To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to post-stroke upper limb spasticity, using the ICF classification.
Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects.
Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge’s g) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/Function, Activity, and Participation levels of the International Classification of Functioning.
Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects (g = 0.46; 95% CI: 0.33–0.59, p < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function (g = 0.41; 95% CI: 0.28–0.55; p < 0.01) and Activity outcomes (g = 0.47; 95% CI: 0.34–0.60, p < 0.01), while Participation outcomes failed to reach significance (g = 0.38; 95% CI: -0.29-1.04, p = 0.27). Superior benefits for Body Structure/Function (g = 0.56) and Activity outcomes (g = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results (k = 4) suggested small to medium effects for cognitive outcomes (g = 0.41; 95% CI: 0.28–0.55; p < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury.
VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.
Stroke is one of the leading global causes of disability [1, 2], with over 17 million individuals worldwide sustaining a stroke each year . Although stroke mortality is decreasing with improvements in medical technology , the neurological trauma resulting from stroke can be devastating, and the majority of stroke survivors have substantial motor [4, 5], cognitive [6–9] and functional rehabilitation needs [3, 10, 11], and much reduced quality of life [3, 12, 13]. Targeted rehabilitation can help address some of these post-stroke deficits, however, historically, many individuals, in particular patients with cognitive impairment, have difficulty engaging in standard therapies [14–16] at a level that will produce meaningful and lasting improvements [16–19]. Enriched and interactive rehabilitation programs are clearly needed to minimize functional disability [13, 20], increase participation in age-appropriate roles and activities , lead to greater motivation and treatment compliance [17, 22], and reduce the long-term expense of care in stroke survivors [20, 23, 24].
Virtual reality refers to simulated interactions with environments and events that are presented to the performer with the aid of technology. These so-called virtual environments may mirror aspects of the real world or represent spaces that are far removed from it, while allowing various forms of user interaction through movement and/or speech . Virtual reality based rehabilitation, or Virtual Rehabilitation (VR), shows considerable promise as a safe, engaging, interactive, patient-centered and relatively inexpensive medium for rehabilitation training [26–31]. VR has the potential to target a wide range of motor, functional, and cognitive issues , affords methods that automatically record and track patient performance , and offers a high level of flexibility and control over therapeutic tasks [17, 18, 33]. This scalability allows patients to train at the highest intensity that would be possible for their individual ability , while keeping the experience of interaction with therapeutic tasks enjoyable and compelling [17, 29]. At the same time, VR may enable patients with a neurodisability (like stroke) to practice without excessive physical fatigue [32, 35] which otherwise may deter continued effort and engagement in therapy [36, 37].
Currently, there are two main types of VR: purpose-designed Virtual Environments (VE) and Commercial Gaming (CG) systems. Both types of systems can provide augmented feedback, additional forms of sensory feedback about the patient’s movement over and above the feedback that is provided as a natural consequence of the movement itself [11, 38]. VE systems are often designed by rehabilitation scientists (and others) to enhance the delivery of augmented feedback in order to develop the patient’s sense of position in space [39–41], to reinforce different movement parameters (like trajectory and endpoint) and reduce extraneous movements (e.g. excessive trunk displacement) [42, 43].
VE systems are also more likely to involve specially designed tangible user interfaces used in mixed reality rehabilitation systems  or training of daily functional activities . By comparison, CG rehabilitation systems are typically “off-the-shelf” devices such as Wii (Nintendo), Xbox (Microsoft) and PlayStation (Sony), which have the advantage of being readily available and relatively inexpensive when compared with VE systems . On the other hand, CG systems are typically designed for able-bodied participants and may not consider the physiological, motor, and cognitive aspects of recovery in rehabilitation, and may lack the scalability of purpose-designed VE systems .
There is conflicting evidence about the relative effectiveness of VE- and CG-based VR systems. In a recent Cochrane review of VR following stroke , VE systems demonstrated a significant treatment effect on upper-limb function when compared to controls (d = 0.42; 95%CI: 0.07–0.76), while the effect for CG systems failed to reach significance (d = 0.50; 95%CI: -0.04-1.04); a caveat, however, was that only two of nine studies (22%) in these comparisons were CG-based. In contrast, a meta-analysis by Lohse and colleagues of VR following stroke  found no significant difference between VE (g = 0.43, based on 13 studies) and CG interventions (g = 0.76, based on three studies) on Body Structure/Function level outcomes. For Activity level outcomes, CG interventions showed a large but non-significant effect (g = 0.76, p = 0.14), but was based on only four of 26 studies (15%); VE interventions, however, showed a significant treatment effect (g = 0.54, p < .001). Taken together, these two reviews suggest benefits of VE systems, while previous analyses of CG treatment effects have been underpowered and inconclusive.
