Stroke Neurorehabilitation and the Role of Motor Imagery Training: Do ARAT and Barthel Index Improvements Support Its Clinical Use? A Systematic Review and Meta-Analysis.

Background and Objectives: Although several meta-analyses have evaluated the effects of motor imagery (MI) on upper-limb recovery using the Fugl-Meyer Assessment for the Upper Extremity (FM-UE), evidence based on more specific (Action Research Arm Test, ARAT) and functional (Barthel Index, BI) outcomes remains scarce. This study examined the effect of MI combined with conventional rehabilitation therapy (CRT), which translates into meaningful improvements in upper-limb performance and functional independence after stroke, accounting for methodological quality and publication bias. Materials and Methods: A systematic review and meta-analysis were carried out in accordance with PRISMA recommendations, with prior registration in PROSPERO (CRD420251120044). Comprehensive searches were conducted across six electronic databases up to July 2025. The methodological rigor of the included studies was evaluated using the PEDro scale, and risk of bias was appraised with the Cochrane RoB 2 instrument. Random-effects models estimated pooled effect sizes (ESs) for the ARAT and BI, alongside analyses of heterogeneity, publication bias, and moderators. Results: Eleven RCTs (n = 425) were included. A small pooled improvement in ARAT was observed (ES = 0.25; 95% CI: 0.13-0.37; p < 0.001); however, this effect was rendered non-significant after correction for publication bias (ES = 0.08; 95% CI: -0.14-0.31). No significant differences were found for the BI (ES = 0.41; 95% CI: -0.35-1.18; p = 0.268), with substantial heterogeneity (I2 = 96.6%). The mean PEDro score was 6.6, indicating moderate methodological quality. Conclusions: MI combined with CRT yields small and inconsistent effects on upper-limb recovery and no improvement in functional independence. Current evidence does not support its routine use in stroke rehabilitation. Well-designed, adequately powered randomized controlled trials employing standardized MI protocols are required to determine its true clinical relevance.