Effects of Bihemispheric Transcranial Direct Current Stimulation Combined With Repetitive Peripheral Nerve Stimulation in Acute Stroke Patients

Current and future clinical trials for the use of neuromodulation in the treatment of stroke: A review of the clinical Trials.gov database

Neuromodulation is a rapidly growing field in neurosurgery and has shown promise in the treatment of stroke. The aim of this study is to review current clinical trials assessing the role of neuromodulation in the treatment of stroke and post-stroke impairments. Clinical trials were found using the search terms "stroke" and "stimulation." A total of 996 clinical trials were included in this study with 386 excluded before analysis. Overall, the number of published clinical trials significantly increased over time (p < 0.001; r = 0.927). Of these, 452 (63.7 %) clinical trials were completed, 242 (34.1 %) were in the recruitment stage, and 16 (2.3 %) in the active and not recruiting stage. Of these trials, 77 were completed with published results. By treatment modality, 35 of the published trials evaluated the use of tDCS or TMS. An additional 28 of the published trials evaluated neuromuscular stimulation. Finally, three evaluated VNS, two evaluated medication treatment and nine were found evaluating a wide variety of other modalities. Other interventions included electrical stimulation of various peripheral nerves or muscles, vagal nerve stimulation, deep brain stimulation, and thermoneuromodulation. A majority of trials studied the effects of stroke on motor function (47). The remaining studies assessed outcomes including aphasia (10), pain (6), coordination and gait (5), imaging outcomes (5), swallowing (2), sensation (1) and cognition (1). There has been strong interest in studying the effect of neuromodulation on recovery after stroke with majority of the current clinical trials studying the use of tDCS or TMS to improve motor function.

Comparison of the efficacy of different protocols of repetitive transcranial magnetic stimulation and transcranial direct current stimulation on motor function, activities of daily living, and neurological function in patients with early stroke: a systematic review and network meta-analysis

BACKGROUND

The application of transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in patients with early stroke has recently received considerable attention, but the optimal protocol remains inconclusive. This study intends to evaluate and compare the effects of different protocols of tDCS and rTMS on improving motor function, activities of daily living (ADL), and neurological function in patients with early stroke, and to comprehensively assess their efficacy and safety.

METHODS

MEDLINE, Embase, Cochrane Library, and Web of Science were searched. Risk of bias (RoB) was assessed using the Cochrane Risk of Bias 2.0 tool, and Bayesian NMA was conducted using R4.3.1 and Stata16.

RESULTS

The results of NMA showed that after early intervention, bilateral application of high- and low-frequency rTMS (BL-rTMS) performed best in improving the upper extremity motor function at the end of intervention (SUCRA: 92.8%) and 3 months (SUCRA: 95.4%). Besides, low-frequency rTMS (LF-rTMS) performed best in improving the lower extremity motor function (SUCRA: 67.7%). BL-rTMS was the most effective in ameliorating the ADL at the end of intervention (SUCRA: 100%) and 3 months (SUCRA: 85.6%). In terms of the NIHSS scores, BL-rTMS had the highest probability of being the most effective measure at the end of intervention (SUCRA: 99.7%) and 3 months (SUCRA: 97.05%). Besides, LF-rTMS (0%), 5 Hz-rTMS (0%), and intermittent theta-burst stimulation (iTBS) (0%) all exhibited a good safety profile.

CONCLUSION

BL-rTMS is the optimal stimulation protocol for improving upper extremity motor function, ADL, and neurological function in early stroke, with long-term efficacy.

Effects of repetitive transcranial magnetic stimulation combined with repetitive peripheral magnetic stimulation on upper limb motor function after stroke: a systematic review and meta-analysis

Objective

To evaluate the effectiveness of repetitive transcranial magnetic stimulation (rTMS) combined with repetitive peripheral magnetic stimulation (rPMS) on upper limb motor dysfunction after stroke.

Methods

We systematically searched databases up to May 2024, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, Wanfang, and CBM. Randomized controlled trials (RCTs) examining the application of rTMS combined rPMS on upper limb motor dysfunction after stroke were included based on predefined inclusion criteria. We used Cochrane Risk of Bias 2 tool to assess bias risk of the included RCTs. Meta-analysis was conducted using RevMan 5.4 and Stata 17.0 software.

Results

A total of 9 RCTs involving 483 participants were included in this study. Compared with the control groups that used either conventional therapy or rTMS alone, the experimental group that used rTMS combined rPMS showed significant improvements in stroke patients' upper limb motor function [MD = 3.65, 95% CI (2.75, 4.54), P < 0.05], ability of daily living [MD = 4.50, 95% CI (3.50, 5.50), P < 0.05], and spasticity [MD = -0.34, 95% CI (-0.48, -0.20), P < 0.05]. Meanwhile, in terms of neurophysiological indicators, significant differences were found both for motor evoked potential latency [MD = -1.77, 95% CI (-3.19, -0.35), P < 0.05] and motor evoked potential amplitude [MD = 0.25, 95% CI (0.01, 0.49), P < 0.05].

Conclusion

This study provides low-level evidence that the therapy of LF-rTMS or HF-rTMS combined with rPMS can improve the upper limb motor function and daily living ability of stroke patients. However, given that the low quality of the evidence for the evaluation results, further evidence from high-quality studies is needed to substantiate this conclusion.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024539195, PROSPERO Platform [CRD42024539195].

