex: 11 women, 13 men

Inclusion criteria: ischaemic stroke during the previous 12 months, between 20 and 85 years old, could understand simple verbal instructions (MMSE > 21), BRS between stage 2 and 5 for the hand, mAS < 3

Exclusion criteria: not stated

Interventions

3 arms

1, 2 and 3: conventional physiotherapy programme

1. Additional MT: unaffected wrist, hand flexion, extension and forearm circumduction, and supination–pronation movements, participants practised at home after supervised sessions

2. EMG‐triggred electrical muscle stimulation of wrist and finger extensor muscles (pulse duration 200 μs, frequency 50 Hz, 1 sec ramp up, 5 sec biphasic stimulation, 1 sec ramp down; intensity was determined for each participant

3. No additional therapy

1, 2 and 3: 3 weeks, 5 days a week, 2 hours a day

1 and 2: additional 30 minutes a day

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline, after 3 weeks of treatment and 3 months after treatment

1. FM‐UE motor (0 ‐ 66 points)

2. Jamar Goniometer (wrist ROM)

3. Jamar Dynamometer for grip strength

4. BBT

Notes

Published and unpublished information

Funding source: not stated

Declarations of trialists’ interests: there are no conflicts of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random‐number sequence

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All participants analysed as assigned to groups (authors' statement)

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessor was blinded to group allocation

Methods

RCT

Participants

Country: India

Setting: inpatient hospital, home after discharge

Age: adults (mean age: 45.6 years)

Sample size: 33 participants (17 in experimental group, 16 in control group, 1 dropout)

Sex: 8 women, 25 men

Inclusion criteria: aged < 60 years, single unilateral stroke with hemiparesis, more than 24 weeks post‐stroke, able to understand instructions, Brunnstrom recovery stage of arm (BRS‐A) 2 or above

Exclusion criteria: associated neurological complications, severe perceptual and visual deficits (as evaluated by the National Institutes of Health Stroke Subscales and clinical tests: copying and drawing, line‐bisection, cancellation tasks, and functional performance), shoulder subluxation, uncontrolled medical illness

Interventions

2 arms

1 and 2: usual occupational therapy using principles of Brunnstrom and Bobath approaches

1. MT: participants observed mirror image of task‐specific movements of the less affected upper limb, each task 20 to 100 times in an increment of 5 to 10 a session

1: 8 weeks, 5 days a week, 45 minutes MT, additional 45 minutes usual occupational therapy

2: 8 weeks, 5 days a week, 90 minutes usual occupational therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 8 weeks of treatment

1. BRS (Arm and Hand)

2. FM‐UE motor (0 ‐ 66 points)

Notes

Information partly based on authors' information

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned (authors' statement), computer‐generated random‐number sequence

Allocation concealment (selection bias)

Low risk

Concealed allocation by numbered sealed envelopes

Incomplete outcome data (attrition bias)
All outcomes

Low risk

ITT using 'last measure carried forward' method

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: India

Setting: inpatient rehabilitation centre

Age: adults (mean age: 46.4 years)

Sample size: 36 participants (19 in experimental group, 17 in control group; 6 dropouts)

Sex: 6 women, 30 men

Inclusion criteria: post‐stroke hemiparesis due to unilateral stroke; post‐stroke duration > 6 months; paresis of either right or left side; age range between 30 and 60 years; functional ambulation classification (FAC) level 2 and above; ability to walk for a distance of at least 10 metres without any orthosis and walking device

Exclusion criteria: any other associated neurological disorder; severe cognitive, perceptual and visual deficits (evaluated by the National Institutes of Health Stroke Subscales and copying, drawing, line bisection, cancellation, and functional tasks); cardiovascular instability; any musculoskeletal disorder affecting locomotion

Interventions

2 arms

1 and 2: conventional rehabilitation programme

1. Activity‐based MT: activities of the unaffected lower limb, ball rolling, rocking‐on‐board, wiping, pedaling, and shifting

1: 3 to 4 weeks, 30 sessions, 30 minutes MT and 30 minutes conventional rehabilitation programme

2: 3 to 4 weeks, 30 sessions, 60 minutes conventional rehabilitation programme

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 3 months

1. Brunnstrom recovery stages‐ lower extremity

2. Fugl‐Meyer‐Assessment‐ lower extremity

3. Rivermead visual gait assessment

4. 10 metre walk test

Notes

Information based on abstract and authors' information, full‐text publication received in 2017

Funding source: Pandit Deendayal Upadhayaya National Institute for Persons with Physical Disabilities, 4 VD Marg, New Delhi‐110002, India

Declarations of trialists’ interests: no potential conflict of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned (authors' statement), computer‐generated (SPSS software) random‐number sequence

Allocation concealment (selection bias)

Low risk

Concealed allocation by sealed envelopes (authors' statement)

Incomplete outcome data (attrition bias)
All outcomes

Low risk

ITT using 'last measure carried forward' method (authors' statement)

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors, participants, and therapists were blinded to group allocation (authors' statement)

Methods

RCT

Participants

Country: Republic of Korea

Setting: inpatient rehabilitation centre

Age: adults (mean age: 53.9 years)

Sample size: 20 (10 in each group; no dropouts published)

Sex: 7 women, 13 men

Inclusion criteria: onset of stroke within 6 months

Exclusion criteria: did not understand treatment method of the study, MMSE < 16, visual impairment, damage on musculoskeletal system or peripheral nerve on paretic side, mAS score > 2, Brunnstrom recovery stage 1, 5 or 6

Interventions

2 arms

1 and 2: usual rehabilitation treatment and additional:

1. MT: participants observed their unaffected upper limb in mirror while performing movements of both arms, 5 exercises for 6 minutes, 5 times a session

2. Sham therapy: participants performed the same treatment protocol as in group 1 but only for the paretic arm

1 and 2: 4 weeks, 5 days a week, 30 minutes MT or sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks

1. MFT (0 ‐ 32 points, higher score indicate better motor function)

2. Brain waves using QEEG‐8

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by cards composed of odd and even numbers

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Iran

Setting: not stated

Age: adults (age not stated)

Sample size: 50 participants (25 in each group, no dropouts published)

Sex: not stated

Inclusion criteria: 1st unilateral stroke (ischaemic or haemorrhagic verified by CT‐scan or MRI), between 1 month and 1 year after stroke, Brunnstrom recovery stages 1 ‐ 3

Exclusion criteria: severe cognitive deficit, severe aphasia, visual deficits, dementia, not able to understand instructions, did not participate in 4 sessions or 2 consecutive sessions

Interventions

2 arms

1 and 2: physiotherapy and neuromuscular stimulation

1. MT: participants observed movements of healthy upper and lower extremities in front of the mirror

2. No additional therapy

1 and 2: 20 sessions, 3 to 5 days a week, 30 minutes

1: 20 sessions, 3 to 5 days a week, additional 30 minutes MT

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after the 5th, 10th, and 15th session

1. BI (0 ‐ 100)

Notes

Information based on abstract, partly translated from Persian language

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by coin tossing

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Italy

Seting: inpatient and outpatient rehabilitation centre

Age: adults (mean age: 58.4 years)

Sample size: 48 participants (24 in each group; 6 dropped out post‐treatment, 3 more dropped out after 6 months)

Sex: 26 women, 22 men

Inclusion criteria: hemiparesis after first‐ever ischaemic or haemorrhagic stroke; during 1st 6 months post‐stroke; diagnosed with CRPS‐type 1 with a VAS pain score > 4 cm

Exclusion criteria: intra‐articular injection into the affected shoulder during the previous 6 months or use of systemic corticosteroids during the previous 4 months; presence of another explanation of pain; prior surgery to shoulder or neck; serious uncontrolled medical conditions; global aphasia or cognitive impairments; visual impairments which might interfere with the aims of the study; evidence of recent alcohol or drug abuse; or severe depression

