This randomized controlled trial aims to compare the effects of Mirror Therapy (MT) and Action Observation Therapy (AOT) on upper limb motor function, functional independence, and health-related quality of life in individuals with chronic stroke. Stroke-related upper limb impairment remains a major cause of long-term disability and reduced independence. Both MT and AOT are neurocognitive rehabilitation approaches based on activation of the mirror neuron system and promotion of neuroplasticity. Eligible participants with chronic stroke will be randomly allocated to either a Mirror Therapy group or an Action Observation Therapy group and will receive supervised interventions in addition to standard physiotherapy. Outcomes will be assessed using the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES), Fugl-Meyer Assessment for Upper Extremity (FMA-UE), and Short Form-36 Health Survey (SF-36). The study seeks to determine the comparative effectiveness of these interventions for improving upper limb function, functional independence, and quality of life among chronic stroke survivors.

Stroke is a leading cause of long-term disability worldwide and frequently results in persistent upper limb impairments that limit functional independence and participation in daily activities. Despite advances in rehabilitation, many stroke survivors continue to experience deficits in motor control, coordination, dexterity, and upper extremity function, particularly during the chronic phase of recovery. Therefore, identifying effective rehabilitation strategies that promote neuroplasticity and enhance motor recovery remains a priority in stroke rehabilitation.

Mirror Therapy (MT) and Action Observation Therapy (AOT) are neurocognitive rehabilitation interventions that have gained increasing attention because of their potential to facilitate motor recovery through activation of the mirror neuron system. Mirror Therapy involves observation of the reflection of movements performed by the unaffected limb, creating the visual illusion that the affected limb is moving normally. This visual feedback is believed to stimulate motor cortical areas and promote motor relearning. Action Observation Therapy involves observation of goal-directed motor tasks performed by another individual, followed by active imitation of the observed movements. Through observation and execution of actions, AOT is intended to enhance motor planning, motor learning, and cortical reorganization.

Although both interventions have demonstrated potential benefits in stroke rehabilitation, limited evidence exists directly comparing their effectiveness for improving upper limb function, functional independence, and quality of life among individuals with chronic stroke. This study has been designed to address this gap by evaluating and comparing the clinical effects of MT and AOT within a randomized controlled trial framework.

The study will be conducted at Goshe Shifa Hospital, Lahore, Pakistan. Participants diagnosed with chronic stroke (six months or more post-stroke), aged 45-75 years, with mild-to-moderate upper limb motor impairment, will be screened for eligibility. Eligible participants will be randomly assigned to one of two intervention groups using a computer-generated randomization sequence with allocation concealment through sealed opaque envelopes.

Participants allocated to the Mirror Therapy group will receive a structured upper limb rehabilitation program utilizing mirror-induced visual feedback. Sessions will include simple upper limb movements, functional activities, and task-specific training performed while observing the mirror reflection of the unaffected limb. Participants allocated to the Action Observation Therapy group will observe videos demonstrating goal-directed upper limb activities and subsequently practice the observed tasks under physiotherapy supervision.

Both interventions will be delivered for six weeks, five sessions per week, with each session lasting approximately 45 minutes. Outcome assessments will be performed at baseline and after completion of the intervention period by assessors blinded to group allocation.

The primary outcomes of interest include upper limb motor function, functional independence, and health-related quality of life. These outcomes will be measured using the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES), Fugl-Meyer Assessment for Upper Extremity (FMA-UE), and Short Form-36 Health Survey (SF-36), respectively.

The study is expected to contribute evidence regarding the comparative effectiveness of two widely used neurorehabilitation approaches and may assist clinicians in selecting appropriate interventions for upper limb rehabilitation in individuals with chronic stroke.

Inclusion Criteria:

• Individuals diagnosed with chronic stroke (≥6 months post-stroke).
• Patients with stroke affecting either the left or right upper limb will be included.
• Mild-to-moderate upper limb motor impairment (Fugl-Meyer Upper Extremity Score between 19-55).
• Ability to follow verbal and visual instructions.
• Medically stable with no active comorbidities affecting rehabilitation (Tang et al., 2024).

Exclusion Criteria:

• Severe cognitive or communication impairments prevent task understanding.
• Presence of severe upper limb spasticity or contractures.
• History of severe visual or perceptual deficits (e.g., neglect, hemianopia).
• Uncontrolled epilepsy or active psychiatric disorders.
• Participation in other upper limb rehabilitation programs during the study period.