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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Complement Med Ther . 2026 Mar 5;26:136. doi: 10.1186/s12906-026-05327-0 Search in PMC Search in PubMed View in NLM Catalog Add to search Effect of Tai Chi Yunshou motor imagery training on upper limb motor dysfunction with stroke patients Xiang Chen Xiang Chen 1 School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, 1200 Cai Lun Road, Zhangjiang Hi-TechPark, Pudong New Area, Shanghai, 201203 China 2 Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai University of Traditional Chinese Medicine, 1200 Cai Lun Road, Zhangjiang Hi-TechPark, Pudong New Area, Shanghai, 201203 China Find articles by Xiang Chen 1, 2 , Rui Qi Rui Qi 3 Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine Shanghai, No. 110 Ganhe Road, Hongkou District, Shanghai, China Find articles by Rui Qi 3, ✉ , Hanyu Zou Hanyu Zou 4 School of Acupuncture-Moxibustion and Tuina, Shanghai University of Traditional Chinese Medicine, Shanghai, China Find articles by Hanyu Zou 4 , Linhong Jiang Linhong Jiang 1 School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, 1200 Cai Lun Road, Zhangjiang Hi-TechPark, Pudong New Area, Shanghai, 201203 China Find articles by Linhong Jiang 1 , Banghua Yang Banghua Yang 1 School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, 1200 Cai Lun Road, Zhangjiang Hi-TechPark, Pudong New Area, Shanghai, 201203 China 2 Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai University of Traditional Chinese Medicine, 1200 Cai Lun Road, Zhangjiang Hi-TechPark, Pudong New Area, Shanghai, 201203 China 5 School of Mechatronic Engineering and Automation, Research Center of Brain-Computer Engineering, Shanghai University, Shanghai, China Find articles by Banghua Yang 1, 2, 5, ✉ Author information Article notes Copyright and License information 1 School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, 1200 Cai Lun Road, Zhangjiang Hi-TechPark, Pudong New Area, Shanghai, 201203 China 2 Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai University of Traditional Chinese Medicine, 1200 Cai Lun Road, Zhangjiang Hi-TechPark, Pudong New Area, Shanghai, 201203 China 3 Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine Shanghai, No. 110 Ganhe Road, Hongkou District, Shanghai, China 4 School of Acupuncture-Moxibustion and Tuina, Shanghai University of Traditional Chinese Medicine, Shanghai, China 5 School of Mechatronic Engineering and Automation, Research Center of Brain-Computer Engineering, Shanghai University, Shanghai, China ✉ Corresponding author. Received 2025 Jan 17; Accepted 2026 Feb 27; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13072524 PMID: 41787487 Abstract Background Upper limb motor dysfunction is common among stroke patients. Motor imagery, as a non-invasive brain training method, has gained increasing attention and application in stroke rehabilitation. However, there is currently limited research comparing the effectiveness of different motor imagery interventions for upper limb function. This study was designed to compare the effects of Tai Chi Yunshou motor imagery training and upper limb multi-joint linkage motor imagery training in stroke patients. Methods This study is an assessor blinding, parallel-design, simple randomized controlled trial. 70 stroke patients who had a recovery period from 2 weeks to 6 months were recruited from a rehabilitative inpatient unit and then were randomly (enrolled from September 25, 2022, to February 1, 2023). Participants were randomized to undergo Tai Chi Yunshou motor imagery training combined with conventional rehabilitation training ( n = 35) or upper limb multi-joint linkage motor imagery training combined with conventional rehabilitation training ( n = 35). Each group received 6 sessions per week, for 3 weeks. The primary outcome was the Fugl-Meyer Assessment for Upper Extremity at week 3, with higher scores indicating better motor function. The secondary outcomes included the Brunnstrom Assessment, Modified Barthel Index, Modified Ashworth Scale, grip strength, pinch strength, and the Functional Test for the Hemiplegic Upper Extremity (Hong Kong version). Results Among the 70 randomized participants (mean [SD] age, 64.3 [9.2] years), 66 participants (mean [SD] age, 64.5 [8.7] years) completed 3 weeks in the study. At week 3, both groups showed improvement in daily living activities, motor