Cognitive impairments, including difficulties in attention, language, visuospatial skills, memory, and executive function are common and persistent sequelae of stroke [14, 47] and exert considerable influence on rehabilitation outcomes . Cognitive dysfunction may reduce the ability to (re-)acquire motor [25, 49–52] and functional skills , and decrease engagement and participation in rehabilitation program [48, 53]. While the important role of cognition in both conventional and VR-based rehabilitation is increasingly recognized [52–54] the impact of VR on cognitive function has not yet been formally evaluated in a quantitative review.
The World Health Organization’s International Classification of Functioning, Disability, and Health (ICF-WHO ) is currently one of the most widely used classification systems. It is a foundation for understanding outcome effects in clinical practice  and the preferred means for translating clinical findings in a patient-centered manner . Under the ICF-WHO, disability and functioning are seen to arise by the interaction of the health condition, the environment, and personal factors, and can be measured at three main levels: (i) Body Structure/Function, (ii) Activity (or skill), and (iii) Participation. The ICF-WHO has been used to classify outcome measures in studies of VR (for example ) and in recent systematic reviews [11, 58, 59]. A brief critique of these reviews reveals a number of important conclusions, but also some significant gaps in the research.
An early systematic review by Crosbie and colleagues  examined the efficacy of VR for stroke upon motor and cognitive outcomes. Of the 11 studies reviewed (up to 2005), only five addressed upper-limb function and two addressed cognitive outcomes. Overall, the review reported significant benefits of VR, but only three studies were RCTs and no effect size estimates were reported. At around the same time, a systematic review by Henderson and colleagues  showed that there was very good evidence that immersive VR was more beneficial than no therapy for upper-limb rehabilitation in adult stroke, but insufficient evidence for non-immersive VR. Comparisons with traditional physical therapy were less impressive, however.
A 2016 systematic review by Vinas-Diz and colleagues  included both controlled clinical trials and randomized controlled trials (RCTs) in stroke, and spanned 2009–2014. The review included 25 papers: four systematic reviews [19, 46, 63, 64] and 21 original trials. Evidence for treatment efficacy on upper-limb function was strong on a mix of measures like the Fugl-Meyer Test, Wolf Motor Function Test, and Motricity Index. However, a quantitative analysis of the effects was not undertaken, and important aspects of treatment implementation like dose and session scheduling were not formally examined.
A recent systematic review by Santos-Palma and colleagues  examined the efficacy of VR on motor outcomes for stroke using the ICF-WHO framework, covering work published up to June 2015. Of the studies deemed high quality, 20 examined outcomes at the Body Structure/Function level, 17 at the Activity level, and eight examined Participation. Intriguingly, positive outcomes were evident only at the Body Structure/Function level, while results for Activity and Participation were not conclusive. Unfortunately, only three studies addressed manual ability at the Activity level, which severely limited any evaluation of skill-specific effects.
In a combined systematic review and meta-analysis of 37 RCTs published between 2004 and 2013, Laver and colleagues  present a more comprehensive examination of the effects of VR on upper-limb function. As well, they classified outcomes broadly into upper-limb function, Activities of Daily Living (ADLs) and other aspects of motor function. In general, study quality was low, and the risk of bias high, in roughly one-half of the studies. Outcomes were significant for upper-limb function (d = 0.28) and ADLs (d = 0.43), but somewhat smaller than those reported by Lohse and colleagues . Results for other aspects of motor function, including several at what may be considered the Body Structure/Function level, were non-significant. Dose varied considerably between studies, ranging from less than 5 h to more than 21 h in total. In general, studies that used higher doses (> 15 h of therapy) were reported as more effective. Unfortunately, results could not be pooled for cognitive outcomes, and the importance of additional treatment implementation parameters like training frequency and duration, and the impact of specific study design factors including the recovery stage of participants and type of control group (i.e. active vs passive) were not determined.