Interventions

2 arms: 4‐week conventional stroke rehabilitation programme and additional:

1. MT: participants performed upper extremity movements while looking in the mirror, without additional verbal feedback

2. Sham therapy: participants performed the same treatment protocol as in group 1 but with covering the reflecting side of the mirror

1 and 2: 5 days a week, 30 minutes of therapy for the 1st 2 weeks; and 5 days a week, 60 minutes of therapy for the last 2 weeks

Date of intervention: October 2000 to December 2006

Outcomes

Outcomes were recorded at baseline, 1 week after the intervention period and after 6 months

1. WMFT/FA; 0 to 5, lower scores indicating better functioning

2. WMFT/PT; in seconds

3. QOM item in the MAL (0 to 5)

4. Pain at rest (VAS 0 to 10)

5. Pain on movement (VAS 0 to 10)

6. Pain tactile allodynia (VAS 0 to 10)

Notes

Published and unpublished data

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Participants were randomly allocated (authors' statement)

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Results were analysed on an ITT basis

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Italy

Setting: inpatient and outpatient rehabilitation centre

Age: adults (mean age: 62 years)

Sample size: 24 participants (8 in each group)

Sex: 13 women, 11 men

Inclusion criteria: 1st ischaemic or haemorrhagic stroke (> 6 months); diagnosis of CRPS‐type 1 (pain VAS > 4 cm)

Exclusion criteria: intra‐articular shoulder injection in the previous 6 months or systemic corticosteroid in the previous 4 months; another obvious explanation for pain; prior surgery to shoulder or neck region; serious uncontrolled medical conditions; global aphasia or cognitive impairments interfering with understanding instructions, motor testing and treatment; visual impairments interfering with aims of the study; evidence of recent alcohol or drug abuse; or severe depression

Interventions

3 arms

1. MT: participants performed cardinal upper extremity movements while looking in the mirror

2. Sham therapy: participants performed the same treatment protocol as in group 1 but with covering the reflecting side of the mirror

3. Mental imagery: participants performed mental imagery

1, 2 and 3: 5 days a week; 30 minutes of therapy for 4 weeks

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after the intervention period

1. WMFT/FA: 0 to 5, lower scores indicating better functioning

2. WMFT/PT: in seconds

3. Pain (VAS 0 to 10)

4. Brushed induced allodynia

5. Oedema

Notes

Published and unpublished data; we only analysed the 1st intervention period (4 weeks); we combined groups 2 and 3 into 1 control group

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Block randomisation; cards composed with random‐numbers method

Allocation concealment (selection bias)

Low risk

A therapist not involved in the treatments opened sealed envelopes and assigned appointments according to treatment group (authors' statement)

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Results were analysed on an ITT basis

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Republic of Korea

Setting: not stated

Age: adults (mean age: 58.7 years)

Sample size: 36 participants (19 in experimental group, 17 in control group, no dropouts published)

Sex: 17 women, 19 men

Inclusion criteria: stroke onset duration of > 6 months; no neurological deficits in the cerebellum or the brainstem; no hemineglect or visual field deficits; no cognitive problems (> 24 points in the MMSE); independent walking (with or without walking aids)

Excludion criteria: not stated

Interventions

2 arms

1. MT + rTMS: activities with the unaffected limb; flexing and extending the hip, knee, and ankle at a self‐selected speed under supervision but without additional verbal feedback; 10 minutes of rest period in the middle of the session; rTMS‐ 70 mm coil and a Magstim Rapid (Magstim, Wales, UK) 1 Hz rTMS was applied for 20 minutes to the hotspot of the lesional hemisphere in 10‐second trains, with 50‐second intervals between the trains

2. Sham therapy + rTMS: same therapy protocol, except the mirror was covered; rTMS: 70 mm coil and a Magstim Rapid (Magstim, Wales, UK) 1 Hz rTMS was applied for 20 minutes to the hotspot of the lesional hemisphere in 10‐second trains, with 50‐second intervals between the trains

1 and 2: 4 weeks, 5 days a week, 40 minutes (20 minutes rTMS and 20 minutes MT or sham therapy)

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after the 4 weeks of therapy:

1. Berg‐Balance‐Scale

2. Balance Index

3. Timed‐up and go test

4. Dynamics limits of stability

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomisation by blindly drawing 1 card out of an envelope containing 2 cards that were each marked as experimental group and control group

Allocation concealment (selection bias)

Low risk

Concealment by sealed envelopes

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated; no dropouts

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Republic of Korea

Setting: not stated

Age: adults (mean age: 59.3 years)

Sample size: 27 participants (14 in experimental group, 13 in control group, no dropouts published)

Sex: 12 women, 15 men

Inclusion criteria: stroke with hemiplegic symptoms, a score of 24 or higher on the MMSE‐K, stroke onset more than 6 months earlier

Exclusion criteria: orthopaedic or neurological disease history

Interventions

2 arms

1 and 2: tDCS

1: MT: participants performed movements of both upper limbs, 10 sets, 20 repetitions of each motion, 2‐minute rest between sets

2: sham therapy: participants performed the same exercises with non‐reflective surface between limbs

1 and 2: 6 weeks, 3 days a week, 20 minutes tDCS + 5 minutes rest + 20 minutes MT or sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after the 6 weeks of therapy

1. BBT

2. Grip strength

3. Jebsen‐Taylor test (in seconds)

4. FM‐UE motor (0 ‐ 66)

Notes

Funding source: Wonkwang Health Science University

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned (authors' statement)

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Spain

Setting: outpatient rehabilitation centre

Age: adults (mean age: 53.5 years)

Sample size: 34 (17 in experimental group (2 dropped out); 16 in control group (1 dropped out))

Sex: 5 women, 26 men

Inclusion criteria: stroke > 6 months, BRS 1 or 2, FM‐UE < 19, sensory impairment assessed by clinical examination, able to maintain sitting position for at least 60 minutes, MMSE > 23

Exclusion criteria: impaired comprehension that hindered understanding of instructions (Mississippi Aphasia screening < 45), upper limb pain that limited participation in rehabilitation protocol, spatial neglect, self‐awareness disorder, emotional circumstances that impeded adequate collaboration

Interventions

2 arms

1 and 2: usual physical therapy:

1. MT: participants observed their unaffected upper limb in mirror while performing movements with less affected upper limb: flexion‐extension of shoulder, pronation and supination of forearm, fine and gross motor tasks with and without objects (balls, cups)

2. Control group: passive mobilisation of affected upper limb

1 and 2: 8 weeks, 5 days a week, 60 minutes each, additional 3 days a week, 45 minutes a session MT or passive mobilisation

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 8 weeks of intervention

1. WMFT

2. FM‐UE

3. NSA

Notes

Published information

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random‐number sequence

Allocation concealment (selection bias)

Low risk

Concealed allocation by sealed envelopes and independent investigator

Incomplete outcome data (attrition bias)
All outcomes

High risk

No ITT analysis was performed

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessor was blinded to group allocation

Methods

RCT

Participants

Country: Switzerland

Setting: not stated

Age: adults (age not stated)

Sample size: 10 participants (no dropouts published)

Sex: not stated

Inclusion criteria: 3 months after stroke; severe disability (NIHSS 10 ‐ 14), hand paresis

Exclusion criteria: not stated

Interventions

2 arms

1 and 2: TMS: double‐pulse TMS through a figure‐eight focal coil for bilateral intracortical inhibition in primary motor at rest and during movement preparation