recovery, and upper limb function. The intervention group had a greater decrease in the Fugl-Meyer Assessment for Upper Extremity (10.97 scores) than the control group with a mean difference of 3.88 scores (95% CI, 2.64 to 5.11; P < 0.001). Conclusions Among stroke patients in a recovery period, the Tai Chi Yunshou motor imagery training, compared with the upper limb multi-joint linkage motor imagery training, resulted in better motor function after 3 weeks. Further studies are required to explore the underlying mechanisms of the intervention. Trial registration This trial was registered in the China Clinical Trials Registry on 19 September 2022 (registration number: ChiCTR2200063876, http://www.chictr.org/cn/ ). Supplementary Information The online version contains supplementary material available at 10.1186/s12906-026-05327-0. Keywords: Stroke, Hemiplegia, Rehabilitation, Motor Imagery Training, Tai Chi Background Stroke is a cerebrovascular disease marked by disrupted brain blood flow [ 1 ]. It is the leading cause of adult disability in China and a major global public health concern [ 2 ]. In the United States, stroke ranks as the fifth leading cause of death, following heart disease, cancer, respiratory diseases, and accidents [ 3 ]. Approximately 85% of stroke survivors experience upper extremity motor dysfunction [ 4 ], which severely impacts daily activities and increases caregiver burden [ 5 , 6 ]. Given the high demand for stroke rehabilitation in China, the scarcity of medical resources, and regional disparities in care quality, there is an urgent need to explore safe, effective, and accessible rehabilitation strategies. Motor imagery training (MIT) involves simulating movement scenarios in the brain without actual physical execution [ 7 ]. Studies have shown that MIT actively supports motor recovery in stroke patients, enhancing upper limb function and movement precision [ 8 – 10 ]. Evidence also suggests that MIT achieves greater accuracy in upper limb movements compared to physical movement alone [ 11 ]. Tai Chi is a traditional Chinese therapy and a mind-body therapy [ 12 ]. It integrates physical movements, breathing, and attentional training to alleviate disease symptoms and promote health. A network meta-analysis [ 13 ] suggested that Tai Chi was associated with favourable effects on functional recovery in stroke survivors, including improvements in balance, limb motor function, activities of daily living, and depressive symptoms. The Yunshou movement, a basic form of Tai Chi, involves circular arm motions performed inward and outward [ 14 ]. It promotes calmness and concentration by regulating attention and breathing [ 15 ]. Research indicates that Tai Chi can alleviate limb stiffness, improve circulation, reduce sensory numbness, and support motor recovery in stroke survivors [ 14 , 16 , 17 ]. It also aids cognitive rehabilitation, enhances brain oxygenation in the parietal and occipital lobes, strengthens functional brain connectivity, and fosters neural plasticity [ 18 – 21 ]. Although Tai Chi Yunshou is widely applied in motor rehabilitation for stroke patients in China, high-quality randomized clinical trials remain scarce due to methodological challenges in traditional Chinese medicine research [ 22 ]. This study aims to compare the therapeutic outcomes of Tai Chi Yunshou motor imagery training (TCY-MIT) and upper limb multi-joint linkage motor imagery training (ULML-MIT). The findings seek to advance the application of traditional Chinese medicine in stroke rehabilitation and provide alternative treatment options for stroke patients. Methods Study design This parallel, 2-group, single-blind, randomized clinical study was conducted at 1 hospital in China from September 25, 2022, to February 1, 2023. The study adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines [ 23 ] and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 statement [ 24 ]. The study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2200063876) on September 19, 2022. A total of 70 stroke patients voluntarily participated after providing informed consent. Each patient received 18 treatment sessions over 3 weeks. Written informed consent was obtained from all participants. Details of the trial protocol are available in the supplementary materials. Participants Stroke patients with hemiplegic upper extremity motor dysfunction were recruited through poster advertisements at