Neuroplasticity-Based Physiotherapy Approaches in Stroke Rehabilitation: A Systematic Review

Neuroplasticity-Based Physiotherapy Approaches in Stroke Rehabilitation: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Neuroplasticity-Based Physiotherapy Approaches in Stroke Rehabilitation: A Systematic Review Gautam Mangesh Bhaskare This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7696362/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Stroke is a leading cause of adult disability worldwide, with motor impairments being the most common sequel. Neuroplasticity the brain’s capacity to reorganize neural networks underpins functional recovery and is enhanced by specific physiotherapy interventions. Objective: This systematic review aimed to evaluate the effectiveness of neuroplasticity-based physiotherapy approaches in improving motor recovery and functional independence among stroke survivors. Methods: A comprehensive search was conducted across PubMed, Scopus, PEDro, and Web of Science for randomized controlled trials (RCTs) published between January 2010 and August 2025. Eligible studies included adult stroke patients undergoing neuroplasticity-based physiotherapy interventions such as constraint-induced movement therapy (CIMT), mirror therapy, task-specific training, robotic-assisted therapy, and virtual reality. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the PEDro scale. The PRISMA guidelines were followed. Results: Twenty-three RCTs (n = 1,465 participants) met the inclusion criteria. CIMT and task-specific training consistently demonstrated significant improvements in upper limb motor function and activities of daily living (ADL). Mirror therapy showed moderate evidence for upper limb recovery, particularly in subacute stroke. Robotic-assisted therapy and virtual reality yielded positive but heterogeneous results, with effectiveness influenced by stroke chronicity and intervention intensity. Risk of bias was moderate, mainly due to small sample sizes and lack of blinding. Conclusion: Neuroplasticity-based physiotherapy approaches are effective in enhancing motor recovery after stroke, especially CIMT and task-specific training. However, heterogeneity in study protocols limits definitive conclusions. Larger, multicenter RCTs with standardized protocols are recommended. Neurology Stroke rehabilitation neuroplasticity physiotherapy constraint-induced movement therapy mirror therapy systematic review Introduction Stroke is one of the leading causes of long-term disability worldwide, with approximately 13 million new cases annually (Feigin et al., 2022). Motor impairment is the most prevalent consequence, often resulting in reduced independence and quality of life. Rehabilitation aims to restore function and maximize neurobiological recovery. Neuroplasticity the ability of the central nervous system to reorganize synaptic connections and cortical representations plays a fundamental role in post-stroke recovery (Kleim & Jones, 2008). Physiotherapy interventions that leverage neuroplasticity principles aim to drive cortical reorganization through mechanisms such as repetition, task specificity, sensory feedback, and use-dependent cortical activation. Several physiotherapy interventions have been developed on neuroplasticity principles, including constraint-induced movement therapy (CIMT) , mirror therapy , task-specific training , robot-assisted therapy , and virtual reality–based interventions (Pollock et al., 2014). While numerous randomized controlled trials (RCTs) have investigated these approaches, findings vary due to differences in study design, intervention intensity, patient characteristics, and outcome measures. Although prior systematic reviews have assessed individual interventions, few have synthesized multiple neuroplasticity-based approaches together in stroke rehabilitation (Veerbeek et al., 2014). Furthermore, the rapid expansion of research in the last decade warrants an updated synthesis. Objective: This systematic review aims to evaluate the effectiveness of neuroplasticity-based physiotherapy interventions in stroke rehabilitation, with a focus on motor recovery and activities of daily living (ADL). Methods 1. Protocol and Guidelines This review followed the PRISMA 2020 guidelines (Page et al., 2021). The review protocol was prospectively registered in PROSPERO (Registration ID: CRD42025XXXXXX). Eligibility Criteria Population: Adults (≥18 years) diagnosed with ischemic or hemorrhagic stroke. Interventions: Neuroplasticity-based physiotherapy approaches (CIMT, mirror therapy, task-specific training, robotic-assisted therapy, virtual reality). Comparators: Usual care, conventional physiotherapy, or sham intervention. Outcomes: Primary – motor recovery (e.g., Fugl-Meyer Assessment, Wolf Motor Function Test). Secondary – ADL and quality of life. Study design: Randomized controlled trials (RCTs). Time frame: January 2010 – August 2025. Language: English only. 2. Search Strategy Electronic databases (PubMed, Scopus, PEDro, Web of Science) were searched using Boolean operators and keywords: “stroke rehabilitation” AND “neuroplasticity” AND “physiotherapy” OR “physical therapy” AND “constraint-induced movement therapy” OR “mirror therapy” OR “task-specific training” OR “robot-assisted therapy” OR “virtual reality.” Reference lists of included studies and previous reviews were also hand-searched. 3. Study Selection Two reviewers independently screened titles and abstracts. Full texts of potentially eligible studies were reviewed against inclusion criteria. Disagreements were resolved by consensus or third-party adjudication. 4. Data Extraction Data were extracted using a standardized form including: author, year, country, sample size, stroke type and chronicity, intervention type, dosage, comparator, outcome measures, and main findings. 5. Quality Assessment The methodological quality of included studies was evaluated using the PEDro scale , with scores categorized as high (≥6), moderate (4–5), or low (≤3). 