1. Additional MT

2. No additional therapy

1 and 2: 4 weeks, 3 days a week, 15 minutes TMS

1: additional 15 minutes MT

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after therapy period

1. MRC Scale for Muscle Strength

2. BRS

3. FM‐UE

4. FAB

5. Beck Depression Scale

6. 10‐item Spiegelberger Trait Anger Scale

7. MoCA

8. Functional Independence Measure (FIM)

Notes

Information based on authors' information and abstract

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned (authors' statement)

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Germany

Setting: inpatient rehabiltation centre

Age: aduts (mean age: 56.5 years)

Sample size: 48 participants (24 in each group, 12 dropped out)

Sex: 10 women, 26 men

Inclusion criteria: first‐ever ischaemic stroke in the territory of the middle cerebral artery; not more than 8 weeks post‐stroke; between 25 and 80 years old; able to follow therapy instructions; capable of participating in 30‐minute daily therapy sessions

Exclusion criteria: experienced previous stroke; major haemorrhagic changes; increased intracranial pressure; hemicraniectomy or orthopaedic, rheumatologic, or other diseases interfering with their ability to sit or to move either upper limb

Interventions

2 arms

1. MT: participants were instructed to move both arms "as well as possible" while looking in the mirror

2. Bilateral arm training: participants performed the same treatment protocol as in group 1 but without a mirror

1 and 2: 5 days a week; 30 minutes of therapy for 6 weeks

Date of intervention: October 2004 to April 2006

Outcomes

Outcomes were recorded at baseline and after the intervention

1. FM‐UE motor, ROM, pain and sensory section (FM‐UE 0 to 126)

2. ARAT 0 to 57

3. FIM self‐care and mobility items (7 to 77)

4. self‐defined Neglect score (0 to 4)

Notes

Published and unpublished data; we extracted the motor section of the FM‐UE (without reflex activity, 0 to 60)

Funding source: rehabilitation research network (refonet) of the German Pension Scheme Rhineland

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Sealed, numbered envelopes were created

Allocation concealment (selection bias)

Low risk

Sealed envelopes were broken after study inclusion

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts were not included in analysis

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors of primary outcome were blinded to group allocation

Methods

RCT

Participants

Country: USA

Setting: outpatient (at home)

Age: adults (34 to 73 years old)

Sample size: 6 participants (4 in 2 experimental groups, 2 in control group; dropouts not published)

Sex: 3 women, 3 men

Inclusion criteria: first‐time unilateral stroke occurring at least 3 months prior with FMA‐UE scores between 10 and 50

Exclusion criteria: not stated

Interventions

3 arms

1 ‐ 3 : occupational therapy (OT)

1. Bimanual MT as home programme

2. Unimanual MT as home programme

3. Traditional OT as home programme

1 ‐ 3: 6 weeks, 2 times a week OT in the clinic

1 ‐ 3: 6 weeks, 5 days a week, 30‐minute home programme bimanual MT, unimanual MT or traditional OT

Date of intervention: not stated

Outcomes

Outcomes were recorded

1. FM‐UE

2. ARAT

3. Stroke Impact Scale

Notes

Information based on abstract

Funding source: not stated

Declarations of trialists’ interests: there are no conflicts of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not stated

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Turkey

Setting: inpatient rehabiltation centre

Age: adults (mean age: 60.9 years)

Sample size: 31 (16 in experimental group, 15 in control group, no dropouts published)

Sex: 14 women, 17 men

Inclusion criteria: unilateral hemiplegia due to first‐ever stroke (verified by CT or MRI); < 6 months; BRS for the upper extremity between I and IV; MMSE 24 and above; lack of excessive spasticity in the joints of the affected upper extremity (stage 2 and below according to the mAS)

Exclusion criteria: joint movement limitations in the healthy upper extremity; a visual field defect or neglect syndrome; and those who had previously undergone a rehabilitation programme

Interventions

2 arms

1 and 2: upper extremity rehabilitation programme

1. Additional mirror therapy: activities of the affected limb; flexion and extension of the wrist and finger

2. Additional sham therapy: same therapy protocol with a covered mirror

1 and 2: 4 weeks, 5 times a week, 60 to 120 minutes upper extremity rehabilitation programme

1 and 2: 4 weeks, 5 times a week, 20 minutes MT or sham therapy

Date of intervention: July 2013 to July 2014

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy

1. FMA‐UE

2. FIM self‐care subscale (Turkish version)

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by random‐number table

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated; no dropouts published

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessor was blinded to group allocation

Methods

RCT

Participants

Country: Japan

Setting: inpatient hospital

Age: adults (mean age: 67.5 years)

Sample size: 14 participants (7 in each group, no dropouts published)

Sex: 6 women, 8 men

Inclusion criteria: 1st episode of stroke with hemiparesis or second episode of stroke with no upper limb motor dysfunction after 1st stroke, > 1 month since stroke, Brunnstrom recovery stage finger 1 ‐ 5, no severe cognitive disorders (MMSE score ≥ 24, and item score of consciousness, gaze, visual fields, language, attention of National Institutes of Health Stroke scale = 0)

Exclusion criteria: hypertonia of upper limb, limitation in range of motion of upper limb, other diseases interfering with ability to move upper limbs

Interventions

2 arms

1 and 2: conventional stroke rehabilitation programme (physiotherapy, occupational therapy)

1. Additional MT: non‐paretic‐side movements (e.g. supination and eversion of the forearm, flexion and extension of the wrist and finger, grasp a block) while participants looked into the mirror. During the session participants were asked to try to do the same movements with the paretic hand

2. No additional therapy

1 and 2: 4 weeks, 6 ‐ 7 days a week, daily 2 hours

1: additional 30 minutes MT

Date of intervention: October 2010 to March 2011

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy

1. BRS

2. FM‐UE

3. WMFT

4. FIM self‐care

Notes

Published and unpublished information

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by stratified randomisation

Allocation concealment (selection bias)

Low risk

Concealed allocation by an independent author who drew sealed envelopes

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No dropouts and group changes

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessor was blinded to group allocation

Methods

RCT

Participants

Country: Republic of Korea

Setting: inpatient rehabilitation centre

Age: adults (mean age: 63.9 years)

Sample size: 24 participants (14 in experimental group, 10 in control group; 5 dropouts)

Sex: 8 women, 11 men

Inclusion criteria: onset of stroke at least 6 months prior to study, able to understand and follow simple verbal instructions, MMSE > 21, Brunnstrom stages 1 ‐ 4

Exclusion criteria: apraxia, hemineglect, orthopaedic conditions or digital neuropathy in upper extremities

Interventions

2 arms

1 and 2: conventional stroke rehabilitation programme

1. Additional Virtual MT: affected arm lay in a box with a monitor positioned on the box, the unaffected arm was positioned under a camera, looking on the screen while performing movements of both arms, supervision of caregivers

2. Additional sham therapy (same treatment, but the monitor was off)

1 and 2: 4 weeks, 5 days a week, 30 minutes additional virtual reality (VR) reflection therapy or additional sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks

1. FM‐UE (0 ‐ 66)

2. Modified Ashworth Scale

3. BBT

4. JTHFT

5. MFT

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random sequence

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts were not included in analysis

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Republic of Korea

Seting: inpatient rehabilitation centre

Age: adults (mean age: 55.9 years)

Sample size: 30 participants (15 in experimental group and 15 in control group; 5 dropouts)

Sex: 10 women, 15 men

Inclusion criteria: onset of stroke at least 6 months prior to study; were able to understand and follow simple verbal instructions; had a MMSE score over 21; had a Brunnstrom score between stages I and IV

Exclusion criteria: had no apraxia or hemineglect; had no orthopaedic and neurologic conditions such as fractures and digital neuropathy on their lower extremities

Interventions

2 arms

1 and 2: conventional stroke rehabilitation programme

1. Additional Virtual MT: affected leg stood in a box with a monitor positioned on the box, the unaffected leg was positioned under a camera, looked on the screen while performing movements of both legs, supervision of caregivers