Repetitive peripheral sensory stimulation for motor recovery after stroke: a scoping review

BACKGROUND AND PURPOSE

Enhancing afferent information from the paretic limb can improve post-stroke motor recovery. However, uncertainties exist regarding varied sensory peripheral neuromodulation protocols and their specific impacts. This study outlines the use of repetitive peripheral sensory stimulation (RPSS) and repetitive magnetic stimulation (rPMS) in individuals with stroke.

METHODS

This scoping review was conducted according to the JBI Evidence Synthesis guidelines. We searched studies published until June 2023 on several databases using a three-step analysis and categorization of the studies: pre-analysis, exploration of the material, and data processing.

RESULTS

We identified 916 studies, 52 of which were included (N = 1,125 participants). Approximately 53.84% of the participants were in the chronic phase, displaying moderate-to-severe functional impairment. Thirty-two studies used RPSS often combining it with task-oriented training, while 20 used rPMS as a standalone intervention. The RPSS primarily targeted the median and ulnar nerves, stimulating for an average of 92.78 min at an intensity that induced paresthesia. RPMS targeted the upper and lower limb paretic muscles, employing a 20 Hz frequency in most studies. The mean stimulation time was 12.74 min, with an intensity of 70% of the maximal stimulator output. Among the 114 variables analyzed in the 52 studies, 88 (77.20%) were in the "s,b" domain, with 26 (22.8%) falling under the "d" domain of the ICF.

DISCUSSION AND CONCLUSION

Sensory peripheral neuromodulation protocols hold the potential for enhancing post-stroke motor recovery, yet optimal outcomes were obtained when integrated with intensive or task-oriented motor training.

Transcranial direct current stimulation for upper extremity motor dysfunction in poststroke patients: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of transcranial direct current stimulation in poststroke patients with upper extremity motor dysfunction using a systematic review and meta-analysis.

DATA SOURCES

We searched the Web of Science, Cochrane Library, EMBASE, and PubMed for randomized controlled trials investigating the effects of both active and sham stimulation up until January 27, 2024.

REVIEW METHODS

Efficacy, including the upper extremity Fugl-Meyer Assessment, Action Research Arm Test, Barthel Index, and safety, were assessed. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool and the Physiotherapy Evidence Database Scale. Meta-analysis was performed using the RevMan 5.4 software.

RESULTS

Forty-four studies with 1555 participants were included. Transcranial direct current stimulation proved effective in improving upper extremity motor function (standardized mean difference = 0.22, 95% confidence interval: 0.12-0.32, P < 0.001) and Barthel Index (mean difference = 4.65, 95% confidence interval: 2.82-6.49, P < 0.001). Subgroup analysis revealed the highest transcranial direct current stimulation efficacy in patients with subacute stroke. Both anodal and cathodal stimulation were effective against upper extremity motor dysfunction. C3/C4 was the most effective stimulus target. Optimal stimulation parameters included stimulus current densities <0.057 mA/cm2 for 20-30 min and <30 sessions. Adverse effects and dropouts during follow-up showed that transcranial direct current stimulation is safe and feasible.

CONCLUSIONS

Our findings suggest that both anodal and cathodal stimulation were significantly effective in subacute stroke patients, particularly when preceding other treatments and when C3/C4 is targeted.

Early transcranial direct current stimulation with modified constraint-induced movement therapy for motor and functional upper limb recovery in hospitalized patients with stroke: A randomized, multicentre, double-blind, clinical trial

BACKGROUND

Constraint-induced movement therapy (CIMT) and transcranial direct current stimulation (tDCS) are used to reduce interhemispheric imbalance after stroke, which is why the combination of these therapies has been used for neurological recovery, but not in the acute phase.

OBJECTIVES

To evaluate the effectiveness of combining active or sham bihemispheric tDCS with modified CIMT (mCIMT) for the recovery of the Upper Limb (UL) in hospitalized patients with acute and subacute stroke.

METHODS

This randomized controlled, double-blind, placebo-controlled, parallel group clinical trial was executed between September 2018 to March 2021 recruited 70 patients. The patients were randomized to one of two groups to receive treatment for 7 consecutive days, which included 20 min of active or sham bihemispheric tDCS daily (anodal ipsilesional and cathodal contralesional), with an mCIMT protocol. The primary outcome was the difference in the evolution of motor and functional upper limb recovery with assessment on days 0, 5, 7, 10 and 90. The secondary outcomes were independence in activities of daily living (ADL) and quality of life.

RESULTS

The active group presented a statistically significant gap compared to the simulated group throughout the trend in the scores of the FMA (motor function and joint pain) and WMFT (functional ability and weight to box) (p < 0.05) and showed a minimal clinically important difference (FMA: difference between groups of 4.9 points [CI: 0.007- 9.799]; WMFT: difference between groups of 6.54 points [CI: 1.10-14.15]). In the secondary outcomes, there was a significant difference between the groups in ADL independence (Functional Independence Measure: difference of 8.63 [CI: 1.37-18.64]) and perceived recovery of quality of life evaluated at 90 days (p = 0.0176).

CONCLUSIONS

Combining mCIMT with bihemispheric tDCS in patients hospitalized with acute-subacute stroke allows us to maximize the motor and functional recovery of the paretic upper limb in the early stages and independence in ADL, maintaining the effects over time.