An updated systematic review by Laver and colleagues , included an additional 35 studies that reported outcomes for upper limb function and activity. A subset of only 22 studies that compared VR with conventional therapy showed no significant effect of VR on upper-limb function (d = 0.07). As well, there was no significant difference between higher (> 15 h of therapy), and lower levels of dose. However, when VR was used in addition to usual care (10 studies; 210 participants), there was a significant effect on upper-limb outcomes (d = 0.49). As before, no significant difference was shown between high and low dose studies. Unfortunately, analysis of cognitive outcomes, and moderator analyses including study quality, and implementation parameters (e.g., daily intensity, weekly intensity, treatment frequency, and total number of sessions) were not included in the updated review. As well, the assessment of study quality was limited to the 5-item GRADE system, the ICF classification system was not given full consideration, and no distinction was drawn between treatment as usual (TAU) and active control groups (TAU + some form of additional therapy).
Taken together, recent reviews on the use of VR for adult stroke show encouraging evidence of efficacy at the level of Body Structure/Function, but mixed results for Activity and ADLs, and a paucity of evidence bearing on Participation. The impact and effectiveness of VR on cognitive outcomes also remains poorly understood, despite the important role of cognitive dysfunction in learning and rehabilitation [17, 18], and increased evidence of interconnection between cognitive function and motor deficits at the Body Structure/Function, Activity and Participation levels of the ICF . VE-based platforms have been suggested to be superior to CG approaches  in promoting motor function, but until recently there have been few CG studies available for analysis. As well, other design factors that may moderate treatment effects (like stage of recovery, control group type) have either not been explored or are too few in number to draw firm conclusions. There has been considerable variation in the total dose of VR therapy [46, 60], and no analysis has yet tested the dose-response relationship in moderator analyses. Finally, the bulk of conclusions have relied on qualitative synthesis, and there is a paucity of quantitative analysis of empirical data to inform opinion.
In view of limitations in past reviews and continued acceleration in VR the aim of our review was to conduct a systematic literature review and meta-analysis to re-evaluate the strength of evidence bearing on VR of upper-limb function and cognition in stroke. This review is critical given evidence that stroke rehabilitation needs to better optimize intervention techniques during the recovery windows that exist in the acute phase  and beyond. Focusing only on RCTs, we consider outcomes across levels of the ICF-WHO, and analyze the moderating effect of design factors and dose-related parameters.
The current review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement , it should be noted that the protocol was not registered.
Scopus, Cochrane Database, CINAHL, The Allied and Complementary Medicine Database, Web of Science, MEDLINE, Pre-Medline, PsycEXTRA, and PsycINFO databases were systematically searched from inception until 28 June 2017. Boolean search terms included the following: “stroke, cerebrovascular disease, or cerebrovascular attack” and “Virtual reality, Augment* reality, virtual gam*” (see Appendix for an example of the full MEDLINE search strategy).
RCT studies published in English in peer-reviewed journals, utilizing a VR intervention to address either motor (upper-limb), cognitive, or activities of daily living in stroke patients were included in the current review (see Fig. 1). VR was defined as a type of user-computer interface that involves real-time simulation of an activity/environment, enabling the user to interact with the environment using motor actions and sensory systems. Comparison groups included “usual care”, “standard care” or “conventional therapy”, involving physical therapy and/or occupational therapy. Studies were excluded that applied a “hybrid” approach combining virtual reality with exogenous stimulation or robotics, targeted lower limb function, recruited a mixed study cohort including non-stroke participants, or did not utilize motor, cognitive, or participation outcome measures.
Objective. The aim of this study was to perform a meta-analysis to examine whether virtual reality (VR) training is effective for lower limb function as well as upper limb and overall function in chronic stroke patients. Methods. Three databases, OVID, PubMed, and EMBASE, were used to collect articles. The search terms used were “cerebrovascular accident (CVA),” “stroke”, and “virtual reality”. Consequently, twenty-one studies were selected in the second screening of meta-analyses. The PEDro scale was used to assess the quality of the selected studies. Results. The total effect size for VR rehabilitation programs was 0.440. The effect size for upper limb function was 0.431, for lower limb function it was 0.424, and for overall function it was 0.545. The effects of VR programs on specific outcomes were most effective for improving muscle tension, followed by muscle strength, activities of daily living (ADL), joint range of motion, gait, balance, and kinematics.Conclusion. The VR training was effective in improving the function in chronic stroke patients, corresponding to a moderate effect size. Moreover, VR training showed a similar effect for improving lower limb function as it did for upper limb function.