2. Additional sham therapy (same treatment, but the monitor was off)

1 and 2: 4 weeks, 5 days a week, 30 minutes conventional stroke rehabilitation programme

1 and 2: 4 weeks, 5 days a week, 30 minutes additional virtual reality (VR) reflection therapy or additional sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks:

1. BBS

2. FRT

3. TUG

4. 10‐metre walking velocity

5. Static balance ability (variation: eyes open or eyes closed; sway distance in cm)

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random sequence

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts were not included in analysis

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to the participants’ groups

Methods

RCT

Participants

Country: Italy

Setting: inpatient rehabilitation centre

Age: adults (mean age: 66.6 years)

Sample size: 26 (13 in each group; 1 dropped out)

Sex: 9 women, 17 men

Inclusion criteria: hemiplegia after 1st stroke (diagnosed by CT scan) within 4 weeks post‐stroke, absence of severe attentive deficits, presence of movement in shoulder/elbow/hand with Motricity score < 77;

Exclusion criteria: haemorrhagic stroke, global aphasia and cognitive impairments that interfere with study or treatment participation (MMSE < 22), concomitant cns‐ or pns‐disorder or myopathia

Interventions

2 arms: usual rehabilitation programme 1 hour, 5 times a week, additional:

1. MT: participants observed their unaffected upper limb in mirror while performing movements of the unaffected limb, self‐selected speed, no additional verbal feedback

2. Sham therapy: participants performed the same treatment protocol with a covered mirror

1 and 2: 5 days a week, 30 minutes of MT or sham therapy for 1st 2 weeks, 60 minutes of MT or sham therapy for the last 2 weeks

Date of intervention: October 2009 to August 2011

Outcomes

Outcomes were recorded and reported at baseline and after 4 weeks

1. ARAT

2. MI‐UL

3. FIM

Notes

Published and unpublished information

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random sequence

Allocation concealment (selection bias)

Low risk

Concealed allocation by an independent investigator

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All participants analysed as allocated (authors' information)

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessor was blinded to group allocation

Methods

RCT

Participants

Country: Republic of Korea

Setting: university hospital

Age: adults (mean age: 52.6 years)

Sample size: 35 participants (12 in experimental group 1, 11 in experimental group 2, 12 in control group, no dropouts published)

Sex: 13 women, 22 men

Inclusion criteria: hemiparesis by stroke

Exclusion criteria: not stated

Interventions

3 arms

1, 2 and 3: traditional physiotherapy

1. Additional MT with rTMS: flexion and extension of fingers, 10 Hz rTMS was applied to the hotspot of the lesional hemisphere in 10‐second trains, with 50‐second intervals between trains

2. Additional MT: flexion and extension of fingers wrist extension of non‐paretic upper extremity consisting of daily 4 times for 15 minutes a session

3. Sham therapy using a covered mirror: same movements as in MT

1, 2, and 3: 6 weeks, 5 days a week, 30 minutes a session physiotherapy

1, 2, and 3: additional 15 minutes a day MT or sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 6 weeks of therapy

1. Motor‐evoked potentials

2. FM‐UE

3. BBT

Notes

Information based on published article

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random‐number blocks

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessor was blinded to group allocation

Methods

RCT

Participants

Country: Japan

Setting: inpatient rehabilitation centre

Age: adults (mean age: 64.1 years)

Sample size: 81 participants (19 in group 1 (3 dropped out), 25 in group 2 (6 dropped out), 17 in group 3 (2 dropped out),11 in group 4 (2 dropped out), 9 in group 5 (1 dropped out))

Sex: 24 women, 43 men

Inclusion criteria: hemiplegia following initial supratentorial stroke, admitted to a convalescent rehabilitation ward

Exclusion criteria: time to admission from the onset is within 14 days, difficult communication due to severe cognitive disorder, comorbidity index of 4 or higher, necessity of high‐level consideration and caution for rehabilitation, and scores of hip‐flexion, knee‐extension, and foot‐pat items of the Stroke Impairment Assessment Set (SIAS) lower than 2

Interventions

5 arms

1 to 5: standard rehabilitation programme

1. MT: dorsiflexion of the ankle joint, stepping over, and abduction/adduction of the hip joint with the non‐affected limb

2. Integrated volitional control electrical stimulation (IVES): 50 μs pulse width, 20 Hz frequency bidirectional square waves was applied at an intensity proportional to the voluntary myoelectric activity level on the paralytic side for dorsiflexion of the ankle joint and extension of the knee joint

3. Therapeutic electrical stimulation (TES): 50 μs pulse width, 20 Hz frequency bidirectional square waves applied at the maximum acceptable intensity during 10 minutes each of paralytic ankle dorsiflexion and knee extension

4. Repetitive facilitating exercises (RFE): participants performed ankle dorsiflexion 100 or more times during a 10‐minute period in a supine position using manual tapping stimulation, additional performance of hip flexion‐extension exercise, abduction‐adduction exercise, extension/abduction‐flexion/adduction exercise, and hip extension/abduction/retention of external rotation/knee extension‐hip flexion/adduction/external rotation/knee flexion exercise

5. Control group: training programme of ROM and ADL exercises

1 to 5: 4 weeks, 1 hour a day standard rehabilitation programme

1 to 5: 20 minutes within conventional physiotherapy

Date of intervention: September 2009 to July 2011

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy

1. Stroke Impairment Assessment Set (SIAS)

Notes

Information based on published article

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by table of random numbers

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Republic of Korea

Setting: university hospital

Age: adults (mean age: 55.8 years)

Sample size: 27 (14 in experimental group, 13 in control group, 4 dropouts)

Sex: 9 women, 14 men

Inclusion criteria: onset of stroke within 6 months, MMSE > 21, FMA upper extremity score < 44, Brunnstrom recovery stage 1 ‐ 4, absence of orthopaedic disease in the upper extremity, no visual perception disorder (unilateral neglect, hemianopsia, apraxia), no pacemaker, no anticonvulsant medication, medically stable condition

Exclusion criteria: not stated

Interventions

2 arms

1 and 2: usual rehabilitation treatment

1. Additional MT and FES: participants observed their unaffected upper limb in a mirror while performing extension of wrist and fingers to lift the hand from an FES switch, at the same time attempt to extend affected hand supported by electrical stimulation (20 Hz), pulse rate 300 μs, individual intensity for muscle contraction and complete extension

2. Additional sham therapy and FES: participants performed the same treatment protocol as in group 1 while looking on the non‐reflecting surface of the mirror

1 and 2: 60 minutes/day, 5 times/week, 4 weeks usual rehabilitation treatment

1 and 2: additional 5 days a week, 30 minutes a day, 4 weeks MT or sham therapy

Date of intervention: 1 July to 31 July 2013

Outcomes

Outcomes were recorded and reported at baseline (t1), after 4 weeks of treatment (t2)

1. FM‐UE motor (0 ‐ 66 points)

2. Brunnstrom recovery stages

3. BBT

4. MFT

Notes

Funding source: Sahmyook University

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random sequence

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Outcome assessors were blinded to group allocation

Methods

RCT

Participants

Country: Republic of Korea

Setting: inpatient rehabilitation centre

Age: adults (mean age: 57.7 years)

Sample size: 33 participants (20 in 2 experimental groups, 9 in control group; 4 dropouts)

Sex: 9 women, 20 men

Inclusion criteria: onset of stroke > 6 months, MMSE > 25, absence of cognitive problems, BRS 1 – 4, and the ability to understand the purpose of the study

Exclusion criteria: impaired vision, cognitive problems such as a severe decline in cognition or aphasia that would prevent normal progress in the experiment, neurological or musculoskeletal (fracture or balance‐related) disorders not caused by stroke, hemineglect

