Non-invasive brain stimulation techniques for the improvement of upper limb motor function and performance in activities of daily living after stroke: a systematic review and network meta-analysis

Ishtiaq Ahmed, Rustem Mustafoglu, Simone Rossi, Fatih A Cavdar, Seth Kwame Agyenkwa, Marco Y C Pang, Sofia Straudi

Research output: Contribution to journalArticlepeer-review

Abstract

Objective: To compare the efficacy of non-invasive brain stimulation (NiBS) such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), theta-burst stimulation (TBS), and transcutaneous vagus nerve stimulation (taVNS) in upper limb stroke rehabilitation. Data Sources: PubMed, Web of Science, and Cochrane databases were searched from January 2010 to June 2022. Data Selection: Randomized controlled trials (RCTs) assessing the effects of “tDCS”, “rTMS”, “TBS”, or “taVNS” on upper limb motor function and performance in activities of daily livings (ADLs) after stroke. Data Extraction: Data were extracted by 2 independent reviewers. Risk of bias was evaluated with the Cochrane Risk of Bias tool. Data Synthesis: 87 RCTs with 3750 participants were included. Pairwise meta-analysis showed that all NiBS except continuous TBS (cTBS) and cathodal tDCS were significantly more efficacious than sham stimulation for motor function (standardized mean difference [SMD] range 0.42-1.20), whereas taVNS, anodal tDCS, and both low and high frequency rTMS were significantly more efficacious than sham stimulation for ADLs (SMD range 0.54-0.99). NMA showed that taVNS was more effective than cTBS (SMD:1.00; 95% CI (0.02-2.02)), cathodal tDCS (SMD:1.07; 95% CI (0.21-1.92)), and Physical rehabilitation alone (SMD:1.46; 95% CI (0.59-2.33)) for improving motor function. P-score found that taVNS is best ranked treatment in improving motor function (SMD: 1.20; 95% CI (0.46-1.95)) and ADLs (SMD:1.20; 95% CI (0.45-1.94)) after stroke. After taVNS, excitatory stimulation protocols (intermittent TBS, anodal tDCS, and HF-rTMS) are most effective in improving motor function and ADLs after acute/sub-acute (SMD range 0.53-1.63) and chronic stroke (SMD range 0.39-1.16). Conclusions: Evidence suggests that excitatory stimulation protocols are the most promising intervention in improving upper limb motor function and performance in ADLs. taVNS appeared to be a promising intervention for stroke patients, but further large RCTs are required to confirm its relative superiority.

Original languageEnglish
Pages (from-to)1683-1697
Number of pages15
JournalArchives of Physical Medicine and Rehabilitation
Volume104
Issue number10
Early online date2023
DOIs
Publication statusPublished - Oct 2023

Bibliographical note

Funding Information:
The authors would like to thank the authors who responded to our email inquiry and provided the data for analysis. The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

Publisher Copyright:
© 2023 American Congress of Rehabilitation Medicine

Copyright:
Copyright 2023 Elsevier B.V., All rights reserved.

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