Optimal Method of Electrical Stimulation for the Treatment of Upper Limb Dysfunction After Stroke: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Controlled Trials

Figures & data

Table 1 Data Retrieval Strategy for PubMed Database

Steps	Search
#1	“Electric Stimulation[MeSH]“ OR “Electric Stimulation Therapy[Ti/Ab]“ OR “Electrotherapy[Ti/Ab]“ OR “transcutaneous electrical nerve stimulation[MeSH]“ OR “Transcutaneous Electric Stimulation[Ti/Ab]“ OR “Percutaneous Electric Nerve Stimulation[Ti/Ab]“ OR “TENS[Ti/Ab]“ OR “Transcutaneous Electrical Stimulation[Ti/Ab]“ OR “Transdermal Electrostimulation[Ti/Ab]” OR ”transcutaneous electrical acupoint stimulation[Ti/Ab]” OR ”TEAS[Ti/Ab]” OR ”neuromuscular electrical stimulation[Ti/Ab]” OR ”NMES[Ti/Ab]” OR ”functional electrical stimulation[Ti/Ab]” OR ”FES[Ti/Ab]” OR ”Transcranial Direct Current Stimulation[Ti/Ab]” OR ”tDCS[Ti/Ab]”
#2	“Stroke[MeSH]“ OR “Cerebrovascular Accident[Ti/Ab]” OR ”CVA[Ti/Ab]‘ OR ’Brain Vascular Accident[Ti/Ab]‘ OR ’Apoplexy[Ti/Ab]”
#3	“randomized controlled trial[PT]“ OR “controlled clinical trial[PT]“ OR “randomized[Ti/Ab]“ OR “clinical trials as topic[MeSH]” OR ”randomly[Ti/Ab]” OR ”trial[Ti]” OR ”clinical[Ti]”
#4	“Hemiplegia[MeSH]“ OR “Paralysis[MeSH]“ OR “Upper limb[Ti/Ab]“ OR “Upper extremity[Ti/Ab]“ OR “shoulder[Ti/Ab]“ OR “arm[Ti/Ab]” OR ”forearm[Ti/Ab]” OR ”wrist[Ti/Ab]” OR ”hand[Ti/Ab]” OR ”finger[Ti/Ab]” OR ”motor function[Ti/Ab]”
#5	#1 AND #2 AND #3 AND #4

Figure 1 Flow chart of study selection.

Figure 2 Risk of bias graph.

Figure 3 Risk of bias summary.

Table 2 The Results of Three Outcome Measures

Outcome Measure	Comparison	Number	SMD (95% CI)	I^Citation2(%)	P
FMA-UE	RT+FES vs RT	4	2.57(1.16, 3.98)	95%	<0.00001
	RT+NMES vs RT	5	0.58(−0.02, 1.18)	76%	0.002
	RT+tDCS vs RT	1	0.72(0.30,1.14)	-	-
	RT+tDCS vs RT+SS	5	0.61(0.36,0.86)	24%	0.26
	RT+TEAS vs RT	10	1.16(0.61,1.70)	90%	<0.00001
	RT+TEAS vs RT+SS	2	1.72(−0.76,4.19)	95%	<0.00001
	RT+TENS vs RT	4	0.71(0.12,1.30)	74%	0.01
	RT+TENS vs RT+NMES	2	0.07(−0.47,0.61)	0%	0.92
MBI	RT+FES vs RT	3	1.09(0.26,1.91)	79%	0.009
	RT+NMES vs RT	5	0.44(−0.04,0.91)	63%	0.03
	RT+tDCS vs RT	1	0.97(0.54,1.40)	-	-
	RT+tDCS vs RT+SS	3	0.56(0.27,0.85)	0%	0.4
	RT+TEAS vs RT	9	0.92(0.45,1.38)	89%	<0.00001
	RT+TEAS vs RT+SS	2	1.24(−0.44,2.91)	91%	0.0008
	RT+TENS vs RT	2	0.21(−0.38,0.81)	0%	0.97
	RT+TENS vs RT+NMES	2	0.19(−0.35,0.73)	0%	1
MAS	RT+NMES vs RT	3	0.12(−0.47,0.70)	56%	0.1
	RT+tDCS vs RT+SS	1	0.70(0.06,1.34)	-	-
	RT+TEAS vs RT	6	0.93(0.36,1.50)	83%	<0.0001
	RT+TENS vs RT	1	−0.12(−0.94,0.69)	-	-
	RT+TENS vs RT+NMES	1	−0.11(−0.80,0.58)	-	-

Note: The bold values indicates a statistical difference.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation; FMA-UE, Fugl-Meyer Assessment for Upper Extremity; MBI, Modified Barthel Index; MAS, Modified Ashworth Scale.

Figure 4 Network plot of FMA-UE.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation.

Figure 5 Network plot of MBI.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation.

Figure 6 Network plot of MAS.

Abbreviations: RT, Rehabilitation Treatment; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation.

Figure 7 Network meta-analysis results for FMA-UE and MBI.

Notes: The bold values indicates a statistical difference.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation; FMA-UE, Fugl-Meyer Assessment for Upper Extremity; MBI, Modified Barthel Index.

Figure 8 Network meta-analysis results for MAS.

Note: The bold values indicates a statistical difference.

Abbreviations: RT, Rehabilitation Treatment; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; MAS, Modified Ashworth Scale.

Figure 9 Ranking probability figure for reduction in FMA-UE.

Note: Rank 1 is best, rank N is worst.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation; FMA-UE, Fugl-Meyer Assessment for Upper Extremity.

Figure 10 Ranking probability figure for reduction in MBI.

Note: Rank 1 is best, rank N is worst.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation; MBI, Modified Barthel Index.

Figure 11 Ranking probability figure for reduction in MAS.

Note: Rank 1 is best, rank N is worst.

Abbreviations: RT, Rehabilitation Treatment; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; MAS, Modified Ashworth Scale.

Figure 12 Funnel plot for the network meta-analysis of reduction in FMA-UE.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation.

Figure 13 Funnel plot for the network meta-analysis of reduction in MBI.

Abbreviations: RT, Rehabilitation Treatment; FES, Functional Electrical Stimulation; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation; tDCS, Transcranial Direct Current Stimulation; SS, Sham Stimulation.

Figure 14 Funnel plot for the network meta-analysis of reduction in MAS.

Abbreviations: RT, Rehabilitation Treatment; TENS, Transcutaneous Electrical Nerve Stimulation; TEAS, Transcutaneous Electrical Acupoint Stimulation; NMES, Neuromuscular Electrical Stimulation.

MenkenM, MunsatTL, TooleJF. The global burden of disease study: implications for neurology. Arch Neurol. 2000;57(3):418–420. doi:10.1001/archneur.57.3.41810714674

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