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Li LL, Wu JJ, Li KP, Jin J, Xiang YT, Hua XY, Zheng MX, Xu JG. Comparative efficacy of different noninvasive brain stimulation protocols on upper-extremity motor function and activities of daily living after stroke: a systematic review and network meta-analysis. Neurol Sci 2024:10.1007/s10072-024-07437-4. [PMID: 38520639 DOI: 10.1007/s10072-024-07437-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/29/2024] [Indexed: 03/25/2024]
Abstract
The objectives of the study were to systematically evaluate the rehabilitation effect of noninvasive brain stimulation (NIBS) on upper extremity motor function and activities of daily living in stroke patients and to prioritize various stimulation protocols for reliable evidence-based medical recommendations in patients with upper extremity motor dysfunction after stroke. Web of Science, PubMed, Embase, Cochrane Library, CNKI, Wanfang, VIP, and CBM were searched to collect all randomized controlled trials (RCTs) of NIBS to improve upper extremity motor function in stroke patients. The retrieval time was from the establishment of all databases to May 2023. According to the Cochrane system evaluation manual, the quality of the included studies was evaluated, and the data were extracted. Statistical analysis was carried out by using RevMan 5.3, R 4.3.0, and Stata 17.0 software. Finally, 94 RCTs were included, with a total of 5546 patients. Meta-analysis showed that NIBS improved the Fugl-Meyer assessment (FMA) score (mean difference (MD) = 6.51, 95% CI 6.20 ~ 6.82, P < 0.05), MBI score (MD = 7.69, 95% CI 6.57 ~ 8.81, P < 0.05), ARAT score (MD = 5.06, 95% CI 3.85 ~ 6.27, P < 0.05), and motor evoked potential (MEP) amplitude. The modified Ashworth scale score (MD = - 0.37, 95% CI - 0.60 to - 0.14, P < 0.05), National Institutes of Health Stroke Scale score (MD = - 2.17, 95% CI - 3.32 to - 1.11, P < 0.05), incubation period of MEP (MD = - 0.72, 95% CI - 1.06 to - 0.38, P < 0.05), and central motor conduction time (MD = - 0.90, 95% CI - 1.29 to - 0.50, P < 0.05) were decreased in stroke patients. Network meta-analysis showed that the order of interventions in improving FMA scores from high to low was anodal-transcranial direct current stimulation (tDCS) (surface under the cumulative ranking curve (SUCRA) = 83.7%) > cathodal-tDCS (SUCRA = 80.2%) > high-frequency (HF)-repetitive transcranial magnetic stimulation (rTMS) (SUCRA = 68.5%) > low-frequency (LF)-rTMS (SUCRA = 66.5%) > continuous theta burst stimulation (cTBS) (SUCRA = 54.2%) > bilateral-tDCS (SUCRA = 45.2%) > intermittent theta burst stimulation (iTBS) (SUCRA = 34.1%) > sham-NIBS (SUCRA = 16.0%) > CR (SUCRA = 1.6%). In terms of improving MBI scores, the order from high to low was anodal-tDCS (SUCRA = 88.7%) > cathodal-tDCS (SUCRA = 85.4%) > HF-rTMS (SUCRA = 63.4%) > bilateral-tDCS (SUCRA = 56.0%) > LF-rTMS (SUCRA = 54.2%) > iTBS (SUCRA = 32.4%) > sham-NIBS (SUCRA = 13.8%) > CR (SUCRA = 6.1%). NIBS can effectively improve upper extremity motor function and activities of daily living after stroke. Among the various NIBS protocols, anodal-tDCS demonstrated the most significant intervention effect, followed by cathodal-tDCS and HF-rTMS.
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Affiliation(s)
- Ling-Ling Li
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Jia-Jia Wu
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
| | - Kun-Peng Li
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Jing Jin
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yun-Ting Xiang
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Xu-Yun Hua
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China.
| | - Mou-Xiong Zheng
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China.
