Effects of Motor Imagery Training for Lower Limb Dysfunction in Patients With Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

57% of the included trials were rated low methodological quality on the Jadad scale, and only 3 of the 23 were adequate across all risk-of-bias domains. 65% of trials had a high risk of selection bias and 78% a high risk of performance bias, meaning patients and therapists often knew which group they were in. None of the 23 trials used a blank control or placebo for the imagery component, so it is impossible to tell how much of the effect is due to the imagery versus the extra attention and time it required. The balance outcome carried 95% heterogeneity, and the authors themselves rate it very low quality. A funnel plot also showed asymmetry for this outcome, raising the possibility of publication bias. Some studies did not report long-term follow-up, so the durability of any benefit is unknown. Studies published in languages other than English or Chinese were excluded, which may have left out relevant trials. Several subgroup analyses contained only two or three studies, making those comparisons fragile.

Funded by the Shanghai Municipal Commission of Health and Family Planning and the Shanghai Municipal Health Commission's Special Clinical Research Projects. The authors report no conflicts of interest.

Do not read these results as proof that motor imagery alone improves lower-limb function. Every included trial combined imagery with conventional rehabilitation, so the contribution of the imagery specifically cannot be separated from the extra time and attention it required. The balance finding, in particular, rests on trials that disagreed so much (I² = 95%) that the authors rate it very low quality, and a funnel plot suggested possible publication bias for that outcome.