a hospital. Inclusion criteria were as follows: first-time stroke diagnosed as cerebral hemorrhage or infarction confirmed by computed tomography or magnetic resonance imaging; age between 40 and 80 years [ 25 ], with no gender restrictions; disease duration of 2 weeks to 6 months [ 26 , 27 ]; right-handed dominance determined by the Edinburgh Handedness Inventory (EHI); Brunnstrom recovery stages II to V for the arm and hand [ 28 ]; a score of 25 or higher on the Kinaesthetic and Visual Imagery Questionnaire-10 (KVIQ-10); absence of cognitive impairment that could interfere with study participation; and provision of written informed consent. Exclusion criteria were as follows: a Mini-Mental State Examination (MMSE) score of 26 or lower; diagnosis of severe primary or secondary medical conditions, including liver or kidney failure, hematopoietic disorders, severe pulmonary dysfunction, heart failure, or arrhythmias; concurrent participation in other clinical trials; or inability to complete training or assessments for any reason. Randomization, allocation concealment, and blinding Simple randomization was used to allocate participants into two groups: (1) the control group and (2) the intervention group. A total of 70 random numbers were generated using IBM SPSS (IBM Corp. Published 2023. IBM SPSS Statistics for Windows, Version 26.0.2.0 Armonk, NY: IBM Corp) and were divided into two groups. Opaque envelopes and paper of uniform size and thickness were prepared. Researchers not involved in the intervention process wrote the random numbers on white paper, which were sequentially numbered and placed inside envelopes. Patients were assigned to the groups in a 1:1 ratio based on the order in which the envelopes were opened in their presence. Outcome assessors and statisticians were blinded to the group assignments. To ensure the blinding of participants to randomization into different motor imagery training, participants were informed that they would receive “motor imagery training combined with conventional rehabilitation” without disclosing the specific content of the imagery. Sample size calculation Based on prior research [ 29 ], a sample size of 28 participants per group is required to achieve 90% power with a significance level of 0.05. To account for a potential 20% dropout rate, a total of 70 participants was planned, with 35 allocated to each group (Supplementary Material). Procedure A total of 70 patients were randomized into the intervention group ( n = 35) or the control group ( n = 35). Both groups received conventional rehabilitation training (CRT), which included physical and occupational therapy aimed at improving motor function. All treatments were delivered by experienced rehabilitation therapists in the hospital over 3 weeks. The training intensity was identical for both groups. All participants received 60-minute CRT per day, 6 days per week for 3 weeks. Control group Participants in the control group received ULML-MIT combined with CRT. The ULML-MIT protocol was developed based on the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) [ 30 ]. Participants were instructed to imagine reaching for a glass of water using the affected arm (Fig. 1 ). This task incorporated key components of flexor and extensor synergies in FMA-UE, including shoulder flexion and external rotation, elbow flexion and extension, finger flexion and extension, and grasping a cylindrical object [ 31 ]. This reaching-for-a-cup imagery task was intentionally decomposed into sequential phases to achieve structural comparability with the continuous Yunshou imagery sequence, thereby minimizing confounding effects related to task complexity and training intensity. Fig. 1. Open in a new tab The main movement of upper limb multi-joint linkage movement. The teacher in the image is a member of research group. Permission to use the image has been obtained from the individual. All the movements of upper limb multi-joint linkage movement with the affected arm. A Preparation: Hands hanging naturally at your sides, body upright. B Pick up the Cup: Gently lift the cup with the affected hand from the table, fingers gripping the cup. C Raise to Half Height: Raise the cup to chest height with the affected hand. D Bring to Mouth: Continue raising the cup to ther mouth with the affected hand, preparing to drink Each session included 13 trials, with each trial consisting of 1 min of imagery followed