| | - Jian-Guang Xu
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
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Tang Z, Liu T, Han K, Liu Y, Su W, Wang R, Zhang H. The effects of rTMS on motor recovery after stroke: a systematic review of fMRI studies. Neurol Sci 2024; 45:897-909. [PMID: 37880452 DOI: 10.1007/s10072-023-07123-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) has been widely used in motor rehabilitation after stroke, and functional magnetic resonance imaging (fMRI) has been used to investigate the neural mechanisms of motor recovery during stroke therapy. However, there is no review on the mechanism of rTMS intervention for motor recovery after stroke based on fMRI explicitly. We aim to reveal and summarize the neural mechanism of the effects of rTMS on motor function after stroke as measured by fMRI. We carefully performed a literature search using PubMed, EMBASE, Web of Science, and Cochrane Library databases from their respective inceptions to November 2022 to identify any relevant randomized controlled trials. Researchers independently screened the literature, extracted data, and qualitatively described the included studies. Eleven studies with a total of 420 poststroke patients were finally included in this systematic review. A total of 338 of those participants received fMRI examinations before and after rTMS intervention. Five studies reported the effects of rTMS on activation of brain regions, and four studies reported results related to brain functional connectivity (FC). Additionally, five studies analyzed the correlation between fMRI and motor evaluation. The neural mechanism of rTMS in improving motor function after stroke may be the activation and FCs of motor-related brain areas, including enhancement of the activation of motor-related brain areas in the affected hemisphere, inhibition of the activation of motor-related brain areas in the unaffected hemisphere, and changing the FCs of intra-hemispheric and inter-hemispheric motor networks.
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Affiliation(s)
- Zhiqing Tang
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Tianhao Liu
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Kaiyue Han
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Ying Liu
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Wenlong Su
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, Shandong Province, China
| | - Rongrong Wang
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, Beijing, China.
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China.
- University of Health and Rehabilitation Sciences, Qingdao, Shandong Province, China.
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China.
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Mahmoud W, Hultborn H, Zuluaga J, Zrenner C, Zrenner B, Ziemann U, Ramos-Murguialday A. Testing spasticity mechanisms in chronic stroke before and after intervention with contralesional motor cortex 1 Hz rTMS and physiotherapy. J Neuroeng Rehabil 2023; 20:150. [PMID: 37941036 PMCID: PMC10631065 DOI: 10.1186/s12984-023-01275-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Previous studies showed that repetitive transcranial magnetic stimulation (rTMS) reduces spasticity after stroke. However, clinical assessments like the modified Ashworth scale, cannot discriminate stretch reflex-mediated stiffness (spasticity) from passive stiffness components of resistance to muscle stretch. The mechanisms through which rTMS might influence spasticity are also not understood. METHODS We measured the effects of contralesional motor cortex 1 Hz rTMS (1200 pulses + 50 min physiotherapy: 3×/week, for 4-6 weeks) on spasticity of the wrist flexor muscles in 54 chronic stroke patients using a hand-held dynamometer for objective quantification of the stretch reflex response. In addition, we measured the excitability of three spinal mechanisms thought to be related to post-stroke spasticity: post-activation depression, presynaptic inhibition and reciprocal inhibition before and after the intervention. Effects on motor impairment and function were also assessed using standardized stroke-specific clinical scales. RESULTS The stretch reflex-mediated torque in the wrist flexors was significantly reduced after the intervention, while no change was detected in the passive stiffness. Additionally, there was a significant improvement in the clinical tests of motor impairment and function. There were no significant changes in the excitability of any of the measured spinal mechanisms. CONCLUSIONS We demonstrated that contralesional motor cortex 1 Hz rTMS and physiotherapy can reduce the stretch reflex-mediated component of resistance to muscle stretch without affecting passive stiffness in chronic stroke. The specific physiological mechanisms driving this spasticity reduction remain unresolved, as no changes were observed in the excitability of the investigated spinal mechanisms.
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Affiliation(s)
- Wala Mahmoud
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Hans Hultborn
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Jagoba Zuluaga
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Christoph Zrenner
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Brigitte Zrenner
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany.
