Combination treatment of immersive and non-immersive virtual reality and mirror therapy for the stroke patients: a systematic review and meta-analysis of randomized controlled trials (Preprint)

Stroke frequently leads to various functional impairments. Both virtual reality (VR) and mirror therapy (MT) have shown efficacy in stroke rehabilitation. In recent years, the combination of these 2 approaches has emerged as a potential treatment for patients with stroke. This study aimed to evaluate the efficacy of combined immersive and nonimmersive VR with MT in stroke rehabilitation. Five electronic databases were systematically searched for relevant papers published up to January 2025. Randomized controlled trials (RCTs) that investigated the combination treatment of VR and MT for patients with stroke were included. A gray literature search was also conducted. The risk of bias and the certainty of the evidence were assessed using the Cochrane Collaboration's tool and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. A total of 475 patients from 14 RCTs were included, of which 7 were eligible for meta-analysis. Meta-analysis revealed significant improvements in upper extremity (UE) motor function and hand dexterity, as evidenced by the Fugl-Meyer Assessment-Upper Extremity (FMA-UE; mean difference, MD 3.50, 95% CI 1.47 to 5.53; P=.<001), the manual function test (MD 2.15, 95% CI 1.22 to 3.09; P<.001), and the Box and Block Test (MD 1.09, 95% CI 0.14 to 2.05; P=.03). Subgroup analyses based on disease duration (>6 months or not) revealed significant differences in the FMA-UE outcome. However, the pooled FMA-UE improvement did not consistently exceed the established minimal clinically important difference (4.25-7.25), indicating that while statistically significant, the clinical significance of the observed effect remains uncertain. Narrative evidence also suggested potential benefits for lower extremity function, dynamic balance, and quality of life, though these findings were not meta-analyzed and should be interpreted with caution. Moderate-quality evidence supports combined VR and MT as a promising nonpharmacological intervention to improve upper extremity function and hand dexterity in stroke rehabilitation. While the intervention demonstrates statistically significant effects, it does not reach the minimum clinically important difference for the FMA-UE outcome. Preliminary descriptive evidence indicates possible advantages for lower extremity function, balance, and quality of life.