Stroke is a major cause of death in the modern world; it also causes sensory, motor, cognitive, and visual impairments and restricts performance of activities of daily living (ADL) . Motor impairments are observed in 80% of stroke patients, and these can include loss of balance and gait . These problems are important targets of rehabilitation, because they reduce the ability of individuals to perform ADL and this result in impaired community activities [3, 4].
Most studies on balance and gait rehabilitation have shown positive effects. However, training-based methods often become tiresome are resource-intensive and require specialized facilities or equipment. Therefore, there is a demand for economical and safe methods of rehabilitation .
Virtual reality (VR) is defined by “the use of interactive simulations created with computer hardware and software to present users with opportunities to engage in environments that appear and feel similar to real world objects and events.” Participants interact with projected images, maneuver virtual objects and perform activities programmed into the task, giving the user a sense of immersion in the simulated environment. Various forms of feedback are provided through the environment, the most common being visual and auditory, to enhance enjoyment and motor learning through real-time feedback and immediate results . VR training using these features has recently been widely used in the field of stroke rehabilitation . VR training aims to improve neural plasticity by providing a safe and enriched environment to perform functional task-specific activities with increased repetitions, intensity of practice, and motivation to comply with the intervention .
In the field of stroke rehabilitation, VR training is reported to be mostly effective at increasing upper limb joint range of motion, improving sensation, muscle strengthening, reducing pain, and improving functional processes. Recently, various VR programs have been developed and implemented for the lower limbs as well as the upper limbs, and their effects are being tested. VR training for stroke patients has been shown to be safe and cost-effective at improving lower limb function, specifically improving balance, stair climbing speed, ankle muscle strength, range of motion, and gait speed . Compared with existing treatment methods, it may be more effective at improving dynamic balance control and preventing falls in subacute and chronic stroke patients .
Treatment methods using VR provide a virtual environment for ADLs that are difficult to perform in a hospital, and therefore, it could be very effective at improving both upper limb and lower limb function. However, because the lower limbs have to support the weight of the body, various elements are required, including muscle strength and balance to control body weight, joint movements, and cognitive ability to integrate these other elements. Although studies related to VR training have been increasing in recent years, VR intervention has been used more extensively to improve upper limb function, which is relatively easier to apply than lower limb function.
Furthermore, doubts could be raised as to whether VR treatment methods for the lower limbs can improve these elements; these doubts related to lack of VR equipment or programs, as well as safety issues or dizziness during treatment. For this reason, we aimed to perform a meta-analysis as a scientific method to test the effects of uncertain treatment methods using statistical methods, in order to examine whether VR training is effective for lower limb function as well as upper limb function. […]
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The KTDRR Center and the international Campbell Collaboration are working together to offer a five-part training course that focuses on high-quality methods for synthesis of evidence, including the procedures and methods for conducting systematic reviews/research syntheses as well as software, tools, and strategies for analyzing and reporting data. The training materials are developed by representatives of the Campbell Collaboration. Online resources from various national and international organizations will be provided for each session.
This fifth and final webcast in the series is a pre-recorded session that provides an overview of the foundation of meta-analysis: an effect size (a quantitative indicator of a treatment effect or relation between two variables) and discusses the basic processes of a meta-analysis and how the technique can be used to answer complex questions asked by policymakers and practitioners. (NOTE: This session was previously aired live on September 20, 2018.)
Ryan Williams, PhD, is a principal researcher at AIR and leads large-scale evaluations and research syntheses. Dr. Williams’ work focuses on improving generalizations in education research through research synthesis. He is currently the Principal Investigator (PI) on an Institute for Educational Sciences (IES) meta-analysis that is exploring sources of heterogeneity in mathematics intervention effects. He also is a co-PI of an IES methods training institute for advanced meta-analysis. Dr. Williams is Associate Methods Editor of The Campbell Collaboration Education Coordinating Group.