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Ander Ramos-Murguialday
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Tecnalia, Basque Research and Technology Alliance, San Sebastián, Spain
- Athenea Neuroclinics, San Sebastián, Spain
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Abstract
BACKGROUND Evidence of efficacy of repetitive transcranial magnetic stimulation (rTMS) for stroke recovery is hampered by an unexplained variability of reported effect sizes and an insufficient understanding of mechanisms of action. We aimed to (1) briefly summarize evidence of efficacy, (2) identify critical factors to explain the reported variation in effects, and (3) provide mechanism-based recommendations for future trials. METHODS We performed a systematic review of the literature according to Cochrane and PRISMA Protocols. We included trials with ≥10 patients per treatment group. We classified outcome measures according to the International Classification of Functioning, Disability, and Health. Meta-analysis was done when at least 3 trials were reported on the same construct. In case of significant summary effect sizes with significant heterogeneity, we used sensitivity analyses to test for correlations and differences between found individual effect sizes and possible effect modifiers such as patient-, repetitive transcranial magnetic stimulation-, and trial characteristics. RESULTS We included 57 articles (N=2595). Funnel plots showed no publication bias. We found significant effect sizes at the level of body function (upper limb synergies, muscle strength, language functioning, global cognitive functioning, visual/spatial inattention) with repetitive transcranial magnetic stimulation within or beyond 3 months after stroke. We also found significant effect sizes at the level of activities. We found no subgroup differences or significant correlations between individual summary effect sizes and any tested possible effect modifier. CONCLUSIONS Repetitive transcranial magnetic stimulation holds the potential to benefit a range of motor and cognitive outcomes after stroke, but the evidence of efficacy is challenged by unexplained heterogeneity across many small sampled trials. We propose large trials with the collection of individual patient data on baseline severity and brain network integrity with sufficiently powered subgroup analyses, as well as protocolized time-locked training of the target behavior. Additional neurophysiological and biomechanical data may help in understanding mechanisms and identifying biomarkers of treatment efficacy. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: CRD42022300330.
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Affiliation(s)
- Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Faculty of Science and Technology, University of Twente, Enschede, the Netherlands (J.H.)
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands (J.H.)
| | - Florien Ham
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands (J.H.)
| | - Gert Kwakkel
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, the Netherlands (G.K.)
- Department of Acquired Brain Injuries, Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, the Netherlands (G.K.)
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL (G.K.)
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Zhou L, Jin Y, Wu D, Cun Y, Zhang C, Peng Y, Chen N, Yang X, Zhang S, Ning R, Kuang P, Wang Z, Zhang P. Current evidence, clinical applications, and future directions of transcranial magnetic stimulation as a treatment for ischemic stroke. Front Neurosci 2023; 17:1177283. [PMID: 37534033 PMCID: PMC10390744 DOI: 10.3389/fnins.2023.1177283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/28/2023] [Indexed: 08/04/2023] Open
Abstract
Transcranial magnetic stimulation (TMS) is a non-invasive brain neurostimulation technique that can be used as one of the adjunctive treatment techniques for neurological recovery after stroke. Animal studies have shown that TMS treatment of rats with middle cerebral artery occlusion (MCAO) model reduced cerebral infarct volume and improved neurological dysfunction in model rats. In addition, clinical case reports have also shown that TMS treatment has positive neuroprotective effects in stroke patients, improving a variety of post-stroke neurological deficits such as motor function, swallowing, cognitive function, speech function, central post-stroke pain, spasticity, and other post-stroke sequelae. However, even though numerous studies have shown a neuroprotective effect of TMS in stroke patients, its possible neuroprotective mechanism is not clear. Therefore, in this review, we describe the potential mechanisms of TMS to improve neurological function in terms of neurogenesis, angiogenesis, anti-inflammation, antioxidant, and anti-apoptosis, and provide insight into the current clinical application of TMS in multiple neurological dysfunctions in stroke. Finally, some of the current challenges faced by TMS are summarized and some suggestions for its future research directions are made.