Interventions

3 arms

1, 2 and 3: conventional rehabilitation programme

1. Additional MT with BF‐FES: EMG placed to wrist extensor and brachial muscle of the upper extremity of the less affected side, FES electrode placed to wrist extensor of the affected side, input signal for EMG sensor sampled at 256 Hz, 5 s of electrical stimulation of the affected side after exceeding EMG threshold, MT with physiological and object‐related movements

2. Additional MT with FES: FES adjusted to a tolerable level while the participants were in a state of induced wrist extension every 5 s

3. No additional therapy

1, 2 and 3: 4 weeks, 5 days a week, 30 minutes a day

1 and 2: additional 4 weeks, 5 days per week, 30 minutes a session

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy

1. Muscle strength with hand‐held dynamometer (wrist flexion and extension, elbow flexion and extension)

2. ROM (wrist flexion and extension, elbow flexion and extension)

3. mAS of wrist flexion, elbow flexion and extension

4. Palmar grasp strength (electrodynamometer)

5. BBT

6. JTHFT

7. FIM

8. SSQOL

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random‐number sequence

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts not analysed

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Republic of Korea

Setting: outpatient hospital

Age: adults (mean age: 49.1 years)

Sample size: 25 participants (12 in experimental group, 13 in control group, no dropouts published)

Sex: 9 women, 16 men

Inclusion criteria: hemiplegia due to stroke, stroke > 6 months. MMSE > 24, understanding the procedure and purpose of the study, volunteer participation in the study

Exclusion criteria: not stated

Interventions

2 arms

1. MT: included reaching, grasping, manipulation, towel‐folding, table‐wiping, sponge‐squeezing, pegboard, card‐turnover, and typing with the unaffected limb while watching the mirror

2. Conventional exercises: arm bicycling, peg‐board exercise, skateboard‐supported exercises on a tabletop, donut on base putty kneading, double curved arch, bimanual placing cone, block‐stacking, graded pinch exercise, plastic‐cone stacking, shoulder curved arch without mirror

1and 2: 4 weeks, 5 days a week, 30 minutes a day MT or control intervention

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy

1. FM‐UE

2. ARAT

3. BBT

4. FIM

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by dice with odd and even numbers

Allocation concealment (selection bias)

Low risk

Allocation by throwing dice after inclusion in the study

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Insufficient information, no drop‐outs

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

Randomised cross‐over trial

Participants

Country: Japan

Setting: inpatient rehabilitation centre

Age: adults (mean age: 69.1 years)

Sample size: 13 participants (6 in group 1, 7 in group 2, no dropouts)

Sex: 3 women, 10 men

Inclusion criteria: hemiparesis caused by a single stroke, between 30 and 180 days post‐stroke, MMSE > 20, palpable contraction of paretic wrist and finger extensors, detectable EMG signal (> 5 V) from those muscles

Exclusion criteria: cardiac pacemaker; serious contractures or pain in the shoulder, elbow or wrist; shoulder subluxation; severe cognitive impairment or severe aphasia; inability to give informed consent; engagement in any other experimental studies

Interventions

2 arms

1 and 2: standard physiotherapy and occupational therapy

1. Immediate Electromyography‐triggered neuromuscular stimulation‐Mirror therapy (ETMS‐MT): electrical stimulation of extensor carpi radialis and extensor digitorum communis of the target threshold at the EMG level, which corresponded to 50% to 75% of the maximum active range of motion of wrist extension, if target threshold was exceeded electrical stimulation (10 seconds of symmetrical biphasic pulses at 50 Hz, pulse width of 200s, followed by 20 seconds of rest) triggered full range of motion; MT: bimanual wrist and finger extension during 10 seconds of 'on' period, during 'off' period bimanual exercises under MT condition without electrical stimulation, task difficulty was modulated gradually with functional level

2. Delayed ETMS‐MT: see 1

1 and 2: 8 weeks, 5 days a week, 2 hours a day physiotherapy and occupational therapy

1 and 2: 4 weeks, 5 days a week, two 20‐minute sessions a day; group 1: additional ETMS‐MT for the 1st 4 weeks, group 2: additional ETMS‐MT for the second 4 weeks

Date of intervention: November 2009 to May 2012

Outcomes

Outcomes were recorded at baseline and after 4 weeks and 8 weeks of therapy

1. FM‐UE

2. Active ROM of wrist extension

3. BBT

4. WMFT

5. MAL

Notes

Based on published and unpublished information

Funding source: not stated

Declarations of trialists’ interests: there are no conflicts of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by permuted block randomisation

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

High risk

Assessor not blinded to group allocation

Methods

RCT

Participants

Country: India

Setting: not stated

Age: adults (mean age: 57.3 years)

Sample size: 30 (15 in each group, no dropouts)

Sex: 8 women, 22 men

Inclusion criteria: 1st stroke (ischaemic or haemorrhagic), unilateral stroke with hemiparesis, Brunnstrom recovery stage 2 ‐ 4, age > 25 years, ambulatory before stroke, able to understand simple verbal instructions

Exclusion criteria: severe cognitive disorder, previous stroke, orthopaedic or rheumatologic problems restricting lower limbs, other diseases that interfere with ability to sit or moving lower limbs

Interventions

2 arms

1 and 2: conventional physical therapy and

1. MT: MT for the lower extremity, self‐selected speed, under supervision

2. Control group: no additional therapy

1 and 2: 40 ‐ 45 minutes/day for 10 days conventional physical therapy

1: twice daily for 15 minutes for 10 days

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline, after 5 and 10 days

1. FM‐LE (0 ‐ 34 points)

Notes

Unpublished data

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Participants were randomly allocated (authors' statement)

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Turkey

Setting: not stated

Age: adults (mean age: 61.4 years)

Sample size: 20 participants (10 in experimental group, 10 in control group, no dropouts published)

Sex: 10 women, 10 men

Inclusion criteria (information based on translation): 1st stroke < 8 weeks; Brunnstrom recovery stages 1 ‐ 4

Exclusion criteria (information based on translation): previously received treatment/rehabilitation; mAS > 3; pain in the paretic side; cognitive impairments; vision impairments/neglect

Interventions

2 arms

1 and 2: conventional rehabilitation programme

1. Additional MT: wrist extension of non‐paretic upper extremity

2. No additional therapy

1 and 2: 4 weeks, 5 days a week, daily 1 ‐ 2 hours

1: additional 15 minutes , 4 times daily MT

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy:

1. BRS

2. FM‐UE

3. BI

4. Goniometric measurement of wrist extension

Notes

Information based on an abstract; partly translated; not possible to contact author

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by envelope method
Comment: information based on translation

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated (no dropouts)
Comment: information based on translation

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded
Comment: information based on translation

Methods

RCT

Participants

Country: Republic of Korea

Setting: inpatient rehabilitation centre

Age: adults (mean age: 57.1 years)

Sample size: 28 (14 in each group; 2 dropped out)

Sex: 11 women, 15 men

Inclusion criteria: stroke within last 6 months, able to understand and follow the instructions (MMSE > 21), Brunnstrom recovery stages upper limb 1 ‐ 4

Exclusion criteria: orthopaedic disorders, apraxia, hemineglect, upper‐limb fracture, peripheral nerve injury, participation in other studies or rehabilitation programmes, participation rate < 80%

Interventions

2 arms

1 and 2: usual rehabilitation programme

1. MT: participants were instructed to observe their unaffected upper limb in mirror box while performing movements of the unaffected limb, performed by participants themselves under supervision of a guardian

2. No additional therapy

1 and 2: 75 minutes, 5 times/week

1: 1st 4 weeks, 5 days/week, 25 minutes twice a day MT

Date of intervention: not stated

Outcomes

Outcomes were recorded and reported at baseline and after 1 day after therapy period