Joshua Polanin, PhD, is a principal researcher at AIR who has experience in the application and use of quantitative methodology in criminal justice, education, and behavioral health. He is the PI of two National Institute of Justice–funded systematic reviews and meta-analyses and the co-PI of one IES-funded systematic review and meta-analysis. In addition, he currently serves as the project director for the What Works Clearinghouse’s Statistics, Website, and Training (SWAT) contract and is co-PI of an IES methods training institute for advanced meta-analysis. Dr. Polanin is also active in The Campbell Collaboration and served as an Associate Editor of the Methods Group.
and purpose: The benefits of Kinesio taping (KT) in post-stroke rehabilitation have not been determined. This study aimed to evaluate its effects on lower-extremity rehabilitation in patients after a stroke.
A literature search was performed using EBSCOhost, Embase, Physiotherapy Evidence Database (PEDro), PubMed, Cochrane, Web of Science, China National Knowledge Infrastructure (CNKI), SinoMed, and Wanfang Data through June 2018. Randomized controlled trials (RCTs) on the use of KT during lower-extremity, post-stroke rehabilitation were selected. Meta-analysis was conducted.
A total of 14 RCTs of low to moderate quality were reviewed and included 783 participants. Results indicated that KT significantly improved patients’ lower extremity spasticity, motor function, balance, ambulation, gait parameters, and daily activities, with few adverse effects.
KT may have positive effects on lower-extremity, post-stroke rehabilitation. Due to the limited number and quality of the research, additional studies are needed to identify KT benefits.
This study was to investigate the effectiveness of action observation therapy on arm and hand motor function, walking ability, gait performance, and activities of daily living in stroke patients.
Searches were completed in January 2019 from electronic databases, including PubMed, Scopus, the Cochrane Library, and OTseeker.
Two independent reviewers performed data extraction and evaluated the study quality by the PEDro scale. The pooled effect sizes on different aspects of outcome measures were calculated. Subgroup analyses were performed to examine the impact of stroke phases on treatment efficacy.
Included were 17 articles with 600 patients. Compared with control treatments, the action observation therapy had a moderate effect size on arm and hand motor outcomes (Hedge’s g = 0.564; P < 0.001), a moderate to large effect size on walking outcomes (Hedge’s g = 0.779; P < 0.001), a large effect size on gait velocity (Hedge’s g = 0.990; P < 0.001), and a moderate to large effect size on activities of daily function (Hedge’s g = 0. 728; P = 0.004). Based on subgroup analyses, the action observation therapy showed moderate to large effect sizes in the studies of patients with acute/subacute stroke or those with chronic stroke (Hedge’s g = 0.661 and 0.783).
via Action observation therapy for improving arm function, walking ability, and daily activity performance after stroke: a systematic review and meta-analysis – Tzu-Hsuan Peng, Jun-Ding Zhu, Chih-Chi Chen, Ruei-Yi Tai, Chia-Yi Lee, Yu-Wei Hsieh, 2019
The aim of this study is to investigate the effectiveness of electrical stimulation in arm function recovery after stroke.
Data were obtained from the PubMed, Cochrane Library, Embase, and Scopus databases from their inception until 12 January 2019. Only randomized controlled trials (RCTs) reporting the effects of electrical stimulation on the recovery of arm function after stroke were selected.
Forty-eight RCTs with a total of 1712 patients were included in the analysis. The body function assessment, Upper-Extremity Fugl-Meyer Assessment, indicated more favorable outcomes in the electrical stimulation group than in the placebo group immediately after treatment (23 RCTs (n = 794): standard mean difference (SMD) = 0.67, 95% confidence interval (CI) = 0.51–0.84) and at follow-up (12 RCTs (n = 391): SMD = 0.66, 95% CI = 0.35–0.97). The activity assessment, Action Research Arm Test, revealed superior outcomes in the electrical stimulation group than those in the placebo group immediately after treatment (10 RCTs (n = 411): SMD = 0.70, 95% CI = 0.39–1.02) and at follow-up (8 RCTs (n = 289): SMD = 0.93, 95% CI = 0.34–1.52). Other activity assessments, including Wolf Motor Function Test, Box and Block Test, and Motor Activity Log, also revealed superior outcomes in the electrical stimulation group than those in the placebo group. Comparisons between three types of electrical stimulation (sensory, cyclic, and electromyography-triggered electrical stimulation) groups revealed no significant differences in the body function and activity.
via Effectiveness of electrical stimulation therapy in improving arm function after stroke: a systematic review and a meta-analysis of randomised controlled trials – Jheng-Dao Yang, Chun-De Liao, Shih-Wei Huang, Ka-Wai Tam, Tsan-Hon Liou, Yu-Hao Lee, Chia-Yun Lin, Hung-Chou Chen, 2019
INTRODUCTION: Results of several recent studies suggest that tendon/muscle vibration treatment may improve motor performance and reduce spasticity in individuals with stroke. We performed a systematic review and meta-analysis to assess the efficacy of tendon/muscle vibration treatment for upper limb functional movements in persons with subacute and chronic stroke.
