Posts Tagged systematic review

[ARTICLE] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Fig. 1 Flow diagram for included studies

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

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[Systematic Review] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

Fig. 1 Flow diagram for included studies

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[ARTICLE] Short- and Long-term Effects of Repetitive Transcranial Magnetic Stimulation on Upper Limb Motor Function after Stroke: a Systematic Review and Meta-Analysis – Full Text

The aim of this study was to evaluate the short- and long-term effects as well as other parameters of repetitive transcranial magnetic stimulation (rTMS) on upper limb motor functional recovery after stroke.

The databases of PubMed, Medline, Science Direct, Cochrane, and Embase were searched for randomized controlled studies reporting effects of rTMS on upper limb motor recovery published before October 30, 2016.

The short- and long-term mean effect sizes as well as the effect size of rTMS frequency of pulse, post-stroke onset, and theta burst stimulation patterns were summarized by calculating the standardized mean difference (SMD) and the 95% confidence interval using fixed/random effect models as appropriate.

Thirty-four studies with 904 participants were included in this systematic review. Pooled estimates show that rTMS significantly improved short-term (SMD, 0.43; P < 0.001) and long-term (SMD, 0.49; P < 0.001) manual dexterity. More pronounced effects were found for rTMS administered in the acute phase of stroke (SMD, 0.69), subcortical stroke (SMD, 0.66), 5-session rTMS treatment (SMD, 0.67) and intermittent theta burst stimulation (SMD, 0.60). Only three studies reported mild adverse events such as headache and increased anxiety .

Five-session rTMS treatment could best improve stroke-induced upper limb dyskinesia acutely and in a long-lasting manner. Intermittent theta burst stimulation is more beneficial than continuous theta burst stimulation. rTMS applied in the acute phase of stroke is more effective than rTMS applied in the chronic phase. Subcortical lesion benefit more from rTMS than other lesion site.

Continue —> Short- and Long-term Effects of Repetitive Transcranial Magnetic Stimulation on Upper Limb Motor Function after Stroke: a Systematic Review and Meta-Analysis – Feb 17, 2017

figure

Figure 1. The flow diagram of the selection process.

 

 

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[ARTICLE] Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review – Full Text

Abstract

Question: Is biofeedback during the practice of lower limb activities after stroke more effective than usual therapy in improving those activities, and are any benefits maintained beyond the intervention?

Design: Systematic review with meta-analysis of randomised trials with a PEDro score > 4.

Participants: People who have had a stroke.

Intervention: Biofeedback (any type delivered by any signal or sense) delivered concurrently during practice of sitting, standing up, standing or walking compared with the same amount of practice without biofeedback.

Outcome measures: Measures of activity congruent with the activity trained.

Results: Eighteen trials including 429 participants met the inclusion criteria. The quality of the included trials was moderately high, with a mean PEDro score of 6.2 out of 10. The pooled effect size was calculated as a standardised mean difference (SMD) because different outcome measures were used. Biofeedback improved performance of activities more than usual therapy (SMD 0.50, 95% CI 0.30 to 0.70).

Conclusion: Biofeedback is more effective than usual therapy in improving performance of activities. Further research is required to determine the long-term effect on learning. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised widely in clinical practice.

[Stanton R, Ada L, Dean CM, Preston E (2016) Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review. Journal of Physiotherapy 63: 11–16]

Introduction

This is an update of a systematic review1 that examined the effect of biofeedback in training lower limb activities after stroke. Biofeedback is equipment that transforms biological signals into an output that can be understood by the learner, providing information to the learner that is not consciously available. That is, biofeedback takes intrinsic physiological signals and makes them extrinsic, giving the person immediate and accurate feedback of information about these body functions. Biofeedback can be delivered through various senses, such as visual, auditory and tactile systems, and can provide information about the kinematics, kinetics and/or electromyography of activities. Biofeedback is available from medical equipment (eg, electromyography, force platforms and positional devices traditionally used in clinical practice); or from non-medical equipment that is increasingly available and used in stroke rehabilitation (eg, recreational games such as the Nintendo® Wii™). Biofeedback can be used in addition to verbal content; however, it also has the advantage that it can be set up for the patient to use when left to practise alone. However, biofeedback is not commonly used in stroke rehabilitation.2