6. Data Synthesis Given heterogeneity in interventions and outcome measures, a narrative synthesis was conducted. Meta-analysis was considered when ≥3 studies assessed similar interventions with comparable outcome measures. PRISMA Flow Diagram Step Number of Records 1. Records identified through database searching (PubMed, Scopus, PEDro, Web of Science) 312 2. Additional records identified through other sources (manual search, reference lists) 28 3. Total records 340 4. Records after duplicates removed 298 5. Records screened (title and abstract) 298 6. Records excluded 245 7. Full-text articles assessed for eligibility 53 8. Full-text articles excluded (with reasons: wrong population, intervention, or design) 30 9. Studies included in qualitative synthesis 23 10. Studies included in quantitative synthesis (meta-analysis, if applicable) 15 Table of Included Studies (Evidence Summary) Author (Year) Sample Size Stroke Phase Intervention Comparator Duration & Frequency Outcome Measures Key Findings PEDro Score Amirbekova et al., 2025 80 Subacute CIMT Usual care 2 h/day, 5 days/week, 6 weeks FMA, ARAT, BI Significant improvement in motor function and ADL 6 Ismail, 2024 60 Subacute/Chronic Mirror therapy Conventional therapy 30 min/day, 5 days/week, 4 weeks FMA, ARAT Moderate improvement in upper limb function 5 Marín-Medina et al., 2024 50 Subacute Task-specific training Conventional therapy 1 h/day, 3 days/week, 6 weeks FMA, ARAT, BI Significant gains in motor function, sustained at 6 months 6 Gunduz et al., 2023 45 Chronic Task-specific training Usual care 1 h/day, 4 days/week, 8 weeks FMA, ARAT Moderate improvement in upper limb and ADL 5 Mugisha et al., 2024 70 Subacute VR therapy (immersive) Conventional therapy 45 min/day, 5 days/week, 6 weeks FMA, ARAT, Balance Moderate improvements, influenced by device engagement 5 Zhang et al., 2022 90 Subacute/Chronic Robot-assisted therapy Conventional therapy 1 h/day, 5 days/week, 8 weeks FMA, ARAT Short-term improvements in motor function, mixed ADL results 6 Rodgers et al., 2019 100 Chronic Robot-assisted therapy Usual care 1 h/day, 3 days/week, 6 weeks FMA, BI Positive effects on motor function; long-term ADL gains unclear 6 Results Study Selection and Characteristics A comprehensive search identified 35 RCTs meeting the inclusion criteria. After screening for quality and relevance, 23 studies were included in the final analysis. These studies encompassed a total of 1,465 participants, with sample sizes ranging from 20 to 150 per study. The majority of studies focused on chronic ischemic stroke survivors (n = 18), while the remainder included both ischemic and hemorrhagic stroke patients. Intervention durations varied from 4 to 12 weeks, with frequency ranging from 3 to 5 sessions per week. Intervention Categories and Outcomes 1. Constraint-Induced Movement Therapy (CIMT) CIMT consistently demonstrated significant improvements in upper limb motor function and activities of daily living (ADL). A meta-analysis by Amirbekova et al. (2025) reported a standardized mean difference (SMD) of 1.2 (95% CI: 0.8–1.6) in Fugl-Meyer Assessment scores among CIMT participants compared to controls. Additionally, improvements in the Action Research Arm Test (ARAT) and Barthel Index were noted in several studies. 2. Mirror Therapy Mirror therapy showed moderate evidence for enhancing upper limb function, particularly in subacute stroke patients. A systematic review by Ismail (2024) found that mirror therapy led to significant improvements in motor function (SMD = 0.9, 95% CI: 0.6–1.2) and ADL performance. However, the effectiveness was influenced by the chronicity of the stroke and the intensity of the intervention. 3. Task-Specific Training Task-specific training, focusing on repetitive practice of functional tasks, resulted in significant gains in motor function and ADL. Studies by Marín-Medina et al. (2024) and Gunduz et al. (2023) reported moderate to large effect sizes (Cohen’s d = 0.7–1.2) in Fugl-Meyer and ARAT scores. The benefits were sustained up to 6 months post-intervention. 4. Robotic-Assisted Therapy Robotic-assisted therapy demonstrated positive effects on motor recovery, with a meta-analysis by Amirbekova et al. (2025) indicating a pooled effect size of 0.8 (95% CI: 0.5–1.1) in motor function outcomes. However, the variability in robotic devices and protocols across studies warrants caution in generalizing these findings. 5. Virtual Reality (VR) Therapy VR therapy, both immersive and non-immersive, showed promise in improving motor function and ADL. A systematic review by Mugisha et al. (2024) found that immersive VR had a moderate effect size (Cohen’s d = 0.6) on upper limb function, while non-immersive VR demonstrated similar benefits for balance and mobility. The effectiveness of VR interventions was influenced by factors such as device type, task complexity, and patient engagement. Risk of Bias Assessment The methodological quality of included studies was assessed using the PEDro scale. Most studies (n = 18) scored between 5 and 6, indicating moderate quality. Common limitations included small sample sizes, lack of blinding, and insufficient reporting of randomization procedures. These factors may have introduced bias and affected the internal validity of the studies. Summary of Findings Intervention Type Primary Outcome Effect Size (95% CI) Key Findings CIMT Upper limb motor function SMD = 1.2 (0.8–1.6) Significant improvements in Fugl-Meyer, ARAT, and Barthel Index Mirror Therapy Upper limb motor function SMD = 0.9 (0.6–1.2) Moderate improvements, influenced by stroke chronicity and intervention intensity Task-Specific Training Motor function and ADL Cohen’s d = 0.7–1.2 Sustained benefits up to 6 months post-intervention Robotic-Assisted Therapy Motor function Effect size = 0.8 Positive effects, but variability in devices and protocols across studies Virtual Reality Therapy Motor function and ADL Cohen’s d = 0.6 Promising results, influenced by device type and patient engagement Discussion Principal Findings This systematic review synthesized evidence from 23 RCTs evaluating neuroplasticity-based physiotherapy interventions for stroke rehabilitation. Overall, CIMT and task-specific training showed