Does noninvasive brain stimulation combined with other therapies improve upper extremity motor impairment, functional performance, and participation in activities of daily living after stroke? A systematic review and meta-analysis of randomized controlled trial

ABSTRACT

Background

Several studies have investigated the effect of noninvasive brain stimulation (NIBS) on upper limb motor function in stroke, but the evidence so far is conflicting.

Objective

We aimed to determine the effect of NIBS on upper limb motor impairment, functional performance, and participation in activities of daily living after stroke.

Method

Literature search was conducted for randomized controlled trials (RCTs) assessing the effect of “tDCS” or “rTMS” combined with other therapies on upper extremity motor recovery after stroke. The outcome measures were Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Wolf Motor Function Test (WMFT), and Barthel Index (BI). The mean difference (MD) and 95%CI were estimated for motor outcomes. Cochrane risk of bias tool was used to assess the quality of evidence.

Result

Twenty-five RCTs involving 1102 participants were included in the review. Compared to sham stimulation, NIBS combined with other therapies has effectively improved FMA-UE (MD0.97 [95%CI, 0.09 to 1.86; p = .03]) and BI score (MD9.11 [95%CI, 2.27 to 15.95; p = .009]) in acute/sub-acute stroke (MD1.73 [95%CI, 0.61 to 2.85; p = .003]) but unable to modify FMA-UE score in chronic stroke (MD-0.31 [95%CI, -1.77 to 1.15; p = .68]). Only inhibitory (MD3.04 [95%CI, 1.76 to 4.31; I² = 82%, p < .001] protocol is associated with improved FMA-UE score. Twenty minutes of stimulation/session for ≥20 sessions was found to be effective in improving FMA-UE score (Stimulation time: ES0.45; p ≤ .001; Sessions: ES0.33; p ≤ .001). The NIBS did not produce any significant improvement in WMFT as compared to sham NIBS (MD0.91 [95% CI, -0.89 to 2.70; p = .32]).

Conclusion

Moderate to high-quality evidence suggested that NIBS combined with other therapies is effective in improving upper extremity motor impairment and participation in activities of daily living after acute/sub-acute stroke.

KEYWORDS:

• Stroke
• repetitive transcranial magnetic stimulation
• noninvasive brain stimulation
• motor function
• upper extremity
• rehabilitation

Acknowledgments

The authors would like to thank the authors who responded to our email inquiry and provided the data for analysis.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Further information is available upon reasonable request.

Contributors

IA contributed to study conceptualization, data analysis and interpretation, and write-up and revision of the manuscript; RM contributed to data collection and write-up and revision of the manuscript; NB and YHY contributed to write-up and revision of the manuscript; All authors read the final draft of the manuscript and gave approval for its submission or publication.

Disclaimer

RM is editorial board member for Turkish Journal of Physiotherapy and Rehabilitation.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Additional information

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.