Impact of motor guided imagery therapy on stroke patients with pain symptoms: a three-level meta-analysis and systematic review of randomized controlled trials

Background Post-stroke pain is a common and intractable complication that hinders neurorehabilitation progress. Motor Guided Imagery (MGI), an emerging rehabilitation technique based on brain-computer interaction principles, has shown potential in relieving post-stroke pain, yet high-quality evidence on its multi-dimensional efficacy remains insufficient. This study aimed to systematically evaluate the effects of MGI on pain, sensorimotor function, sleep quality, life status, and psychological mood in stroke patients using a three-level meta-analysis. Objective This study aimed to quantitatively assess the therapeutic effects of Motor Guided Imagery for stroke-related pain and explore potential intervention moderators using a three-level meta-analysis framework. Methods Eight Chinese and English databases were searched from inception to June 29, 2025, to collect randomized controlled trials (RCTs) of MGI for stroke patients with pain. A three-level random-effects model was adopted to pool Hedges’ g effect sizes, accompanied by heterogeneity testing, moderator analysis, influence analysis, and publication bias assessment. Influence-based outlier detection was implemented; analyses retaining all effect-size observations were treated as the primary main analysis, while outlier-removed analyses were reported only as supplementary sensitivity checks. Results Motor-guided imagery training significantly relieved pain ( g = −0.524, 95% CI -0.779 to −0.269, p = 0.0006; negative Hedges’ g indicates clinical improvement for this outcome) and improved sleep quality ( g = −1.658, 95% CI -2.115 to −1.201, p < 0.001; negative Hedges’ g indicates clinical improvement for this outcome) in stroke patients. Meanwhile, it significantly enhanced motor function ( g = 1.395, 95% CI 0.963 to 1.826, p < 0.001), life status ( g = 1.757, 95% CI 0.966 to 2.549, p = 0.0012), and psychological-emotional status ( g = 1.729, 95% CI 1.045 to 2.413, p = 0.0002); positive Hedges’ g indicates clinical improvement for the latter three outcomes. Moderator analysis indicated that acute-phase intervention (≤4 weeks) and high-frequency regimens (>5 sessions/week) tended to produce better analgesic effects, while age, gender, single-session duration, and pain location had no significant moderating effects. Conclusion MGI may produce beneficial rehabilitation effects that can alleviate post-stroke pain and synergistically improve motor function, sleep, daily-living ability, and psychological state of stroke patients. Exploratory subgroup trends indicated potentially larger effects for early implementation within the acute phase and high-frequency short-duration regimens. However, these observations should be interpreted as hypothesis-generating clues given non-significant overall moderator tests. Further high-quality research is required to confirm these findings. Registration The systematic review protocol was retrospectively registered with PROSPERO under registration ID CRD420261278812, after literature search and full-text screening had been completed. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261278812 ; identifier: CRD420261278812