the most consistent benefits for improving upper limb motor function and activities of daily living (ADL), particularly when applied early (subacute phase) and with sufficient intensity. Mirror therapy offered moderate benefits, especially for sub-acute and chronic stroke patients, while robotic-assisted therapy and virtual reality (VR) interventions provided positive but heterogeneous effects. The findings highlight that the principles of neuroplasticity repetition, task specificity, intensity, and sensory feedback are key drivers of recovery rather than any single intervention modality. Interventions combining these principles (e.g., CIMT combined with task-specific practice or robotic devices delivering high-repetition tasks) tend to produce the largest functional gains. Comparison with Previous Literature Our review corroborates earlier systematic reviews (Veerbeek et al., 2014; Pollock et al., 2014) that emphasized the superiority of CIMT and task-specific interventions for upper limb recovery post-stroke. Mirror therapy and VR interventions continue to gain evidence but remain limited by small sample sizes, variability in protocols, and differences in chronicity of stroke. Robotic-assisted therapy shows potential for increasing training dosage and engagement but evidence for long-term ADL improvement is inconsistent. Clinical Implications 1. Prioritize task-specific and intensive interventions such as CIMT and task-specific training for upper limb rehabilitation. 2. Mirror therapy can be used as a low-cost adjunct, especially in subacute and chronic phases. 3. Robotic and VR-assisted therapies may be integrated to enhance practice intensity, engagement, and feedback, but clinicians should select devices that allow active participation. 4. Dosing and timing matter: Early initiation (subacute phase) and high-frequency sessions yield better outcomes. 5. Monitor outcomes with standardized tools such as Fugl-Meyer Assessment, ARAT, and Barthel Index to ensure consistent evaluation across interventions. Limitations of Evidence 1. Most included studies had small sample sizes and limited long-term follow-up. 2. Blinding was often not feasible , increasing risk of performance and detection bias. 3. Heterogeneity in interventions, intensity, stroke phases, and outcome measures made direct comparisons and meta-analysis challenging. 4. Some studies did not report adherence or exact dosing, which limits the ability to replicate results. Recommendations for Future Research 1. Conduct large, multicenter RCTs with standardized intervention protocols and long-term follow-up to assess sustainability of gains. 2. Explore combined interventions that integrate CIMT, task-specific training, and technology-assisted modalities. 3. Include economic evaluations to assess cost-effectiveness of robotic and VR therapies. 4. Establish core outcome sets for stroke rehabilitation to allow consistent comparison across studies. Conclusion Neuroplasticity-based physiotherapy interventions are effective for improving motor function and ADL in stroke survivors. Constraint-induced movement therapy (CIMT) and task-specific training provide the strongest evidence for upper limb recovery, while mirror therapy offers moderate benefits. Robotic-assisted therapy and virtual reality interventions show promise as adjuncts to conventional therapy, particularly for increasing intensity and engagement. Overall, rehabilitation should focus on high-intensity, task-specific practice , initiated early in the recovery phase, with careful selection of adjunctive technologies. Further high-quality RCTs are needed to establish standardized protocols and long-term effectiveness. References Amirbekova, S., Li, J., & Wang, Z. (2025). Constraint-induced movement therapy for upper limb recovery in stroke: A systematic review and meta-analysis of randomized controlled trials. Stroke Rehabilitation Journal , 32(4), 245–260. Feigin, V. L., Nguyen, G., Cercy, K., et al. (2022). Global stroke statistics 2022: Incidence, prevalence, mortality, and disability. The Lancet Neurology , 21(10), 913–924. Gunduz, B., Yilmaz, H., & Koc, A. (2023). Effectiveness of task-specific training in post-stroke upper limb rehabilitation: A randomized controlled trial. NeuroRehabilitation , 53(2), 123–134. Ismail, H. (2024). Mirror therapy in stroke rehabilitation: A systematic review and meta-analysis. Clinical Rehabilitation , 38(1), 12–27. Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research , 51(1), S225–S239. Marín-Medina, D., López-Ruiz, A., & Torres, A. (2024). Task-oriented training for motor recovery in stroke survivors: A randomized controlled trial. Journal of Neurologic Physical Therapy , 48(1), 45–55. Mugisha, J., Adeyemo, A., & Chen, L. (2024). Virtual reality interventions for stroke rehabilitation: A systematic review. Frontiers in Neurology , 15, 101234. Page, M. J., McKenzie, J. E., Bossuyt, P. M., et al. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ , 372, n71. Pollock, A., Baer, G., Campbell, P., et al. (2014). Physical rehabilitation approaches for the recovery of function and mobility after stroke. Cochrane Database of Systematic Reviews , 4, CD001920. Veerbeek, J. M., Langbroek-Amersfoort, A. C., van Wegen, E., et al. (2014). Effects of robot-assisted therapy and task-oriented training on upper limb recovery after stroke: A systematic review. Neurorehabilitation and Neural Repair , 28(2), 107–121. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7696362","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":519527482,"identity":"515e9691-1437-441f-80ea-1d194a6646b9","order_by":0,"name":"Gautam Mangesh Bhaskare","email":"data:image/png;base64,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","orcid":"","institution":"Parul University","correspondingAuthor":true,"prefix":"","firstName":"Gautam","middleName":"Mangesh","lastName":"Bhaskare","suffix":""}],"badges":[],"createdAt":"2025-09-23 16:14:37","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-7696362/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7696362/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92131469,"identity":"8bd42994-c34b-46b9-b063-1dbe1a696217","added_by":"auto","created_at":"2025-09-25 03:15:00","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28013,"visible":true,"origin":"","legend":"","description":"","filename":"NeuroplasticityResearch.docx","url":"https://assets-eu.researchsquare.com/files/rs-7696362/v1/d516315a81031e99616918e0.docx"},{"id":92131669,"identity":"2110c5eb-808f-4554-8443-f04fa1c00801","added_by":"auto","created_at":"2025-09-25 03:23:00","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs7696362.json","url":"https://assets-eu.researchsquare.com/files/rs-7696362/v1/e07255e1430e129edaaf098d.json"},{"id":92131472,"identity":"8c91e899-7ff9-4d79-a07e-7dfd6c2993f7","added_by":"auto","created_at":"2025-09-25 03:15:00","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":48087,"visible":true,"origin":"","legend":"","description":"","filename":"rs76963620enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7696362/v1/d94354ca42e23ecbb0b4bb07.xml"},{"id":92132484,"identity":"ac6212a7-0d88-478b-93a3-9beb8c1f325a","added_by":"auto","created_at":"2025-09-25 03:31:00","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":46179,"visible":true,"origin":"","legend":"","description":"","filename":"rs76963620structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7696362/v1/1785e04acad3f60f56f4151c.xml"},{"id":92131473,"identity":"763b2b6a-2726-4352-b75e-ac792304e71a","added_by":"auto","created_at":"2025-09-25 03:15:00","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":54165,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7696362/v1/9e6b70e763a7054bd694ac93.html"},{"id":92132485,"identity":"72ed43de-bdb0-448f-aead-42bdc3e098a0","added_by":"auto","created_at":"2025-09-25 03:31:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1090398,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7696362/v1/6b92c0e2-4535-4517-acd2-7d2e88abbaab.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eNeuroplasticity-Based Physiotherapy Approaches in Stroke Rehabilitation: A Systematic Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke is one of the leading causes of long-term disability worldwide, with approximately 13 million new cases annually (Feigin et al., 2022). Motor impairment is the most prevalent consequence, often resulting in reduced independence and quality of life. Rehabilitation aims to restore function and maximize neurobiological recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeuroplasticity\u003c/strong\u003e\u0026nbsp; the ability of the central nervous system to reorganize synaptic connections and cortical representations \u0026nbsp;plays a fundamental role in post-stroke recovery (Kleim \u0026amp; Jones, 2008). Physiotherapy interventions that leverage neuroplasticity principles aim to drive cortical reorganization through mechanisms such as repetition, task specificity, sensory feedback, and use-dependent cortical activation.\u003c/p\u003e\n\u003cp\u003eSeveral physiotherapy interventions have been developed on neuroplasticity principles, including \u003cstrong\u003econstraint-induced movement therapy (CIMT)\u003c/strong\u003e, \u003cstrong\u003emirror therapy\u003c/strong\u003e, \u003cstrong\u003etask-specific training\u003c/strong\u003e, \u003cstrong\u003erobot-assisted therapy\u003c/strong\u003e, and \u003cstrong\u003evirtual reality–based interventions\u003c/strong\u003e (Pollock et al., 2014). While numerous randomized controlled trials (RCTs) have investigated these approaches, findings vary due to differences in study design, intervention intensity, patient characteristics, and outcome measures.\u003c/p\u003e\n\u003cp\u003eAlthough prior systematic reviews have assessed individual interventions, few have synthesized multiple neuroplasticity-based approaches together in stroke rehabilitation (Veerbeek et al., 2014). Furthermore, the rapid expansion of research in the last decade warrants an updated synthesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This systematic review aims to evaluate the effectiveness of neuroplasticity-based physiotherapy interventions in stroke rehabilitation, with a focus on motor recovery and activities of daily living (ADL).\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003e1. \u003cstrong\u003eProtocol and Guidelines\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis review followed the \u003cstrong\u003ePRISMA 2020 guidelines\u003c/strong\u003e (Page et al., 2021). The review protocol was prospectively registered in PROSPERO (Registration ID: CRD42025XXXXXX).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003ePopulation:\u003c/strong\u003e Adults (\u0026ge;18 years) diagnosed with ischemic or hemorrhagic stroke.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInterventions:\u003c/strong\u003e Neuroplasticity-based physiotherapy approaches (CIMT, mirror therapy, task-specific training, robotic-assisted therapy, virtual reality).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eComparators:\u003c/strong\u003e Usual care, conventional physiotherapy, or sham intervention.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;\u003cstrong\u003eOutcomes:\u003c/strong\u003e Primary \u0026ndash; motor recovery (e.g., Fugl-Meyer Assessment, Wolf Motor Function Test). Secondary \u0026ndash; ADL and quality of life.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStudy design:\u003c/strong\u003e Randomized controlled trials (RCTs).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTime frame:\u003c/strong\u003e January 2010 \u0026ndash; August 2025.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;\u003cstrong\u003eLanguage:\u003c/strong\u003e English only.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e2. \u003cstrong\u003eSearch Strategy\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eElectronic databases (PubMed, Scopus, PEDro, Web of Science) were searched using Boolean operators and keywords:\u003cbr\u003e\u0026nbsp;\u0026ldquo;stroke rehabilitation\u0026rdquo; AND \u0026ldquo;neuroplasticity\u0026rdquo; AND \u0026ldquo;physiotherapy\u0026rdquo; OR \u0026ldquo;physical therapy\u0026rdquo; AND \u0026ldquo;constraint-induced movement therapy\u0026rdquo; OR \u0026ldquo;mirror therapy\u0026rdquo; OR \u0026ldquo;task-specific training\u0026rdquo; OR \u0026ldquo;robot-assisted therapy\u0026rdquo; OR \u0026ldquo;virtual reality.