by 1 min of rest. After completing the session, participants opened their eyes and focused on their surroundings for 2 min. Each motor imagery training session lasted 30 min. Participants underwent 6 sessions per week for 3 consecutive weeks, totaling 18 sessions. Intervention group Participants in the intervention group received TCY-MIT combined with CRT. The TCY-MIT (Fig. 2 ) was based on the “Yunshou” movement from the 24-form Tai Chi Chuan standardized by the General Administration of Sport of China. During imagery, participants wore headphones through which a prerecorded audio guide provided step-by-step instructions. Participants were instructed to keep their eyes closed and to vividly imagine performing the Yunshou movement with the affected arm, including slight trunk involvement. Each session included 13 trials, with each trial consisting of 1 min of motor imagery followed by 1 min of rest. After completing the session, participants opened their eyes and focused on their surroundings for 2 min. Each motor imagery training session lasted 30 min. Participants underwent 6 sessions per week for 3 consecutive weeks, totaling 18 sessions. Fig. 2. Open in a new tab The main movement of Tai Chi Yunshou. The teacher in the image is a member of research group. Permission to use the image has been obtained from the individual. All the movements of Tai Chi Yunshou with the affected arm. A Starting Position: Begin in a natural standing posture with both hands gently resting at your sides, palms facing inward. B Lift from the Inner Side: Raise your left hand from the inner side, with a slightly bent elbow. C Pull Outward from the Outer Side: Continue to pull your left hand outward to the left side, turning the palm outward. Extend your arm naturally without stiffness, maintaining a relaxed state. D Lower from the Outer Side: Slowly lower your left hand from the outer side back to your side, palm facing downward Adherence To minimize distractions, all participants were treated individually throughout the trial. Participants were inpatients, and research staff assisted with headphone placement and supervised the motor imagery practice. No headphones or audio guidance were provided outside of these supervised sessions, and participants did not engage in self-practice beyond the supervised training. The CRT and MIT therapists did not participate in outcome assessment or data analysis. Outcomes Primary outcome The primary outcome was the change in FMA-UE scores of the stroke-affected upper limb at week 3. The FMA is a comprehensive assessment tool developed by Fugl-Meyer, based on Brunnstrom’s descriptions, to evaluate motor function, sensation, balance, pain, and joint mobility in stroke patients [ 31 ]. The FMA-UE is a widely used and validated scale for assessing stroke-specific motor impairments [ 32 ]. The simplified FMA-UE consists of 33 items, each scored from 0 to 2, with a maximum total score of 66 points. The FMA-UE is a performance-based tool highly recommended for quantifying motor dysfunction after stroke [ 33 ]. Secondary outcomes The secondary outcomes were hand strength (grip strength), finger strength (pinch strength), independence in daily life (Modified Barthel Index [MBI]), upper limb function (Functional Test for the Hemiplegic Upper Extremity-Hong Kong version [FTHUE-HK]), motor recovery (Brunnstrom), and muscle spasticity (Modified Ashworth Scale [MAS]) at 3 weeks post-intervention. Grip strength [ 34 ] was measured using a grip dynamometer. It provided an objective evaluation of distal upper limb muscle strength, including the thenar muscles, finger flexors, and palmaris longus [ 35 ]. Pinch strength [ 36 ] was assessed using a pinch dynamometer to measure the force exerted by the thumb and index finger. The MBI [ 37 , 38 ] evaluates the ability to perform daily living activities [ 39 ]. The total score is 100, with higher scores reflecting greater independence in self-care. The Brunnstrom scale assesses motor recovery stages in stroke patients with hemiplegia [ 40 ]. It consists of six stages, ranging from Stage I (flaccidity) to Stage VI (near-normal motor function). The MAS evaluates the degree of spasticity [ 41 ]. It divides spasticity levels into six grades: 0, 1, 1+, 2, 3, and 4, providing a more detailed classification than the original Ashworth Scale. The FTHUE-HK measures the functional use of the hemiparetic upper limb in daily tasks [ 42 ]. It