Evaluating the Synergistic Neurofunctional Effects of Mirror Therapy Combined with Botulinum Toxin A on Upper Limb Spasticity in Chronic Stroke: A Prospective Randomized Controlled Study

Background Converting the transient spasticity-reducing effect of botulinum toxin A (BTX-A) into durable neuroplastic adaptations through mirror therapy (MT) represents a promising yet understudied approach. Although MT facilitates motor recovery, evidence on its long-term synergistic use with BTX-A in chronic stroke remains limited. Aim To investigate the synergistic effects of MT combined with BTX-A on upper limb spasticity and motor recovery in chronic ischemic stroke. Design Randomized, single-blind, sham-controlled clinical trial. Methods and Population Thirty patients with unilateral chronic ischemic stroke and upper limb spasticity were randomized into two groups following BTX-A injection. The experimental group received MT plus standard rehabilitation, while the control group underwent sham therapy using a transparent panel. Interventions began 2 weeks postinjection and were applied three times weekly for approximately 60 sessions over six months. Outcomes were assessed using Brunnstrom recovery stages, modified Ashworth scale (MAS), and Fugl–Meyer assessment for upper extremity (FMA-UE). Results Both groups showed significant within-group improvements in motor and spasticity scores ( p < 0.001). Greater improvements were observed in the MT group for Brunnstrom hand ( p = 0.021), Brunnstrom upper extremity ( p = 0.029), MAS upper extremity ( p = 0.012), and FMA-UE ( p = 0.002). Muscle strength differences were not significant. Conclusion MT combined with BTX-A improves motor recovery and reduces spasticity more than BTX-A alone in chronic stroke, supporting cortical reorganization and neuromuscular relaxation as a cost-effective rehabilitation strategy.