EVIDENCE ACQUISITION: We searched MEDLINE (Ovid), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials (Wiley) from inception to September 2017. We included randomized controlled trials comparing upper limb tendon/muscle vibration to sham treatment/rest or conventional interventions in persons with subacute and chronic stroke. Our primary outcome was upper limb functional movement at the end of the treatment period.
EVIDENCE SYNTHESIS: We included eight trials enrolling a total of 211 participants. We found insufficient evidence to support a benefit for upper limb functional movement (standard mean difference -0.32, 95% confidence interval (CI) -0.74 to 0.10, I2 25%, 6 trials, 135 participants). Movement time for reaching tasks significantly decreased after using tendon/muscle vibration (standard mean difference -1.20, 95% CI -2.05 to -0.35, I2 65%, 2 trials, 74 participants). We also found that tendon/muscle vibration was not associated with a significant reduction in spasticity (4 trials).
CONCLUSIONS: Besides shorter movement time for reaching tasks, we did not identify evidence to support clinical improvement in upper limb functional movements after tendon/muscle vibration treatment in persons with subacute and chronic stroke. A small number of trials were identified; therefore, there is a need for larger, higher quality studies and to consider the clinical relevance of performance-based outcome measures that focus on time tocomplete a functional movement such as a reach.
via Upper limb tendon/ muscle vibration in persons with subacute and chronic stroke: a systematic review and meta-analysis – European Journal of Physical and Rehabilitation Medicine 2019 Mar 11 – Minerva Medica – Journals
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.
We searched the databases of PubMed, Cochrane Library, and Embase. The randomized controlled trials were published by 25 January 2019.
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).
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.
via Repetitive transcranial magnetic stimulation of lower limb motor function in patients with stroke: a systematic review and meta-analysis of randomized controlled trials – Yi-Chun Tung, Chien-Hung Lai, Chun-De Liao, Shih-Wei Huang, Tsan-Hon Liou, Hung-Chou Chen, 2019
To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to post-stroke upper limb spasticity, using the ICF classification.
Embase.com, PubMed, Wiley/Cochrane Library, and Ebsco/CINAHL were searched from inception up to 16 May 2018.
Randomized controlled trials comparing upper limb BoNT injections with a control intervention in stroke patients were included. A total of 1212 unique records were screened by two independent reviewers. Forty trials were identified, including 2718 stroke patients.
Outcome data were pooled according to assessment timing (i.e. 4-8 and 12 weeks after injection), and categorized into six main clinical goals (i.e. spasticity-related pain, involuntary movements, passive joint motion, care ability, arm and hand use, and standing and walking performance). Sensitivity analyses were performed for the influence of study and intervention characteristics, involvement of pharmaceutical industry, and publication bias.
Robust evidence is shown for the effectiveness of BoNT in reducing resistance to passive movement, as measured with the (Modified) Ashworth Score, and improving self-care ability for the affected hand and arm after intervention (p<0.005) and at follow-up (p<0.005). In addition, robust evidence is shown for the absence of effect on ‘arm-hand capacity’ at follow-up. BoNT significantly reduced ‘involuntary movements’, ‘spasticity-related pain’, and ‘carer burden’, and improved ‘passive range of motion’, while no evidence was found for ‘arm and hand use’ after intervention.
In view of the robustness of current evidence, no further trials are needed to investigate BoNT for its favourable effects on resistance to passive movement of the spastic wrist and fingers, and on self-care. No trials are needed to further confirm the lack of effects of BoNT on arm-hand capacity, whereas additional trials are needed to establish the suggested favourable effects of BoNT on other ‘body functions’ which may result in clinically meaningful outcomes at ‘activity’ and ‘participation’ levels.
via Effectiveness of botulinum toxin treatment for upper limb spasticity after stroke over different ICF domains: a systematic review and meta-analysis – Archives of Physical Medicine and Rehabilitation