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Affiliation(s)
- Li Zhou
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Yaju Jin
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Danli Wu
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Yongdan Cun
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Chengcai Zhang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Yicheng Peng
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Na Chen
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Xichen Yang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Simei Zhang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Rong Ning
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Peng Kuang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Zuhong Wang
- Kunming Municipal Hospital of Traditional Chinese Medicine, Kunming, Yunnan, China
| | - Pengyue Zhang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
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Cheng S, Xin R, Zhao Y, Wang P, Feng W, Liu P. Evaluation of fMRI activation in post-stroke patients with movement disorders after repetitive transcranial magnetic stimulation: a scoping review. Front Neurol 2023; 14:1192545. [PMID: 37404941 PMCID: PMC10315664 DOI: 10.3389/fneur.2023.1192545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/25/2023] [Indexed: 07/06/2023] Open
Abstract
Background Movement disorders are one of the most common stroke residual effects, which cause a major stress on their families and society. Repetitive transcranial magnetic stimulation (rTMS) could change neuroplasticity, which has been suggested as an alternative rehabilitative treatment for enhancing stroke recovery. Functional magnetic resonance imaging (fMRI) is a promising tool to explore neural mechanisms underlying rTMS intervention. Object Our primary goal is to better understand the neuroplastic mechanisms of rTMS in stroke rehabilitation, this paper provides a scoping review of recent studies, which investigate the alteration of brain activity using fMRI after the application of rTMS over the primary motor area (M1) in movement disorders patients after stroke. Method The database PubMed, Embase, Web of Science, WanFang Chinese database, ZhiWang Chinese database from establishment of each database until December 2022 were included. Two researchers reviewed the study, collected the information and the relevant characteristic extracted to a summary table. Two researchers also assessed the quality of literature with the Downs and Black criteria. When the two researchers unable to reach an agreement, a third researcher would have been consulted. Results Seven hundred and eleven studies in all were discovered in the databases, and nine were finally enrolled. They were of good quality or fair quality. The literature mainly involved the therapeutic effect and imaging mechanisms of rTMS on improving movement disorders after stroke. In all of them, there was improvement of the motor function post-rTMS treatment. Both high-frequency rTMS (HF-rTMS) and low-frequency rTMS (LF-rTMS) can induce increased functional connectivity, which may not directly correspond to the impact of rTMS on the activation of the stimulated brain areas. Comparing real rTMS with sham group, the neuroplastic effect of real rTMS can lead to better functional connectivity in the brain network in assisting stroke recovery. Conclusion rTMS allows the excitation and synchronization of neural activity, promotes the reorganization of brain function, and achieves the motor function recovery. fMRI can observe the influence of rTMS on brain networks and reveal the neuroplasticity mechanism of post-stroke rehabilitation. The scoping review helps us to put forward a series of recommendations that might guide future researchers exploring the effect of motor stroke treatments on brain connectivity.
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Affiliation(s)
- Siman Cheng
- Department of Rehabilitation Medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Rong Xin
- Department of Rehabilitation Medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yan Zhao
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Pu Wang
- Department of Rehabilitation Medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Wuwei Feng
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Peng Liu
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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Qin Y, Liu X, Zhang Y, Wu J, Wang X. Effects of transcranial combined with peripheral repetitive magnetic stimulation on limb spasticity and resting-state brain activity in stroke patients. Front Hum Neurosci 2023; 17:992424. [PMID: 37082150 PMCID: PMC10110929 DOI: 10.3389/fnhum.2023.992424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 03/16/2023] [Indexed: 04/07/2023] Open
Abstract
Background and objectiveTranscranial magnetic stimulation and peripheral repetitive magnetic stimulation (rPMS), as non-invasive neuromodulation techniques, can promote functional recovery in patients with post-stroke spasticity (PSS), but the effects of transcranial magnetic stimulation combined with peripheral magnetic stimulation on PSS remain largely unknown. Therefore, we examined the effects of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) combined with rPMS on PSS patients and its potential neural correlates to behavioral improvements.MethodsForty-nine PSS patients were divided randomly into three groups: a combined group (n = 20), a LF-rTMS group (n = 15), and a control group (n = 14). The combined group received LF-rTMS and rPMS treatment, the rTMS group received LF-rTMS treatment, and the control group received only routine rehabilitation. All patients underwent Ashworth Spasm Scale (MAS), upper extremity Fugl-Meyer (FMA-UE), and modified Barthel Index (MBI) assessments before and after intervention. In addition, resting-state functional magnetic resonance imaging data were collected pre- and post-treatment to observe changes in the amplitude of low-frequency fluctuation (ALFF).ResultsThe MAS score was decreased, FMA-UE score and MBI scores were increased in the three groups after therapy than before therapy (all P < 0.05). In particular, the combined group showed significant effect on improved motor function and relieved spasticity in PSS (P < 0.01). Moreover, the combined treatment increased ALFF values mainly in the right supplementary motor area, right middle frontal gyrus, and right cerebellum, while reduced ALFF values mainly in the right post-central gyrus compared with pre-treatment. Compared with the LF-rTMS and control groups, the combined treatment increased ALFF values in the right cerebellum and reduced ALFF values mainly in the frontoparietal cortex. Improvements in the MAS score were positively correlated with the change in ALFF values in the right cerebellum (r = 0.698, P = 0.001) and the right supplementary motor area (r = 0.700, P = 0.001) after combined treatment.ConclusionTranscranial combined with peripheral repetitive magnetic stimulation could improve spastic state and motor function in PSS patients, and this effect may be associated with altered cerebellar and frontoparietal cortical activity.Clinical trial registrationhttp://www.chictr.org.cn/index.aspx, identifier ChiCTR1800019452.