includes seven tasks arranged by difficulty, assessing gross and fine motor skills, muscle tone, strength, cognitive function, and activities of daily living. Blinded researchers conducted all outcome measurements. Before the trial, they underwent one week of training to ensure assessment accuracy. Assessments were performed at baseline and after 1, 2, and 3 weeks of intervention. Adverse events were monitored and documented throughout the trial. An adverse event was defined as any undesirable medical occurrence during the study period. Statistical analysis To evaluate the efficacy of MIT under optimal adherence conditions, statistical analyses were performed on the per-protocol (PP) set, which included only participants who completed the full intervention. All statistical tests were conducted using IBM SPSS (IBM Corp. Published 2023. IBM SPSS Statistics for Windows, Version 26.0.2.0 Armonk, NY: IBM Corp). Descriptive statistics were used to summarize baseline characteristics. Continuous variables with normal distributions were presented as mean (standard deviation [SD]), while non-normally distributed variables were expressed as median (interquartile range [IQR]). A two-sided P < 0.05 was considered statistically significant in all analyses. Missing values were imputed using the last observation carried forward approach. For the primary outcome, FMA-UE scores were analyzed using independent samples t-tests, assuming a normal distribution. The t-test results included 95% confidence intervals (95% CI) to estimate the likely range of the true population mean difference. To examine within-subject changes over time and the interaction effects of time and group, Generalized Estimating Equations(GEE) was used. The covariates in the GEE were the baseline values of the parameters measured at the start of the study. This adjustment controlled for potential baseline differences that might influence the analysis. Bonferroni correction was applied, and analyses of secondary time points and secondary outcomes should be regarded as exploratory. The secondary outcomes except MBI were described in terms of the median (IQR). They were analyzed using the Wilcoxon rank-sum test and reported along with 95% CI. The MBI, a continuous variable, was described in terms of the mean (SD). The MBI was compared between groups using independent samples t-tests, with results reported along with 95% CI. Results A total of 189 stroke participants were screened for eligibility and 119 participants were excluded. 70 (37%) patients (mean [SD] age, 64.3 [9.2] years) were randomly assigned to either TCY-MIT combined with CRT ( n = 35) or ULML-MIT combined with CRT ( n = 35). 66 patients (mean [SD] age, 64.5 [8.74] years) completed treatment, including 33 (94%) patients in the TCY-MIT combined with CRT group and 33 (94%) patients in the ULML-MIT combined with CRT group completed treatment (Fig. 3 ). Four participants did not complete the full intervention. In the intervention group, one withdrew for personal reasons and one was discharged early. In the control group, one withdrew for personal reasons and one experienced a health issue unrelated to the intervention. None of these withdrawals were associated with adverse events or difficulties related to the training itself. Table 1 provides a summary of the patient’s demographic and clinical baseline characteristics. Fig. 3. Open in a new tab Flow of participants randomized to receive TCY-MIT combined with CRT or ULML-MIT combined with CRT Table 1. Participant baseline characteristics Characteristics a Control group Intervention group (n=33) (n=33) Mean age, mean (SD), y 64.94 (1.55) 64.15 (1.51) Sex, No. (%) a Male 23 (69.7) 27 (81.8) Female 10（30.3） 6 (18.2) Duration of disease, mean (SD), d 86.48(40.09) 88.76(41.44) 14-30days, No. (%) 3 (9.1) 1 (3.0) 31-90days, No. (%) 18 (54.5) 20 (60.6) 91-180days, No. (%) 12 (36.4) 12 (36.4) Type of stroke, No. (%) Ischemic 29（87.9） 25（75.8） Hemorrhagic 4（12.1） 8（24.2） Hemiplegia side, No. (%) Right 15（45.5） 19（57.6） Left 18（54.5） 14（42.4） Brunnstrom b , No. (%) Upper limb Ⅱ 9（27.3） 9（27.3） Ⅲ 15（45.4） 14（42.4） Ⅳ 9（27.3） 10（30.3） Ⅴ 0（0） 0（0） Hand Ⅱ 12（36.4） 11（33.3） Ⅲ 13（39.4） 13（39.4） Ⅳ 8（24.2） 9（27.3） Ⅴ 0（0） 0（0） Handedness, No. (%) Right 33 (100) 33 (100) Left 0（0） 0（0） MMSE c , mean (SD) 28.03 (0.92) 28.30 (1.02) KVIQ-10 d , mean (SD) 32.16 (4.79) 32.67 (4.91) Open in a new tab Abbreviations : KVIQ-10 Kinaesthetic and