1. FM‐UE (0 ‐ 66 points)

2. Brunnstrom recovery stages

3. MFT (0 ‐ 32 points)

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random sequence

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts were not analysed

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Republic of Korea

Setting: rehabilitation hospital

Age: adults (mean age: 54.7 years)

Sample size: 30 participants (15 in experimental group (1 dropped out), 15 in control group (2 dropped out))

Sex: 13 women, 14 men

Inclusion criteria: stroke diagnosed by a neurologist using computed tomography or magnetic resonance imaging, hemiplegia for > 6 months after stroke onset, active ankle dorsiflexion ROM > 10 °, ability to walk > 10 metres independently, MMSE > 21, no visual problems, no adverse effects from NMES, absence of use of any medication that could affect balance or gait

Exclusion criteria: uncontrolled blood pressure or angina, history of seizure, pacemaker use, musculoskeletal problems of the lower extremity, any intervention other than conventional therapy

Interventions

2 arms

1 and 2: conventional physiotherapy

1. MT + NMES: NMES electrodes placed on common peroneal nerve to stimulate eversion and dorsiflexion of the affected ankle, an external switch placed on forefoot of less affected side, if switch was released electrical stimulation started, participants dorsiflexed both ankles independently while observing the mirror

2. No additional therapy

1 and 2: 4 weeks, 5 days a week, 1 hour a day

1: additional 4 weeks, 5 days a week MT

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and 1 day after therapy period

1. Muscle strength of the lower extremity (handheld dynamometer)

2. Modified AS

3. BBS

4. TUG

5. 6‐metre walk test

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by random number tables

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

High risk

No ITT analysis

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

2 assessors were blinded to group allocation

Methods

RCT

Participants

Country: Republic of Korea

Setting: inpatient rehablitation centre

Age: adults (mean age: 64.9 years)

Sample size: 60 (30 in each group, no dropouts)

Sex: 21 women, 39 men

Inclusion criteria: hemiplegia due to stroke within 6 months, Korean version of MMSE > 24, BRS upper extremity of 3 to 4

Exclusion criteria: musculoskeletal disease, neglect, mental illness

Interventions

2 arms

1. MT: bilateral task‐oriented MT, during 1st week simple movements, such as forearm pronation‐supination and wrist flexion/extension; in the 2nd week finger flexion‐extension, counting numbers, tapping, and opposing; during 3rd week, simple manipulating tasks, such as picking up coins and beans, flipping over cards and collecting blocks in a bin; during 4th week, more complicated tasks of plugging and unplugging pegboards, drawing simple figures, and colouring

2. Sham therapy: task‐oriented bilateral arm training as stated, but with non‐reflecting board between limbs

1 and 2: 4 weeks, 5 days a week, 20 minutes/day MT or sham therapy

Date of intervention: February to May 2012

Outcomes

Outcomes were recorded at baseline and after therapy period

1. FMA‐UE

2. BRS

3. MBI

Notes

Funding source: not stated

Declarations of trialists’ interests: there are no conflicts of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random‐number sequence

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated (no dropouts)

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Taiwan

Setting: inpatient and outpatient

Age: adults (mean age: 55 years)

Sample size: 43 participants (14 in experimental group 1, 14 in experimental group 2, 15 in control group, 1 dropout)

Sex: 11 women, 32 men

Inclusion criteria: ischaemic or haemorrhagic stroke of at least 6 months duration, Brunnstrom stage 3 or above in the arm

Exclusion criteria: severe spasticity in any joints of the affected arm (modified AS ≤ 2), serious cognitive deficits (MMSE score > 24), serious vision or visual perception deficits (score of 0 on the best gaze and visual subtest of the National Institutes of Health Stroke Scale), history of other neurologic, neuromuscular, or orthopaedic disease, participation in other studies concurrent with this study

Interventions

3 arms

1. MT while using a mesh‐glove for sensory stimulation

2. MT: 10 minutes warm‐up, 1 hour mirror‐box training (bilateral movement (transitive and intransitive gross motor tasks)), 20 minutes functional task practice

3. Task‐oriented treatment

1, 2, and 3: 4 weeks, 5 days a week, 1½ hours daily

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after therapy

1. FM‐UE

2. myotonometric measurements for muscle tone

3. BBT

4. 10‐minute walk test

5. MAL

6. ABILHAND

7. motor control using video‐based analysis

8. VAS of adverse effects (pain, fatigue)

Notes

Funding source: National Health Research Institutes, National Science Council, Healthy Ageing Research Center at Chang Gung University, Taiwan

Declarations of trialists’ interests: there are no conflicts of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned , stratified into 4 strata according to the side of lesion and the level of motor impairment

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts not analysed

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: USA

Setting: home

Age: adults (age not stated)

Sample size: 10 participants

Sex: not stated

Inclusion criteria: 6 months or more post‐cerebrovascular accident

Exclusion criteria: not stated

Interventions

2 arms

1. MT: home exercise programme with a mirror exercise unit

2. Control group: same programme with a plexiglass exercise unit

1 and 2: 4 weeks

Date of intervention: not stated

Outcomes

Outcomes were recorded at pretreatment, mid‐treatment, post‐treatment and after 3 months

1. WMFT

Notes

Abstract data only; not included in the analysis due to insufficient data

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Ability‐matched pairs were created and randomly assigned to groups

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Australia

Setting: inpatient rehabilitation unit

Age: adults (mean age: 68.7 years)

Sample size: 15 participants (5 in experimental group, 10 in 2 control groups, no dropouts)

Sex: 8 women, 7 men

Inclusion criteria: first‐ever neurological injury < 8 weeks, affected dorsiflexion strength of < Grade 3, ambulatory prior to admission

Exclusion criteria: impaired cognition (MoCA < 21), peripheral neuropathy, impaired ROM of the intact lower limb, medically unfit for rehabilitation

Interventions

3 arms

1, 2 and 3: individual physiotherapy sessions

1. MT: alternate ankle dorsiflexion and plantarflexion of both ankles as best they could while looking into the mirror

2. Sham therapy: same as MT but with non‐reflecting side of the mirror

1, 2 and 3: 3 weeks, 5 days a week, 45 minutes a day individual physiotherapy

1 and 2: 15 minutes MT or sham therapy during the individual physiotherapy session

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline, after 3 weeks of therapy, and 6 weeks after the intervention

1. Muscle strength

2. MAS Item 5 (Mobility)

3. Dynamic balance

4. Spasticity

5. Sensation

6. Oedema

Notes

Based on unpublished information, only stroke patients included

Funding source: National Stroke Foundation, Australia

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random numbers

Allocation concealment (selection bias)

Low risk

Concealed allocation by independent person

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All data collected, reported and analysed as allocated

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Netherlands

Setting: home

Age: adults (mean age: 57 years)

Sample size: 40 participants (20 in each group,; 4 dropped out during intervention period, 4 more dropped out after 6 months)

Sex: 20 women, 20 men

Inclusion criteria: knowledge of Dutch language, Brunnstrom score upper extremity between 3 and 5; home dwelling status; at least 1 year post‐stroke

Exclusion criteria: neglect; comorbidities that influenced upper extremity usage; history of multiple strokes

Interventions

2 arms

1. MT: participants were instructed to move both arms while looking in the mirror (moving arm covered)

2. Bilateral arm training: participants performed the same treatment protocol as in group 1, but without a mirror

1 and 2: once a week physiotherapeutic supervision for 60 minutes; 5 times a week, 60 minutes of practice at home for 6 weeks

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline, post‐treatment and after 6 months