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Affiliation(s)
- Yin Qin
- Department of Rehabilitation Medicine, The 900th Hospital of People’s Liberation Army (Fuzhou General Hospital of Nanjing Military Region), Fuzhou, Fujian, China
- *Correspondence: Yin Qin,
| | - Xiaoying Liu
- Department of Rehabilitation Medicine, The 900th Hospital of People’s Liberation Army (Fuzhou General Hospital of Nanjing Military Region), Fuzhou, Fujian, China
| | - Yinxin Zhang
- Department of Rehabilitation Medicine, The 900th Hospital of People’s Liberation Army (Fuzhou General Hospital of Nanjing Military Region), Fuzhou, Fujian, China
| | - Jiwei Wu
- Department of Rehabilitation Medicine, The 900th Hospital of People’s Liberation Army (Fuzhou General Hospital of Nanjing Military Region), Fuzhou, Fujian, China
| | - Xiaoyang Wang
- Department of Radiology, The 900th Hospital of People’s Liberation Army (Fuzhou General Hospital of Nanjing Military Region), Fuzhou, Fujian, China
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Şengül İ, Aşkın A, Altun A, Tosun A. Anti-spastic effect of contralesional dorsal premotor cortex stimulation in stroke patients with moderate-to-severe spastic paresis: a randomized, controlled pilot trial. Acta Neurol Belg 2023. [PMID: 36809647 DOI: 10.1007/s13760-023-02212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/12/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE This study aimed at investigating the effect of a single-session repetitive transcranial magnetic stimulation (rTMS) of the contralesional dorsal premotor cortex on poststroke upper-limb spasticity. MATERIAL AND METHODS The study consisted of the following three independent parallel arms: inhibitory rTMS (n = 12), excitatory rTMS (n = 12), and sham stimulation (n = 13). The primary and secondary outcome measures were the Modified Ashworth Scale (MAS) and F/M amplitude ratio, respectively. A clinically meaningful difference was defined as a reduction in at least one MAS score. RESULTS There was a statistically significant change in MAS score within only the excitatory rTMS group over time [median (interquartile range) of - 1.0 (- 1.0 to - 0.5), p = 0.004]. However, groups were comparable in terms of median changes in MAS scores (p > 0.05). The proportions of patients achieving at least one MAS score reduction (9/12 in the excitatory rTMS group, 5/12 in the inhibitory rTMS group, and 5/13 in the control group) were also comparable (p = 0.135). For the F/M amplitude ratio, main time effect, main intervention effect, and time-intervention interaction effect were not statistically significant (p > 0.05). CONCLUSIONS Modulation of the contralesional dorsal premotor cortex with a single-session of excitatory or inhibitory rTMS does not appear to have an immediate anti-spastic effect beyond sham/placebo. The implication of this small study remains unclear and further studies into excitatory rTMS for the treatment of moderate-to-severe spastic paresis in poststroke patients should be undertaken. CLINICAL TRIAL REGISTRATION NO NCT04063995 (clinicaltrials.gov).
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Fan J, Fu H, Xie X, Zhong D, Li Y, Liu X, Zhang H, Zhang J, Huang J, Li J, Jin R, Zheng Z. The effectiveness and safety of repetitive transcranial magnetic stimulation on spasticity after upper motor neuron injury: A systematic review and meta-analysis. Front Neural Circuits 2022; 16:973561. [PMID: 36426136 PMCID: PMC9679509 DOI: 10.3389/fncir.2022.973561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
To systematically evaluate the effectiveness and safety of repetitive transcranial magnetic stimulation (rTMS) on spasticity after upper motor neuron (UMN) injury. Eight electronic databases were searched from inception to August 6, 2022. Randomized controlled trials (RCTs) investigating the effectiveness and safety of rTMS on spasticity after UMN injury were retrieved. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. Review Manager 5.3 and Stata 14.0 software were used to synthesize data. The certainty of the evidence was appraised with the Grade of Recommendation, Assessment, Development and Evaluation tool. Forty-two studies with a total of 2,108 patients were included. The results of meta-analysis revealed that, compared with control group, rTMS could significantly decrease scores of the Modified Ashworth Scale (MAS) in patients with UMN injury. The subgroup analysis discovered that rTMS effectively decreased the MAS scores in patients with stroke. Meanwhile, rTMS treatment > 10 sessions has better effect and rTMS could decrease the MAS scores of upper limb. Thirty-three patients complained of twitching facial muscles, headache and dizziness, etc. In summary, rTMS could be recommended as an effective and safe therapy to relieve spasticity in patients with UMN injury. However, due to high heterogeneity and limited RCTs, this conclusion should be treated with caution.