Visual Imagery Questionnaire-10, MMSE Minimum Mental State Examination a Data were presented as number (percentage) of participants unless otherwise indicated. No differences were found between groups for any characteristics at baseline b Higher graduates indicated better motor function c MMSE, score range: 0–30; a score of 7 or higher indicates no cognitive disorder d KVIQ-10, score range: 10–50; 25 or higher scores indicated better motor imagination ability For the primary outcome, changes in FMA-UE scores from baseline to week 3 were analyzed. Both groups showed improvement by the end of the 3-week intervention. The increase in FMA-UE scores in the intervention group (mean, 10.97; 95% CI, 9.68 to 12.26) was greater than in the control group (mean, 3.88; 95% CI, 2.64 to 5.11) at week 3. The between-group difference in FMA-UE scores was significant (mean, 7.30; 95% CI, 0.41 to 14.20; P = 0.038) after 3 weeks of intervention (Table 2 ; Fig. 4 ). Table 2. FMA-UE scores among study participants Within-group score change from baseline, mean (SD) Group × time Group c Time c Score, mean (SD) a Time-specific between-group b interaction c Outcome Intervention group (n=33) Control group (n=33) Difference (95% CI) P value Intervention group (n=33) Control group (n=33) F value P value F value P value F value P value FMA-UE score change Baseline 31.39(13.82) 31.18(15.42) 0.21 (-6.99 to 7.41 ) 0.953 NA NA Week 1 33.15(13.66) 32.97(14.53) 0.18 (-6.75 to 7.12) 0.958 1.76 (0.94 to 2.57) 1.79 (0.50 to 3.07) 64.882 <0.001* 0.742 0.392 146.454 <0.001* Week 2 35.48(13.52) 34.09(14.51) 1.39 (-5.50 to 8.29) 0.688 4.09 (2.98 to 5.21) 2.91 (1.73 to 4.09) Week 3 42.36(13.94) 35.06(14.09) 7.30 (0.41 to 14.20) 0.038* 10.97 (9.68 to 12.26) 3.88 (2.64 to 5.11) Open in a new tab Abbreviations : NA Not applicable, FMA-UE Fugl-Meyer Assessment for Upper Extremity a For FMA-UE, higher scores indicate better motor function. b Calculated by independent samples t-test. c Compared using Greenhouse-Gaslaw correction. * Significance difference at P<0.05 Fig. 4. Open in a new tab Changes in FMA-UE, MBI, and grip strength over time in two groups Secondary outcomes, including grip strength, pinch strength, Brunnstrom, MAS, MBI, and FTHUE-HK, all showed improvement in both groups after 3 weeks of intervention. No significant between-group differences were observed for the secondary outcomes (Table 3 ). For FTHUE-HK, 21 participants in the intervention group and 14 in the control group were able to lift a 1 kg bag and hold it for 15 s at week 3. Both groups showed a reduction in spasticity of elbow extension on the MAS from baseline to week 3. No adverse events were reported throughout the trial. No participants withdrew due to adverse events. Table 3. Secondary clinical efficacy at week 3 Baseline Measure Post-Treatment Outcome (Week 3) Difference (95% CI)* h p value h Intervention group Control group Intervention group Control group FMA-UE score change 31.39 (13.82) 31.18 (15.42) 42.36 (13.94) 35.06 (14.09) 7.11 (5.49, 8.72) <0.001 MAS of elbow extension f 1.00 (1.00) 1.00 (1.50) 1.00 (1.00) 1.00 (2.00) -1.41 (-3.20, 0.38) 0.12 FTHUE-HK, No.(%) e , g 2.00 (2.00) 2.00 (1.00) 3.00 (1.00) 2.00 (1.50) -1.96 (-3.43, -0.50) 0.01 Brunnstrom of upper limb e 3.00 (2.00) 3.00 (2.00) 3.00 (1.00) 3.00 (1.00) 0.98 (-0.44, 2.41) 0.18 Brunnstrom of hand e 3.00 (2.00) 3.00 (1.50) 3.00 (1.00) 3.00 (1.00) 0.63 (-0.65, 1.92) 0.33 Grip strength, kg , mean (SD) a , b 1.00 (3.00) 0.00 (5.50) 1.50 (3.25) 0.40 (5.50) 0.05 (-0.22, 0.32) 0.73 Pinch strength, kg , mean (SD) a , c 1.00 (3.00) 0.00 (5.50) 1.50 (3.25) 0.40 (5.50) 0.07 (-0.01, 0.16) 0.09 MBI , mean (SD) d 54.10 (17.43) 55.61 (16.90) 56.52 (17.65) 56.97 (16.44) 1.03 (-0.44, 2.49) 0.17 Open in a new tab Abbreviations : NA Not applicable, MBI Modified Barthel Index, MAS Modified Ashworth Scale, FTHUE-HK Functional Test for the Hemiplegic Upper Extremity-Hong Kong version a Secondary outcomes except MBI are calculated using the Mann-Whitney U test, and MBI is calculated by independent samples t-test. b Measured by grip dynamometer. c Measured by pinch dynamometer. d Scores range from 0 to 100, with higher scores indicating better living ability. e Negative numbers indicate a decrease, and positive numbers indicate an increase in spasticity from baseline to week 3. In these rows, the first number indicates the change in score, and the number in parentheses indicates the number