1. FM‐UE motor score (0 to 66)

2. Pain (VAS 0 to 100 mm)

3. Grip force (in kg)

4. TS elbow and wrist

5. ARAT (0 to 57)

6. ABILHAND questionnaire (self‐perceived arm use)

7. Stroke‐ULAM; accelerometric measurement of arm movements during 24 hours

8. EuroQol (quality of life, EQ‐5D)

Notes

Published and unpublished data

Funding source: Fonds NutsOhra [SNO‐T‐0602‐23]; Innovatiefonds Zorgverzekeraars [06‐262]; Wetenschappelijk College Fysiotherapie [WU/2007/07] and Hersenstichting Nederland [15F07.54]

Declarations of trialists’ interests: there are no conflicts of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random‐number sequence

Allocation concealment (selection bias)

Low risk

Participants received group allocation after baseline measurement

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Results were analysed on an ITT basis (multiple imputation)

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Romania

Setting: inpatient

Age: adults (mean age: 57.5 years)

Sample size: 15 participants (7 in experimental group, 8 in control group, no dropouts published)

Sex: 8 women, 7 men

Inclusion criteria: hemiplegia following a 1st stroke (documented by CT scan), time from stroke between 1 to 3 months, without severe attention deficit

Exclusion criteria: global aphasia and cognitive impairments that might interfere with understanding instructions for testing, concomitant progressive central or peripheral nervous system disorders

Interventions

2 arms

1 and 2: conventional stroke rehabilitation programme (neuro‐rehabilitation technique, electrical stimulation and occupational therapy)

1. MT: bilateral (as good as possible) upper limb movements (flexion and extension of the shoulder, elbow, wrist and finger, pronation and supination of the forearm) under physiotherapeutic supervision

2. No additional therapy

1 and 2: 6 weeks, 5 times a week, 30 minutes a session conventional stroke rehabilitation programme

1: additional 30 minutes of MT

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and 1 day after therapy

1. BRS

2. FM‐UE

3. AS

4. Bhakta test for assessment of finger flexion degree

Notes

Funding source: not financed

Declarations of trialists’ interests: there are no conflicts of interest

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Participants were randomly assigned (authors' statement)

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: India

Setting: inpatient rehabilitation centre

Age: adults (mean age: 63 years)

Sample size: 22 participants (11 in each group, no dropouts published)

Sex: 10 women, 12 men

Inclusion criteria: 1st episode of unilateral stroke with hemiparesis (onset ≤ 2 weeks), able to understand and follow simple verbal instructions, Brunnstrom recovery stage 2 and above, no severe cognitive disorders that would interfere with the study’s purpose (MMSE score > 23), stable medical condition to allow participation in the study, ambulatory before stroke

Exclusion criteria: neglect, Pusher syndrome, visual deficits, and history of multiple stroke, or comorbidities that influenced lower extremity usage

Interventions

2 arms

1 and 2: conventional stroke rehabilitation programme: neurodevelopmental facilitation techniques, sensory motor re‐education, active exercises, mobility training, balance, and gait training

1. Additional MT: unaffected lower limb movements (hip‐knee‐ankle flexion, with the hip and knee placed in flexion, moving the knee inward and outward, hip abduction with external rotation followed by hip adduction with internal rotation, hip‐knee‐ankle flexion, knee extension with ankle dorsiflexion, knee flexion beyond 90 ° (each exercise was performed in 2 sets of 10 repetitions)

2. Additional sham therapy: using non‐reflecting surface of the mirror

1 and 2: 2 weeks, 6 days a week, 60 minutes a day and additional 30 minutes of MT or sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 2 weeks of therapy

1. FM‐LE (0 ‐ 34)

2. Brunnel Balance Assessment

3. FAC (0 ‐ 5)

4. BRS‐LE

5. MCSI (0 ‐ 4)

6. adverse events

Notes

Funding source: not financed (according to authors)

Declarations of trialists’ interests: there are no conflicts of interest (according to authors)

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned (authors' statement) by block randomisation

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All participants analysed as intended

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

Randomised cross‐over trial

Participants

Country: France

Setting: not stated

Age: adults (mean age: 53.5 years)

Sample size: 8 participants (4 in each group, 2 dropouts)

Sex: 4 women, 4 men

Inclusion criteria: neglect (according to Negligence Evaluation Battery) secondary to a unilateral stroke of the right hemisphere

Exclusion criteria: other concomitant cerebral injuries, Illetrism or cognitive dysfunction altering comprehension

Interventions

2 arms

1. MT: sequence of analytical movements with right upper limb while looking to the image in the mirror

2. Sham therapy: the image of the right arm was replaced by landscape images, participants were asked to describe the images in the mirror, no movement

1 and 2: 5 days a week, 30 minutes a day;

1: MT for 5 consecutive days, 1 session a day, after 10 days sham therapy for 5 consecutive days;

2: same protocol as group 1, but participants received sham therapy before MT

Date of intervention: not stated

Outcomes

Outcomes were recorded before and after each session

1. LBT

2. Cancellation task (Mesulam Test)

Notes

Based on unpublished information

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by randomised‐number sequence

Allocation concealment (selection bias)

Low risk

Concealed allocation by drawing lots

Incomplete outcome data (attrition bias)
All outcomes

High risk

No ITT analysis was performed

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessor was blinded to group allocation

Methods

RCT

Participants

Country: India

Seting: hospital

Age: adults (mean age: 44.9 years)

Sample size: 60 participants (40 in 2 experimental groups, 20 in control group, 1 dropout)

Sex: 20 women, 40 men

Inclusion criteria: unilateral hemiplegic stroke, between 6 weeks and 6 months post‐stroke, ischaemic stroke, age 18 to 60 years, both men and women, BRS 2 ‐ 5, modified AS ≥ 1, voluntary extension of wrist and fingers of at least 10 ° from the resting position

Exclusion criteria: > 60 years of age, BRS 1 or 6, wrist and/or finger contracture, cardiac pacemaker or other metal implants, significant visual, auditory and cognitive impairment

Interventions

3 arms

1, 2 and 3: conventional therapy

1. Task‐oriented MT: bilateral active wrist extension and fingers extension in mid‐prone and pronated forearm, task‐specific grasping and releasing of a bottle while looking to the image of the unaffected hand in the mirror

2. FES: electrodes placed on wrist extensors of the affected upper limb, participants were instructed to look into the opaque side of the mirror while the stimulation was given and was asked to perform the following exercises synchronously with the duty cycle of the stimulation, parameters of stimulation: frequency 35 Hz, pulse width 250 μs, symmetrical biphasic waveform, duty cycle of 5 secs on and 5 secs off, amplitude adjusted to maximal tolerance of the participant up to 90 mA

3. Task‐oriented MT plus FES: participants were instructed to observe the mirror reflection and asked to perform simultaneous bilateral movements with the affected limb performing synchronously with the duty cycle of electrical stimulation

1, 2 and 3: 2 weeks, 6 days a week, 30 minutes daily MT, MT + FES, or FES

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 2 weeks of therapy

1. ARAT

Notes

Based on published information

Funding source: not stated

Declarations of trialists’ interests: none

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by cards composed of odd and even numbers

Allocation concealment (selection bias)

Low risk

Concealed allocation by sealed envelopes

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All data were collected and analysed as allocated

Blinding of outcome assessment (detection bias)
primary outcome

High risk

Assessors were not blinded to group allocation

Methods

RCT

Participants

Country: India

Setting: inpatient rehabilitation centre and home training after discharge

Age: adults (mean age: 63.4 years)

Sample size: 48 participants (27 in experimental group, 21 in control group, 2 dropouts)

Sex: 20 women, 28 men

Inclusion criteria: stroke patients with thalamic and parietal lobe lesions within 48 hours of stroke onset who had upper limb weakness, provided informed consent