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Affiliation(s)
- Jin Fan
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China,Mental Health Center, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Hui Fu
- Department of Rehabilitation Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaolong Xie
- Department of Rehabilitation Medicine, The Affiliated Meishan Hospital of Chengdu University of Traditional Chinese Medicine, Meishan, China
| | - Dongling Zhong
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuxi Li
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaobo Liu
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Huiling Zhang
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jun Zhang
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jiaxi Huang
- Mental Health Center, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Juan Li
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China,Juan Li,
| | - Rongjiang Jin
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China,*Correspondence: Rongjiang Jin,
| | - Zhong Zheng
- Mental Health Center, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China,Zhong Zheng,
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Chen G, Lin T, Wu M, Cai G, Ding Q, Xu J, Li W, Wu C, Chen H, Lan Y. Effects of repetitive transcranial magnetic stimulation on upper-limb and finger function in stroke patients: A systematic review and meta-analysis of randomized controlled trials. Front Neurol 2022; 13:940467. [PMID: 35968309 PMCID: PMC9372362 DOI: 10.3389/fneur.2022.940467] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention for stroke rehabilitation. Several studies have demonstrated the effectiveness of rTMS in restoring motor function. This meta-analysis aimed to summarize the current evidence of the effect of rTMS in improving upper limb function and fine motor recovery in stroke patients. Methods Three online databases (Web of Science, PubMed, and Embase) were searched for relevant randomized controlled trials. A total of 45 studies (combined n = 2064) were included. Random effects model was used for meta-analysis and effect size was reported as standardized mean difference (SMD). Results rTMS was effective in improving fine motor function in stroke patients (SMD, 0.38; 95% CI 0.19–0.58; P = 0). On subgroup analyses, for post-stroke functional improvement of the upper extremity, bilateral hemisphere stimulation was more effective than unilateral stimulation during the acute phase of stroke, and a regimen of 20 rTMS sessions produced greater improvement than <20 sessions. In the subacute phase of stroke, affected hemispheric stimulation with a 40-session rTMS regimen was superior to unaffected hemispheric stimulation or bilateral hemispheric stimulation with <40 sessions. Unaffected site stimulation with a 10-session rTMS regimen produced significant improvement in the chronic phase compared to affected side stimulation and bilateral stimulation with >10 rTMS sessions. For the rTMS stimulation method, both TBS and rTMS were found to be significantly more effective in the acute phase of stroke, but TBS was more effective than rTMS. However, rTMS was found to be more effective than TBS stimulation in patients in the subacute and chronic phases of stroke. rTMS significantly improved upper limb and fine function in the short term (0–1-month post-intervention) and medium term (2–5 months), but not for upper limb function in the long term (6 months+). The results should be interpreted with caution due to significant heterogeneity. Conclusions This updated meta-analysis provides robust evidence of the efficacy of rTMS treatment in improving upper extremity and fine function during various phases of stroke. Systematic Review Registration https://inplasy.com/inplasy-2022-5-0121/, identifier: INPLASY202250121.