of patients with that change in score. f MAS categorizes muscle tone into a scale from 0 to 4 (0, 1, 1.5, 2, 3, 4), where 0 represents no increase in muscle tone, and 4 indicates the affected body part is rigid and cannot be moved passively. g FTHUE-HK consists of seven sequential grades, and higher grades indicate a higher ability to use the upper limb during daily life. h P value and Difference (95% CI) represent the between-group effects derived from the Generalized Estimating Equations (GEE) analysis. P values indicate the statistical significance of the group differences, while the Difference (95% CI) presents the estimated difference between the groups with its corresponding 95% confidence interval. Baseline values for each parameter were used as covariates in the model Discussion In this study, we evaluated the effectiveness of TCY-MIT combined with CRT and ULML-MIT combined with CRT for stroke rehabilitation. The TCY-MIT combined with CRT was found to be safe. TCY-MIT combined with CRT resulted in significantly higher FMA-UE scores at the end of the 3-week intervention, compared to the control group. The increase in FMA-UE scores in the intervention group was 10.97 (9.68 to 12.26) after 3 weeks of treatment. The FMA scale is a critical tool for monitoring recovery from hemiplegic stroke [ 31 ]. A similar clinical trial [ 43 ] involving TCY-MIT combined with CRT reported that the TCY-MIT group showed significant improvement in upper limb function compared to the CRT-only group. After 6 weeks of intervention, the FMA-UE scores increased from 21 [5] to 47 [6] (mean [SD]) in the TCY-MIT group and from 19 [3] to 36 [9] (mean [SD]) in the CRT group. Moreover, a meta-analysis [ 16 ] showed that Tai Chi Yunshou improved stroke patients’ motor function, balance, and daily living activities, particularly the motor function of the upper limbs. The synchronization of consciousness, respiration, and physical movement during Tai Chi Yunshou significantly alleviates tension and depression. Both groups demonstrated significant improvements in secondary outcomes, including Brunnstrom stage, MAS, MBI, FTHUE-HK, grip strength, and pinch strength, indicating that both intervention protocols were beneficial for post-stroke upper limb rehabilitation. However, a statistically significant between-group difference was observed only for FMA-UE scores. This finding may be related to the relatively short intervention duration and, importantly, to differences in task characteristics between the two imagery protocols. Tai Chi Yunshou is a core movement in Tai Chi practice that integrates continuous, circular, and coordinated upper limb motions with attentional focus and breath regulation [ 44 , 45 ]. TCY-MIT offers a feasible therapeutic alternative for patients who are unable to perform physical Tai Chi movements, with advantages including non-invasiveness, flexibility in training setting, and good patient adherence. Previous studies have shown that MIT combined with CRT yields superior motor outcomes compared with CRT alone [ 46 ], supporting the clinical relevance of imagery-based mind–body interventions in stroke rehabilitation. The neurophysiological mechanisms underlying the effects of TCY-MIT remain to be fully elucidated. Existing evidence suggests that MIT may reduce maladaptive bilateral cortical activation and promote functional reorganisation within the ipsilesional hemisphere, thereby enhancing sensorimotor network integration and motor recovery [ 7 , 46 ]. In the present study, TCY-MIT combined with CRT resulted in greater improvement in FMA-UE scores, further supporting its potential role as an effective adjunctive rehabilitation strategy. Notably, the imagery tasks differed between groups in terms of movement structure and complexity. Compared with the cup-reaching task used in the control group, the Tai Chi Yunshou task involves a continuous, multi-joint sequence incorporating shoulder abduction, elbow flexion and extension, wrist circumduction, and forearm pronation–supination, without clear segmentation points within each movement cycle. Such continuous movements impose higher demands on inter-segmental coordination, proprioceptive integration, and temporal control than discrete, phase-based tasks. From a motor control and rehabilitation perspective, these task characteristics may engage broader neural networks and promote more extensive sensorimotor integration. Task-oriented