Transcranial Direct Stimulation, Mirror Therapy, and Virtual Reality Interventions for Upper Limb Motor Recovery After Stroke: A Systematic Review and Meta-Analysis with Implications for Low-Resource Settings

Abstract Background: Stroke rehabilitation remains a major global challenge, especially in low-resource settings where access to specialized rehabilitation centers is limited. Structured, feasible, and evidence-based neuroplasticity intervention service delivery is not widely used in Sub-Saharan Africa, including Ethiopia. This meta-analysis assesses three neuroplasticity-based interventions: mirror therapy (MT), transcranial direct-current stimulation (tDCS), and virtual reality (VR) rehabilitation, with particular consideration of their potential applicability in resource-constrained settings. Objective: To evaluate the effectiveness of tDCS, VR, and MT compared to conventional rehabilitation in improving upper limb motor function after stroke and to consider their potential applicability to low-resource settings. Methods: A PRISMA-guided search across PubMed, Medline, Google Scholar, the Cochrane Library, and Web of Science (2015–2025) identified randomized controlled trials (RCTs) evaluating mirror therapy (MT), transcranial direct current stimulation (tDCS), or virtual reality (VR) versus conventional rehabilitation (CRT) in adults with ischemic or hemorrhagic stroke. Upper-limb motor function was measured via the Fugl-Meyer Assessment (FMA). After removing duplicates and studies not meeting inclusion criteria (target intervention, population, or outcome; full-text availability; no confounding interventions), 12 studies with 489 participants were included. Meta-analysis was conducted using a fixed-effect inverse-variance model when heterogeneity is <50%; otherwise, a random effect was used in RevMan 5.4.1. Heterogeneity was assessed via Cochrane Q and I². SPSS 27 was used for supplementary descriptive and exploratory regression analysis. The review was not prospectively registered. Results: tDCS vs. Conventional Rehab: Pooled MD = +7.80 (95% CI: 5.48–10.11, p < 0.0001), I² = 54%. VR vs. Conventional Rehab: Pooled MD = +5.50 (95% CI: 2.88–8.11, p < 0.0001), I² = 0% MT vs. Conventional Rehab: Pooled MD = +6.54 (4.48–8.60, p < 0.0001), I² = 0%Overall, all three interventions significantly improved post-stroke motor recovery compared with conventional rehabilitation alone. Conclusion: tDCS, VR, and MT are effective adjunctive therapies in stroke rehabilitation. Mirror therapy achieved the most favorable balance in effect size and required relatively minimal equipment and training, making it particularly attractive for further evaluation in resource-limited rehabilitation settings. Sensitivity analysis (removing large-sample studies) showed that overall effect estimates for tDCS and VR were somewhat more sensitive to sample size than MT estimates. Larger, high-quality RCTs with standardized protocols and longer follow-ups are needed to confirm these findings and evaluate implementation in low-resource settings. Key Words: Stroke rehabilitation; Neuroplasticity Interventions; Upper Limb Motor Recovery; Low-Resource Settings