The previous version of this review,2 which was published in 2011, examined biofeedback broadly in training lower limb activities after stroke, including trials where any form of biofeedback was provided during practice of the whole activity (rather than part of the activity), with outcomes measured during the same activity. Twenty-two trials met the inclusion criteria and were included in the review; however, meta-analyses demonstrated significant heterogeneity that was best explained by the quality of the included trials. When analyses were limited to higher quality trials (PEDro score > 4), biofeedback had a moderate effect in the short term (10 trials, 241 participants, SMD 0.49, 95% CI 0.22 to 0.75) compared with usual therapy, which was maintained beyond intervention (five trials, 138 participants, SMD 0.41, 95% CI 0.06 to 0.75), suggesting that learning had occurred. For a direct comparison of the effect of biofeedback interventions and usual therapy (which includes therapist communication), a post hoc meta-analysis was conducted of those trials where the amount of practice was equal in each group. That is, trials where the control group practised the same activity for the same amount of time as the experimental group, with the only difference being the substitution of biofeedback for therapist communication (presumably including feedback) in the experimental group. This meta-analysis demonstrated a moderate effect of a similar magnitude to the overall analysis (eight trials, 170 participants, SMD 0.51, 95% CI 0.20 to 0.83), suggesting that biofeedback is superior to therapist communication.

Since that review1 was published in 2011, a number of additional trials have been published that investigated the effect of biofeedback, warranting an update of the review. In particular, the potential of using recreational games in stroke rehabilitation has gained attention. The inclusion criteria for this updated review incorporated findings from the previous review. Specifically, this meant that the updated review would include any randomised trial investigating biofeedback from any signal (position, force, EMG) via any sense (visual, auditory, tactile), delivered concurrently during whole activity practice, compared with usual therapy that was practice of the same activity for the same amount of time in the control group with no biofeedback (but presumably with therapist communication), with outcome measures at the activity level and congruent with the activity trained. This ensures a true comparison of the effect of biofeedback compared with usual therapist communication. For the biofeedback intervention, inclusion in this update was based on whether the biofeedback delivered was concurrent rather than terminal feedback. This meant that commercially available recreational games would be included if the majority of the games played within the study delivered concurrent biofeedback, rather than inclusion based on the equipment itself. In order to make recommendations based on the highest level of evidence, this review included only randomised trials with a PEDro score > 4.

Therefore, the research questions for this systematic review were:

  • 1. In adults following stroke, is biofeedback during the practice of lower limb activities more effective than usual therapy in improving those activities in the short term?
  • 2. Are any benefits maintained beyond the intervention?

Continue —> Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review – Journal of Physiotherapy

 

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[Systematic Review] Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke – Full Text

Abstract

Question: Is biofeedback during the practice of lower limb activities after stroke more effective than usual therapy in improving those activities, and are any benefits maintained beyond the intervention? Design: Systematic review with meta-analysis of randomised trials with a PEDro score > 4. Participants: People who have had a stroke. Intervention: Biofeedback (any type delivered by any signal or sense) delivered concurrently during practice of sitting, standing up, standing or walking compared with the same amount of practice without biofeedback. Outcome measures: Measures of activity congruent with the activity trained. Results: Eighteen trials including 429 participants met the inclusion criteria. The quality of the included trials was moderately high, with a mean PEDro score of 6.2 out of 10. The pooled effect size was calculated as a standardised mean difference (SMD) because different outcome measures were used. Biofeedback improved performance of activities more than usual therapy (SMD 0.50, 95% CI 0.30 to 0.70). Conclusion: Biofeedback is more effective than usual therapy in improving performance of activities. Further research is required to determine the long-term effect on learning. Given that many biofeedback machines are relatively inexpensive, biofeedback could be utilised widely in clinical practice. [Stanton R, Ada L, Dean CM, Preston E (2016) Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review.Journal of PhysiotherapyXX: XX-XX]