training frameworks suggest that complex, coordinated movements may facilitate neural adaptation and transfer to functional activities [ 47 , 48 ]. Therefore, the observed between-group differences in FMA-UE outcomes may be partly attributable to differences in task complexity and coordination demands, rather than to motor imagery training alone. This consideration underscores the need for cautious interpretation of the intervention effects and highlights task characteristics as an important factor when comparing imagery-based rehabilitation protocols. Strengths and limitations The strengths of this study include blinding participants, assessors, and data analysts to the allocation of TCY-MIT and ULML-MIT. Both groups underwent standard rehabilitation therapy, which supports motor function recovery and ensures a comparable baseline between groups. By comparing two types of motor imagery—daily activities such as drinking water and the mind-body exercise Tai Chi—this study aims to optimize motor imagery therapy by identifying the most effective parameter settings. This study has several limitations. First, it was not possible to blind the therapists and participants to the treatment, which could introduce performance bias. Second, a 3-week intervention period was necessitated due to hospitalization constraints, which may have influenced the outcomes. No significant differences were found for the secondary outcomes, which may be attributed to the short duration of the intervention and the small sample size. To confirm the potential benefits of TCY-MIT for post-stroke rehabilitation, larger-scale and longer-term studies are essential. Third, this trial did not include a follow-up period to assess the long-term outcomes and sustainability of the interventions. The absence of a follow-up period may limit the generalizability of the study’s conclusions. Additionally, it was difficult to ensure that participants followed the MIT regimen as prescribed, despite the regulatory rules established. Conclusions This study shows that both TCY-MIT combined with CRT and ULML-MIT combined with CRT significantly improved upper limb motor function in patients. The TCY-MIT group demonstrated greater improvement in the primary outcome measure (FMA-UE) compared to the ULML-MIT group. These results suggest that TCY-MIT may serve as an effective motor imagery intervention for upper limb rehabilitation. Supplementary Material Supplementary Material 1. (184.8KB, docx) Acknowledgements We thank all clinician investigators and the Rehabilitation Department of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine. Abbreviations MIT Motor Imagery Training TCY-MIT Tai Chi Yunshou Motor Imagery Training ULML-MIT Upper Limb Multi-Joint Linkage Motor Imagery Training CONSORT Consolidated Standards of Reporting Trials SPIRIT Standard Protocol Items: Recommendations for Interventional Trials EHI Edinburgh Handedness Inventory KVIQ-10 Kinaesthetic and Visual Imagery Questionnaire-10 MMSE Mini-Mental State Examination CRT Conventional Rehabilitation Training FMA-UE Fugl-Meyer Assessment for Upper Extremity MBI Modified Barthel Index FTHUE-HK Functional Test for the Hemiplegic Upper Extremity-Hong Kong version MAS Modified Ashworth Scale PP Per-Protocol GEE Generalized Estimating Equations SD Standard Deviation IQR Interquartile Range Authors’ contributions XC contributed to the content of the work and the manuscript draft. RQ contributed to the design of the work. BY critically revised the manuscript. LJ contributed to the data analysis. HZ contributed to the interpretation of data. All authors read and approved the final manuscript. Funding This work was supported by the National Key Research and Development Program of China (2024YFF1206500, 2024YFF1206502), the National Natural Science Foundation of China (No. 32571279, No. 62376149), and the Science and Technology Commission of Shanghai Municipality Project (No. 25YL1900100). Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate This trial protocol has been approved by the ethics committee of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine (ethics approval number: 2022-055). All participants have provided written informed consent after fully discussing potential benefits and risks before participating. All methods were performed in accordance with the relevant guidelines and regulations. 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