Exclusion criteria: Glasgow Coma Scale score < 7, unco‐operative patients

Interventions

2 arms

1 and 2: home programme

1. Additional MT: bilateral flexion and extension of wrist and fingers, active or assistive limb activation (tapping the affected hand or fingers on a plain surface and goal‐oriented activities (combing, tying turban (for men), wearing garments, picking up objects and placing them on the table, pouring and drinking from a cup)

2. Additional sham therapy: using non‐reflecting surface of the mirror and active or assistive limb activation

1: 4 weeks, 5 days a week, 1 hour a day MT and 1 hour limb activation

2: 4 weeks, 5 days a week, 1 hour a day sham therapy and 1 hour limb activation

Date of intervention: January 2011 to August 2013

Outcomes

Outcomes were recorded at baseline and at 1, 3 and 6 months

1. SCT

2. LBT

3. FIM

4. mRS

5. Picture identification task (PIT)

Notes

Published and unpublished information

Funding source: Christian Medical College, Department of Neurology, India, Intramural research fund

Declarations of trialists’ interests: there are no conflicts of interest to the manuscript; full disclosures at http://n.neurology.org/content/83/11/1012/tab‐article‐info

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by computer‐generated random sequence

Allocation concealment (selection bias)

Low risk

Concealed allocation by sealed numbered envelopes

Incomplete outcome data (attrition bias)
All outcomes

Low risk

ITT analysis performed ('last observation carried forward' method)

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Republic of Korea

Setting: inpatient

Age: adults (mean age: 56.3 years)

Sample size: 30 participants (15 in each group)

Sex: 13 women, 17 men

Inclusion criteria: diagnosis of hemiplegia due to stroke of at least a 6‐month duration, scores of ≥ 24 points on the MMSE‐Korean (MMSE‐K; no difficulty with cognitive functions), Brunnstrom’s upper extremity stage IV, no difficulties with perceptual abilities including hemineglect based on the MVPT, voluntary consent to participate in the study

Exclusion criteria: not stated

Interventions

2 arms

1 and 2: conventional occupational therapy

1. Additional MT: movements of the non‐paretic side

2. Additional sham therapy: participants performed the same exercises as the MT group while watching the non‐reflecting surface of the mirror

1 and 2: 4 weeks, 5 days a week, 30 minutes MT or sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after therapy

1. FM‐UE

2. BBT

3. FIM

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by random card selection

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: South Korea

Setting: rehabilitation unit

Age: adults (mean age: 60 years)

Sample size: 30 participants (15 in experimental group, 15 in control group, no dropouts published)

Sex: 15 women, 15 men

Inclusion criteria: stroke > 3 months identifiable by CT or MRI, no cognitive dysfunction that would interfere with the study purpose as indicated by a MMSE‐K > 24, no perceptual disorder or unilateral neglect that would have interfered with the study purpose as indicated by the MVPT, Brunnstrom score between stages I – IV for the UE

Exclusion criteria: aphasia, vision or hearing disorders, or had had MT previously

Interventions

2 arms

1. Task‐oriented mirror therapy: unilateral, performed 8 different tasks, e.g. lift/grasp a cup, reach to grasp a cone

2. Sham therapy (covered mirror): same 8 tasks

1 and 2: 6 weeks, 5 days a week task‐oriented MT or sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and immediately after treatment and 1 month after treatment

1. MFT

2. FIM

Notes

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Participants were randomly assigned

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: Thailand

Setting: inpatient rehabilitation centre

Age: adults (mean age: 56 years)

Sample Size: 47 participants (20 in each group; 7 dropped out)

Sex: 19 women, 21 men

Inclusion criteria: 1st stroke hemiparesis onset more than 3 months, age > 18 years, able to follow 2‐step command, upper extremity Brunnstrom stage between 1 and 4, able to sit with or without support more than 30 minutes, cognitive function evaluated by MMSE ≥ 24, no previous disease of the hemiparetic side
Exclusion criteria: unstable medical conditions, sensory or global aphasia, severe spasticity (mAS > 3), neglect of the hemiparetic side

Interventions

2 arms

1. MT: MT with task‐oriented activity consisted of grasping and releasing the tennis balls, pins and cylindrical shape

2. Sham therapy: same tasks without mirror (use the other side of the mirror box)

1 and 2: 30 minutes/session, 10 sessions

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and at the end of 2 weeks, 4 weeks and 12 weeks

1. Brunnstorm stage of recovery

2. MAS upper extremity

3. Modified AS

4. Tip and lateral pinch gauges

Notes

Published and unpublished data

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned by blocked randomisation, computer‐generated random sequence

Allocation concealment (selection bias)

Low risk

Central randomisation by a third party

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts not analysed

Blinding of outcome assessment (detection bias)
primary outcome

Low risk

Assessors were blinded to group allocation

Methods

RCT

Participants

Country: Malaysia

Setting: nursing homes

Age: adults (mean age: 58 years)

Sample size: 30 participants (15 in each group: 1 dropped out from the experimental group)

Sex: 9 women, 21 men

Inclusion criteria: men and women, age 50 to 70 years, 1st episode of unilateral stroke with hemiparesis, 2 to 12 months post‐stroke, diagnosis of stroke with involvement of middle cerebral artery on MRI or CT scan by neurologist

Exclusion criteria: MMSE < 24, uncontrolled systemic hypertension, perceptual or apraxic deficits, visual deficit such as homonymous hemianopia, reflex sympathetic dystrophy, severe shoulder subluxation, contracture in the affected upper limb and botox injection within past 6 months to the affected upper limb

Interventions

2 arms

1 and 2: conventional rehabilitation programme

1. MT: bilateral finger flexion, extension, abduction, adduction; wrist flexion, extension, ulnar deviation and radial deviation; task‐specific movements such as power and prehension grip using different size and weighted objects while looking into the mirror

2. Sham therapy: same tasks as MT but using the non‐reflecting side of the mirror

1 and 2: 4 weeks, 5 days a week, 1 hour a day conventional rehabilitation programme

1 and 2: additional 30 minutes a day MT or sham therapy

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy

1. FM‐UE

2. UEFI

Notes

Information based on unpublished data

Funding source: not stated

Declarations of trialists’ interests: not stated

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Participants were randomly assigned (authors' statement)

Allocation concealment (selection bias)

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

High risk

Dropouts were not included in the analysis

Blinding of outcome assessment (detection bias)
primary outcome

Unclear risk

Not stated

Methods

RCT

Participants

Country: India

Setting: outpatient

Age: adults (mean age: 54.8/57.9 years)

Sample size: 20 participants (6 in experimental group, 6 in control group, 8 dropped out)

Sex: not stated

Inclusion criteria: age 45 to 65 years, 1st episode of ischaemic and haemorrhagic stroke, stroke between 1 to 6 months, men and women, MMSE > 23, BRS 4 and 5

Exclusion criteria: any musculoskeletal disorders, neurological disorder other than stroke, visual impairment, systemic disease, non‐cooperative patients, psychological problems

Interventions

2 arms

1 and 2: conventional therapy

1. MT: bilateral intransitive exercises such as hand opening, wrist extension and flexion, forearm pronation and supination, hand sliding on a flat surface while looking into the mirror

2. MRP: Motor relearning programme exercises for training of wrist extensors, extension of wrist and holding objects, training of supination of forearm, opposition of thumb, cupping of hand and training of manipulation of the objects

1 and 2: 4 weeks, 6 days a week, 30 minutes a day conventional therapy

1 and 2: additional 30 minutes a day MT or MRP

Date of intervention: not stated

Outcomes

Outcomes were recorded at baseline and after 4 weeks of therapy

1. CAHAI

Notes

Information based on unpublished data

Funding source: not stated

Declarations of trialists’ interests: none

Risk of bias

Bias