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Affiliation(s)
- Gengbin Chen
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
- Postgraduate Research Institute, Guangzhou Sport University, Guangzhou, China
| | - Tuo Lin
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Manfeng Wu
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Guiyuan Cai
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Qian Ding
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jiayue Xu
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Wanqi Li
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Cheng Wu
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Hongying Chen
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yue Lan
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
- Guangzhou Key Laboratory of Aging Frailty and Neurorehabilitation, Guangzhou, China
- *Correspondence: Yue Lan
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Wang X, Ge L, Hu H, Yan L, Li L. Effects of Non-Invasive Brain Stimulation on Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Brain Sci 2022; 12:brainsci12070836. [PMID: 35884643 PMCID: PMC9312973 DOI: 10.3390/brainsci12070836] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/12/2022] [Accepted: 06/24/2022] [Indexed: 12/30/2022] Open
Abstract
In recent years, the potential of non-invasive brain stimulation (NIBS) for the therapeutic effect of post-stroke spasticity has been explored. There are various NIBS methods depending on the stimulation modality, site and parameters. The purpose of this study is to evaluate the efficacy of NIBS on spasticity in patients after stroke. This systematic review and meta-analysis was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. PUBMED (MEDLINE), Web of Science, Cochrane Library and Excerpta Medica Database (EMBASE) were searched for all randomized controlled trials (RCTs) published before December 2021. Two independent researchers screened relevant articles and extracted data. This meta-analysis included 14 articles, and all included articles included 18 RCT datasets. The results showed that repetitive transcranial magnetic stimulation (rTMS) (MD = −0.40, [95% CI]: −0.56 to −0.25, p < 0.01) had a significant effect on improving spasticity, in which low-frequency rTMS (LF-rTMS) (MD = −0.51, [95% CI]: −0.78 to −0.24, p < 0.01) and stimulation of the unaffected hemisphere (MD = −0.58, [95% CI]: −0.80 to −0.36, p < 0.01) were beneficial on Modified Ashworth Scale (MAS) in patients with post-stroke spasticity. Transcranial direct current stimulation (tDCS) (MD = −0.65, [95% CI]: −1.07 to −0.22, p < 0.01) also had a significant impact on post-stroke rehabilitation, with anodal stimulation (MD = −0.74, [95% CI]: −1.35 to −0.13, p < 0.05) being more effective in improving spasticity in patients. This meta-analysis revealed moderate evidence that NIBS reduces spasticity after stroke and may promote recovery in stroke survivors. Future studies investigating the mechanisms of NIBS in addressing spasticity are warranted to further support the clinical application of NIBS in post-stroke spasticity.
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Affiliation(s)
- Xiaohan Wang
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710072, China; (X.W.); (H.H.)
| | - Le Ge
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China;
| | - Huijing Hu
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710072, China; (X.W.); (H.H.)
| | - Li Yan
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710072, China; (X.W.); (H.H.)
- Correspondence: (L.Y.); (L.L.); Tel.: +86-186-2939-5063 (L.Y.); +86-135-6041-5367 (L.L.)
| | - Le Li
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710072, China; (X.W.); (H.H.)
- Correspondence: (L.Y.); (L.L.); Tel.: +86-186-2939-5063 (L.Y.); +86-135-6041-5367 (L.L.)
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12
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Winters B, Kuluris B, Pathmanaban R, Vanderwalt H, Thibaut A, Schnakers C. Changes of Spasticity across Time in Prolonged Disorders of Consciousness: A Retrospective Study. Brain Sci 2022; 12:295. [PMID: 35204057 DOI: 10.3390/brainsci12020295] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES In this retrospective study, we investigated how spasticity developed in patients diagnosed with a prolonged DOC over an almost two-year observation period (21 months), and how it related to the patients' age, gender, time since injury, etiology, level of consciousness, and anti-spastic medications. METHODS In total, 19 patients with a severe brain injury and prolonged DOC admitted to a long-term care facility were included in this study (14 male, age: 45.8 ± 15.3 years, 10 traumatic brain injury, 1.01 ± 0.99 years after brain injury, 11 minimally conscious state vs. 8 vegetative state). Each patient was assessed at admission and then quarterly, totaling eight assessments over 21 months. Spasticity was measured with the Modified Ashworth Scale (MAS) for both upper and lower limbs. The Western Neuro Sensory Stimulation Profile (WNSSP) was administered to assess the level of consciousness. Any other medical and demographic information of interest was obtained through medical records. Linear mixed models were used to assess each variable's impact on the change of spasticity over time. RESULTS Significant differences were observed in the evolution of spasticity in patients based on their etiology for the upper limbs [F (7, 107.29) = 2.226; p = 0.038], and on their level of consciousness for the lower limbs [F (7, 107.07) = 3.196; p = 0.004]. CONCLUSION Our preliminary results suggest that spasticity evolves differently according to the type of brain lesion and the level of consciousness. Spasticity in DOCs might therefore be mediated by different mechanisms and might have to be treated differently among patients. Future longitudinal studies should be performed prospectively in a bigger cohort and with data collection beginning earlier after brain injury to confirm our results and better understand the evolution of spasticity in this population.
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