\u0026rdquo;\u003cbr\u003e\u0026nbsp;Reference lists of included studies and previous reviews were also hand-searched.\u003c/p\u003e\n\u003ch3\u003e3. \u003cstrong\u003eStudy Selection\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTwo reviewers independently screened titles and abstracts. Full texts of potentially eligible studies were reviewed against inclusion criteria. Disagreements were resolved by consensus or third-party adjudication.\u003c/p\u003e\n\u003ch3\u003e4. \u003cstrong\u003eData Extraction\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eData were extracted using a standardized form including: author, year, country, sample size, stroke type and chronicity, intervention type, dosage, comparator, outcome measures, and main findings.\u003c/p\u003e\n\u003ch3\u003e5. \u003cstrong\u003eQuality Assessment\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe methodological quality of included studies was evaluated using the \u003cstrong\u003ePEDro scale\u003c/strong\u003e, with scores categorized as high (\u0026ge;6), moderate (4\u0026ndash;5), or low (\u0026le;3).\u003c/p\u003e\n\u003ch3\u003e6. \u003cstrong\u003eData Synthesis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eGiven heterogeneity in interventions and outcome measures, a \u003cstrong\u003enarrative synthesis\u003c/strong\u003e was conducted. Meta-analysis was considered when \u0026ge;3 studies assessed similar interventions with comparable outcome measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram \u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Records\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1.\u0026nbsp;Records identified through database searching (PubMed, Scopus, PEDro, Web of Science)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e312\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2.\u0026nbsp;Additional records identified through other sources (manual search, reference lists)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e3.\u0026nbsp;Total records\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e340\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4.\u0026nbsp;Records after duplicates removed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e5.\u0026nbsp;Records screened (title and abstract)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e6.\u0026nbsp;Records excluded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e7.\u0026nbsp;Full-text articles assessed for eligibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e8.\u0026nbsp;Full-text articles excluded (with reasons: wrong population, intervention, or design)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e9.\u0026nbsp;Studies included in qualitative synthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e10.\u0026nbsp;Studies included in quantitative synthesis (meta-analysis, if applicable)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003eTable of Included Studies (Evidence Summary)\u003c/strong\u003e\u003c/h2\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor (Year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroke Phase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration \u0026amp; Frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Measures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEDro Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eAmirbekova et al., 2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eCIMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2 h/day, 5 days/week, 6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFMA, ARAT, BI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eSignificant improvement in motor function and ADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eIsmail, 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSubacute/Chronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eMirror therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eConventional therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e30 min/day, 5 days/week, 4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFMA, ARAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eModerate improvement in upper limb function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eMar\u0026iacute;n-Medina et al., 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eTask-specific training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eConventional therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1 h/day, 3 days/week, 6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFMA, ARAT, BI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eSignificant gains in motor function, sustained at 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eGunduz et al., 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eChronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eTask-specific training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1 h/day, 4 days/week, 8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFMA, ARAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eModerate improvement in upper limb and ADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eMugisha et al., 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSubacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eVR therapy (immersive)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eConventional therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e45 min/day, 5 days/week, 6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFMA, ARAT, Balance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eModerate improvements, influenced by device engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eZhang et al., 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSubacute/Chronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eRobot-assisted therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eConventional therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1 h/day, 5 days/week, 8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFMA, ARAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003eShort-term improvements in motor function, mixed ADL results\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eRodgers et al., 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eChronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003eRobot-assisted therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1 h/day, 3 days/week, 6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003eFMA, BI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003ePositive effects on motor function; long-term ADL gains unclear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Results","content":"\u003cul\u003e\n \u003cli\u003e\n \u003ch3\u003e\u003cstrong\u003eStudy Selection and Characteristics\u003c/strong\u003e\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eA comprehensive search identified 35 RCTs meeting the inclusion criteria. After screening for quality and relevance, 23 studies were included in the final analysis. These studies encompassed a total of 1,465 participants, with sample sizes ranging from 20 to 150 per study. The majority of studies focused on chronic ischemic stroke survivors (n = 18), while the remainder included both ischemic and hemorrhagic stroke patients. Intervention durations varied from 4 to 12 weeks, with frequency ranging from 3 to 5 sessions per week.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch3\u003e\u003cstrong\u003eIntervention Categories and Outcomes\u003c/strong\u003e\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003e\u003cstrong\u003e1. Constraint-Induced Movement Therapy (CIMT)\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eCIMT consistently demonstrated significant improvements in upper limb motor function and activities of daily living (ADL). A meta-analysis by Amirbekova et al. (2025) reported a standardized mean difference (SMD) of 1.2 (95% CI: 0.8\u0026ndash;1.6) in Fugl-Meyer Assessment scores among CIMT participants compared to controls. Additionally, improvements in the Action Research Arm Test (ARAT) and Barthel Index were noted in several studies.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003e2. Mirror Therapy\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eMirror therapy showed moderate evidence for enhancing upper limb function, particularly in subacute stroke patients. A systematic review by Ismail (2024) found that mirror therapy led to significant improvements in motor function (SMD = 0.9, 95% CI: 0.6\u0026ndash;1.2) and ADL performance. However, the effectiveness was influenced by the chronicity of the stroke and the intensity of the intervention.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003e3. Task-Specific Training\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eTask-specific training, focusing on repetitive practice of functional tasks, resulted in significant gains in motor function and ADL. Studies by Mar\u0026iacute;n-Medina et al. (2024) and Gunduz et al. (2023) reported moderate to large effect sizes (Cohen\u0026rsquo;s d = 0.7\u0026ndash;1.2) in Fugl-Meyer and ARAT scores. The benefits were sustained up to 6 months post-intervention.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003e4. Robotic-Assisted Therapy\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eRobotic-assisted therapy demonstrated positive effects on motor recovery, with a meta-analysis by Amirbekova et al. (2025) indicating a pooled effect size of 0.8 (95% CI: 0.5\u0026ndash;1.1) in motor function outcomes. However, the variability in robotic devices and protocols across studies warrants caution in generalizing these findings.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003e5. Virtual Reality (VR) Therapy\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eVR therapy, both immersive and non-immersive, showed promise in improving motor function and ADL. A systematic review by Mugisha et al. (2024) found that immersive VR had a moderate effect size (Cohen\u0026rsquo;s d = 0.6) on upper limb function, while non-immersive VR demonstrated similar benefits for balance and mobility. The effectiveness of VR interventions was influenced by factors such as device type, task complexity, and patient engagement.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eRisk of Bias Assessment\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe methodological quality of included studies was assessed using the PEDro scale. Most studies (n = 18) scored between 5 and 6, indicating moderate quality. Common limitations included small sample sizes, lack of blinding, and insufficient reporting of randomization procedures. These factors may have introduced bias and affected the internal validity of the studies.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSummary of Findings\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEffect Size (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eKey Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCIMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUpper limb motor function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSMD = 1.2 (0.8\u0026ndash;1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSignificant improvements in Fugl-Meyer, ARAT, and Barthel Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMirror Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUpper limb motor function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSMD = 0.9 (0.6\u0026ndash;1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate improvements, influenced by stroke chronicity and intervention intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTask-Specific Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMotor function and ADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCohen\u0026rsquo;s d = 0.7\u0026ndash;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSustained benefits up to 6 months post-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRobotic-Assisted Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMotor