Repetitive transcranial magnetic stimulation of lower limb motor function in patients with stroke: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objective: The aim of this study was to evaluate the effects of repetitive transcranial magnetic stimulation (rTMS) on the post-stroke recovery of lower limb motor function. Data sources: We searched the databases of PubMed, Cochrane Library, and Embase. The randomized controlled trials were published by 25 January 2019. Review methods: We included randomized controlled trials that evaluated the effects of rTMS on lower limb motor recovery in patients with stroke. Two reviewers independently screened the searched records, extracted data, and assessed the risk of bias. The treatment effect sizes were pooled in a meta-analysis by using the RevMan 5.3 software. The internal validity was assessed using topics suggested by the Physiotherapy Evidence Database (PEDro). Results: Eight studies with 169 participants were included in the meta-analysis. Pooled estimates demonstrated that rTMS significantly improved the body function of the lower limbs (standardized mean difference (SMD) = 0.66; P < 0.01), lower limb activity (SMD = 0.66; P < 0.01), and motor-evoked potential (SMD = 1.13; P < 0.01). The subgroup analyses results also revealed that rTMS improved walking speed (SMD = 1.13) and lower limb scores on the Fugl-Meyer Assessment scale (SMD = 0.63). We found no significant differences between the groups in different mean post-stroke time or stimulation mode over lower limb motor recovery. Only one study reported mild adverse effects. Conclusion: rTMS may have short-term therapeutic effects on the lower limbs of patients with stroke. Furthermore, the application of rTMS is safe. However, this evidence is limited by a potential risk of bias.

Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls

“…In detail, the results included the following: seven studies for motor function, 62–68 three for manual dexterity, 69–71 three for walking and balance, 72–74 three for spasticity, 64,75,76 six for dysphagia, 77–82 five for aphasia, 83–87 three for unilateral neglect, 88–90 three for post-stroke depression and vascular depression, 66,91,92 one for cognitive function, 66 and one for CPSP. 93 The study by Graef and colleagues 64 included data on both motor function and spasticity and, therefore, the results were independently considered for both categories.…”

“…73 Conversely, Tung and colleagues found a positive effect of rTMS on lower limb motor function, regardless of the stimulation frequency or stroke phase. 72…”

These legs were made for propulsion: advancing the diagnosis and treatment of post-stroke propulsion deficits

“…Restorative therapies that aim to restore the normal functioning of the neural circuits affected by stroke may have strong potential to improve post-stroke propulsion. For example, neuromodulatory treatments such as repetitive TMS and transcranial direct current stimulation can be paired with gait training interventions to augment the excitability of the lesioned corticospinal pathways [80][81][82][83][84]. Paired associative stimulation has also been used to promote targeted plasticity in corticospinal circuits in individuals with stroke and spinal cord injury [85][86][87].…”

Individualized Responses to Ipsilesional High-Frequency and Contralesional Low-Frequency rTMS in Chronic Stroke: A Pilot Study to Support the Individualization of Neuromodulation for Rehabilitation

“…This is in part due to the location of the lower extremity motor neurons being deeper within the brain and thus needing a more powerful magnetic field to penetrate further from the coil to elicit responses, especially in clinical populations such as stroke. Even with this knowledge, most studies using rTMS to modulate the lower extremity cortical representations have not used a double-cone coil (Tung et al, 2019). Along with the few studies measuring clinical outcomes with double-cone coil delivered rTMS post-stroke, there are even fewer studies reporting the neurophysiological changes that occur with this type of treatment (Huang et al, 2018).…”

“…Wang et al (2012) and Kakuda et al (2013) paired rTMS with task-oriented training and reported improvements in clinical variables such as gait speed, step length, and double-support time. A promising recent meta-analysis by Tung et al (2019) showed that rTMS paired with lower extremity task-oriented training generally improved clinical outcomes (e.g., LE Fugl-Meyer, gait speed, and Berg balance) to a greater degree than training without rTMS. However, differences in rTMS protocols, task training, and coil types make it hard to form strong conclusions about the effectiveness of physical therapy augmented with rTMS.…”