Systematic Review of Parameters of Stimulation, Clinical Trial Design Characteristics, and Motor Outcomes in Non-Invasive Brain Stimulation in Stroke

Abstract

Introduction/Objectives: Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation are two powerful non-invasive neuromodulatory therapies that have the potential to alter and evaluate the integrity of the corticospinal tract. Moreover, recent evidence has shown that brain stimulation might be beneficial in stroke recovery. Therefore, investigating and investing in innovative therapies that may improve neurorehabilitative stroke recovery are next steps in research and development. Participants/Materials and Methods: This article presents an up-to-date systematic review of the treatment effects of rTMS and tDCS on motor function. A literary search was conducted, utilizing search terms “stroke” and “transcranial stimulation.” Items were excluded if they failed to: (1) include stroke patients, (2) study motor outcomes, or (3) include rTMS/tDCS as treatments. Other exclusions included: (1) reviews, editorials, and letters, (2) animal or pediatric populations, (3) case reports or sample sizes ≤2 patients, and (4) primary outcomes of dysphagia, dysarthria, neglect, or swallowing. Results: Investigation of PubMed English Database prior to 01/01/2012 produced 695 applicable results. Studies were excluded based on the aforementioned criteria, resulting in 50 remaining studies. They included 1314 participants (1282 stroke patients and 32 healthy subjects) evaluated by motor function pre- and post-tDCS or rTMS. Heterogeneity among studies’ motor assessments was high and could not be accounted for by individual comparison. Pooled effect sizes for the impact of post-treatment improvement revealed consistently demonstrable improvements after tDCS and rTMS therapeutic stimulation. Most studies provided limited follow-up for long-term effects. Conclusion: It is apparent from the available studies that non-invasive stimulation may enhance motor recovery and may lead to clinically meaningful functional improvements in the stroke population. Only mild to no adverse events have been reported. Though results have been positive results, the large heterogeneity across articles precludes firm conclusions.

Non-Invasive Brain Stimulation Improves Paretic Limb Force Production: A Systematic Review and Meta-Analysis

“…Further, these meta-analytic findings were consistent with previous systematic reviews and meta-analyses that reported benefits of the NIBS techniques on stroke motor function assessed by various clinical assessments [25,26,28]. Thus, the present findings extended the positive effects of NIBS techniques on stroke motor recovery as indicated by quantifying a common outcome measure, paretic limb force production.…”

“…Previous meta-analysis studies reported that balanced cortical activity between M1 of the hemispheres following tDCS or rTMS protocols may contribute to motor improvements in paretic limbs (e.g., various clinical assessments or activities of daily living) [25][26][27][28]. However, Chhatbar and Feng pointed out that these meta-analytic findings are still susceptible to inconsistency in outcome measures as well as selection criteria [29].…”

Multiple sessions of transcranial direct current stimulation and upper extremity rehabilitation in stroke: A review and meta-analysis

“…Adeyemo et al (2012) demonstrated a significant effect size (0.58) of non-invasive brain stimulation on motor function. Bastani and Jaberzadeh, 2012 showed that anodal tDCS had a small non-significant effect size of 0.39 on hand function in stroke, but a moderate significant effect size of 0.59 on motor evoked potential amplitude.…”

“…Recent meta-analyses have explored the effect of tDCS in addition to rehabilitation on UE activity in stroke (Bastani and Jaberzadeh, 2012;Adeyemo et al, 2012;Butler et al, 2013;Elsner et al, 2013). Adeyemo et al (2012) demonstrated a significant effect size (0.58) of non-invasive brain stimulation on motor function.…”

Physical Therapy for Cerebellar Ataxia

“…NIBS, which is repetitive TMS (rTMS) [96,98] and transcranial direct current stimulation (tDCS) [124], over the primary motor cortex can modulate the excitability of the motor cortex [125] and is often used as an effective tool for enhancing behavioral training after stroke with hemiplegia [125][126][127][128]. Furthermore, the NIBS to the cerebellum modulates cerebellar excitability [98,[129][130][131], motor function [132,133], and motor learning [32,[134][135][136][137][138] in healthy population.…”