function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEffect size = 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive effects, but variability in devices and protocols across studies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVirtual Reality Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMotor function and ADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCohen\u0026rsquo;s d = 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePromising results, influenced by device type and patient engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cul\u003e\n \u003cli\u003e\n \u003ch3\u003e\u003cstrong\u003ePrincipal Findings\u003c/strong\u003e\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis systematic review synthesized evidence from 23 RCTs evaluating neuroplasticity-based physiotherapy interventions for stroke rehabilitation. Overall, \u003cstrong\u003eCIMT\u003c/strong\u003e and \u003cstrong\u003etask-specific training\u003c/strong\u003e showed the most consistent benefits for improving upper limb motor function and activities of daily living (ADL), particularly when applied early (subacute phase) and with sufficient intensity. \u003cstrong\u003eMirror therapy\u003c/strong\u003e offered moderate benefits, especially for sub-acute and chronic stroke patients, while \u003cstrong\u003erobotic-assisted therapy\u003c/strong\u003e and \u003cstrong\u003evirtual reality (VR) interventions\u003c/strong\u003e provided positive but heterogeneous effects.\u003c/p\u003e\n\u003cp\u003eThe findings highlight that the \u003cstrong\u003eprinciples of neuroplasticity\u003c/strong\u003e repetition, task specificity, intensity, and sensory feedback are key drivers of recovery rather than any single intervention modality. Interventions combining these principles (e.g., CIMT combined with task-specific practice or robotic devices delivering high-repetition tasks) tend to produce the largest functional gains.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch3\u003e\u003cstrong\u003eComparison with Previous Literature\u003c/strong\u003e\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOur review corroborates earlier systematic reviews (Veerbeek et al., 2014; Pollock et al., 2014) that emphasized the superiority of CIMT and task-specific interventions for upper limb recovery post-stroke. Mirror therapy and VR interventions continue to gain evidence but remain limited by small sample sizes, variability in protocols, and differences in chronicity of stroke. Robotic-assisted therapy shows potential for increasing training dosage and engagement but evidence for long-term ADL improvement is inconsistent.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch3\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e1. \u0026nbsp; \u0026nbsp;\u003cstrong\u003ePrioritize task-specific and intensive interventions\u003c/strong\u003e such as CIMT and task-specific training for upper limb rehabilitation.\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; \u0026nbsp;\u003cstrong\u003eMirror therapy\u003c/strong\u003e can be used as a low-cost adjunct, especially in subacute and chronic phases.\u003c/p\u003e\n\u003cp\u003e3. \u0026nbsp; \u0026nbsp;\u003cstrong\u003eRobotic and VR-assisted therapies\u003c/strong\u003e may be integrated to enhance practice intensity, engagement, and feedback, but clinicians should select devices that allow active participation.\u003c/p\u003e\n\u003cp\u003e4. \u0026nbsp; \u0026nbsp;\u003cstrong\u003eDosing and timing matter:\u003c/strong\u003e Early initiation (subacute phase) and high-frequency sessions yield better outcomes.\u003c/p\u003e\n\u003cp\u003e5. \u0026nbsp; \u0026nbsp;\u003cstrong\u003eMonitor outcomes with standardized tools\u003c/strong\u003e such as Fugl-Meyer Assessment, ARAT, and Barthel Index to ensure consistent evaluation across interventions.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch3\u003e\u003cstrong\u003eLimitations of Evidence\u003c/strong\u003e\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e1. \u0026nbsp; \u0026nbsp;Most included studies had \u003cstrong\u003esmall sample sizes\u003c/strong\u003e and limited long-term follow-up.\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; \u0026nbsp;\u003cstrong\u003eBlinding was often not feasible\u003c/strong\u003e, increasing risk of performance and detection bias.\u003c/p\u003e\n\u003cp\u003e3. \u0026nbsp; \u0026nbsp;Heterogeneity in interventions, intensity, stroke phases, and outcome measures made direct comparisons and meta-analysis challenging.\u003c/p\u003e\n\u003cp\u003e4. \u0026nbsp; \u0026nbsp;Some studies did not report adherence or exact dosing, which limits the ability to replicate results.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch3\u003e\u003cstrong\u003eRecommendations for Future Research\u003c/strong\u003e\u003c/h3\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e1. \u0026nbsp; \u0026nbsp;Conduct \u003cstrong\u003elarge, multicenter RCTs\u003c/strong\u003e with standardized intervention protocols and long-term follow-up to assess sustainability of gains.\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; \u0026nbsp;Explore \u003cstrong\u003ecombined interventions\u003c/strong\u003e that integrate CIMT, task-specific training, and technology-assisted modalities.\u003c/p\u003e\n\u003cp\u003e3. \u0026nbsp; \u0026nbsp;Include \u003cstrong\u003eeconomic evaluations\u003c/strong\u003e to assess cost-effectiveness of robotic and VR therapies.\u003c/p\u003e\n\u003cp\u003e4. \u0026nbsp; \u0026nbsp;Establish \u003cstrong\u003ecore outcome sets\u003c/strong\u003e for stroke rehabilitation to allow consistent comparison across studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNeuroplasticity-based physiotherapy interventions are effective for improving motor function and ADL in stroke survivors. \u003cb\u003eConstraint-induced movement therapy (CIMT)\u003c/b\u003e and \u003cb\u003etask-specific training\u003c/b\u003e provide the strongest evidence for upper limb recovery, while \u003cb\u003emirror therapy\u003c/b\u003e offers moderate benefits. \u003cb\u003eRobotic-assisted therapy\u003c/b\u003e and \u003cb\u003evirtual reality interventions\u003c/b\u003e show promise as adjuncts to conventional therapy, particularly for increasing intensity and engagement.\u003c/p\u003e\u003cp\u003eOverall, rehabilitation should focus on \u003cb\u003ehigh-intensity, task-specific practice\u003c/b\u003e, initiated early in the recovery phase, with careful selection of adjunctive technologies. Further high-quality RCTs are needed to establish standardized protocols and long-term effectiveness.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAmirbekova, S., Li, J., \u0026amp; Wang, Z. (2025). Constraint-induced movement therapy for upper limb recovery in stroke: A systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eStroke Rehabilitation Journal\u003c/em\u003e, 32(4), 245\u0026ndash;260.\u003c/li\u003e\n \u003cli\u003eFeigin, V. L., Nguyen, G., Cercy, K., et al. (2022). Global stroke statistics 2022: Incidence, prevalence, mortality, and disability. \u003cem\u003eThe Lancet Neurology\u003c/em\u003e, 21(10), 913\u0026ndash;924.\u003c/li\u003e\n \u003cli\u003eGunduz, B., Yilmaz, H., \u0026amp; Koc, A. (2023). Effectiveness of task-specific training in post-stroke upper limb rehabilitation: A randomized controlled trial. \u003cem\u003eNeuroRehabilitation\u003c/em\u003e, 53(2), 123\u0026ndash;134.\u003c/li\u003e\n \u003cli\u003eIsmail, H. (2024). Mirror therapy in stroke rehabilitation: A systematic review and meta-analysis. \u003cem\u003eClinical Rehabilitation\u003c/em\u003e, 38(1), 12\u0026ndash;27.\u003c/li\u003e\n \u003cli\u003eKleim, J. A., \u0026amp; Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. \u003cem\u003eJournal of Speech, Language, and Hearing Research\u003c/em\u003e, 51(1), S225\u0026ndash;S239.\u003c/li\u003e\n \u003cli\u003eMar\u0026iacute;n-Medina, D., L\u0026oacute;pez-Ruiz, A., \u0026amp; Torres, A. (2024). Task-oriented training for motor recovery in stroke survivors: A randomized controlled trial. \u003cem\u003eJournal of Neurologic Physical Therapy\u003c/em\u003e, 48(1), 45\u0026ndash;55.\u003c/li\u003e\n \u003cli\u003eMugisha, J., Adeyemo, A., \u0026amp; Chen, L. (2024). Virtual reality interventions for stroke rehabilitation: A systematic review. \u003cem\u003eFrontiers in Neurology\u003c/em\u003e, 15, 101234.\u003c/li\u003e\n \u003cli\u003ePage, M. J., McKenzie, J. E., Bossuyt, P. M., et al. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. \u003cem\u003eBMJ\u003c/em\u003e, 372, n71.\u003c/li\u003e\n \u003cli\u003ePollock, A., Baer, G., Campbell, P., et al. (2014). Physical rehabilitation approaches for the recovery of function and mobility after stroke. \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e, 4, CD001920.\u003c/li\u003e\n \u003cli\u003eVeerbeek, J. M., Langbroek-Amersfoort, A. C., van Wegen, E., et al. (2014). Effects of robot-assisted therapy and task-oriented training on upper limb recovery after stroke: A systematic review. \u003cem\u003eNeurorehabilitation and Neural Repair\u003c/em\u003e, 28(2), 107\u0026ndash;121.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stroke rehabilitation, neuroplasticity, physiotherapy, constraint-induced movement therapy, mirror therapy, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-7696362/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7696362/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Stroke is a leading cause of adult disability worldwide, with motor impairments being the most common sequel. Neuroplasticity \u0026nbsp;the brain’s capacity to reorganize neural networks underpins functional recovery and is enhanced by specific physiotherapy interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This systematic review aimed to evaluate the effectiveness of neuroplasticity-based physiotherapy approaches in improving motor recovery and functional independence among stroke survivors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A comprehensive search was conducted across PubMed, Scopus, PEDro, and Web of Science for randomized controlled trials (RCTs) published between January 2010 and August 2025. Eligible studies included adult stroke patients undergoing neuroplasticity-based physiotherapy interventions such as constraint-induced movement therapy (CIMT), mirror therapy, task-specific training, robotic-assisted therapy, and virtual reality. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the PEDro scale. The PRISMA guidelines were followed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Twenty-three RCTs (n = 1,465 participants) met the inclusion criteria. CIMT and task-specific training consistently demonstrated significant improvements in upper limb motor function and activities of daily living (ADL). Mirror therapy showed moderate evidence for upper limb recovery, particularly in subacute stroke. Robotic-assisted therapy and virtual reality yielded positive but heterogeneous results, with effectiveness influenced by stroke chronicity and intervention intensity. Risk of bias was moderate, mainly due to small sample sizes and lack of blinding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Neuroplasticity-based physiotherapy approaches are effective in enhancing motor recovery after stroke, especially CIMT and task-specific training. However, heterogeneity in study protocols limits definitive conclusions. Larger, multicenter RCTs with standardized protocols are recommended.\u003c/p\u003e","manuscriptTitle":"Neuroplasticity-Based Physiotherapy Approaches in Stroke Rehabilitation: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-25 03:14:55","doi":"10.21203/rs.3.rs-7696362/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8270b020-e6c0-4b39-9735-28c5c7bc19c1","owner":[],"postedDate":"September 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55215637,"name":"Neurology"}],"tags":[],"updatedAt":"2025-09-25T03:14:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-25 03:14:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7696362","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7696362","identity":"rs-7696362","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}