Introduction

This is an update of a systematic review1 that examined the effect of biofeedback in training lower limb activities after stroke. Biofeedback is equipment that transforms biological signals into an output that can be understood by the learner, providing information to the learner that is not consciously available. That is, biofeedback takes intrinsic physiological signals and makes them extrinsic, giving the person immediate and accurate feedback of information about these body functions. Biofeedback can be delivered through various senses, such as visual, auditory and tactile systems, and can provide information about the kinematics, kinetics and/or electromyography of activities. Biofeedback is available from medical equipment (eg, electromyography, force platforms and positional devices traditionally used in clinical practice); or from non-medical equipment that is increasingly available and used in stroke rehabilitation (eg, recreational games such as the Nintendo® Wii™). Biofeedback can be used in addition to verbal content; however, it also has the advantage that it can be set up for the patient to use when left to practise alone. However, biofeedback is not commonly used in stroke rehabilitation.2

Continue —> Biofeedback improves performance in lower limb activities more than usual therapy in people following stroke: a systematic review

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[Review] Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery – Full Text PDF

Abstract

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients’ mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients.

This multiple systematic review focuses both on standard treatment methods and on innovating  rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed.

At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some  interventions may be under debate, motor skill learning and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Introduction

The World Health Organisation (WHO) estimates that stroke events in EU countries are likely to increase by 30% between 2000 and 2025 (Truelsen et al., 2006). The most common deficit after stroke is hemiparesis of the contralateral upper limb, with more than 80% of stroke patients experiencing this condition acutely and more than 40% chronically (Cramer et al., 1997).

Common manifestations of upper extremity motor impairment include muscle weakness or contracture, changes in muscle tone, joint laxity and impaired motor control. These impairments induce disabilities in common activities such as reaching, picking up objects, and holding onto objects (for a review on precision grip deficits, see Bleyenheuft and Gordon, 2014).

Motor paresis of the upper extremity may be associated with other neurological manifestations that affect the recovery of motor function and thus require focused therapeutic intervention. Deficits in somatic sensations (body senses such as touch, temperature, pain and proprioception)  after stroke are common with prevalence rates variously reported to be 11%-85% (Carey et al., 1993; Hunter, 2002; Yekutiel, 2000). Functionally, the motor problems resulting from sensory deficits after stroke can be summarized as (1) impaired detection of sensory information, (2) disturbed motor tasks performance requiring somatosensory information, and (3) diminished upper extremity rehabilitation outcomes (Hunter, 2002). Sensation is essential for safety even  if there is adequate motor recovery (Yekutiel, 2000). Also, up to 50% of patients experience  pain of the upper extremity during the first year after stroke, especially shoulder pain and complex regional pain syndrome-type I (CRPS-type I), which may impede adequate early rehabilitation (Jönsson et al., 2006; Kocabas et al., 2007; Lundström et al., 2009; Sackley et al.,2008). Furthermore, joint subluxation and muscle contractures can lead to nociceptive musculoskeletal pain (de Oliveira et al., 2012). Among other complications of stroke the neglect syndrome (Ringman et al., 2004) and spasticity (Sommerfeld et al., 2004; Welmer et al., 2010) affect motor and functional outcomes.

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[Abstract] Effect of transcranial magnetic stimulation combined with upper-limb training for improving function after stroke: A systematic review and meta-analysis – Journal of the Neurological Sciences

Highlights

  • The rTMS and the combined rTMS with upper-limb training show an improvement in upper-limb function .
  • There is not enough evidence to support the hypothesis that a combination of rTMS and upper-limb training has a stronger effect on upper-limb function than upper-limb training alone.
  • New studies with larger sample sizes, standardized rTMS and upper-limb protocols are needed to clarify the effects of combining these treatment methods for the developmental of upper-limb function.

Abstract

Background

Several neuromodulation treatments have been developed, and their effects have been studied in recent years in order to improve neurological rehabilitation after a stroke. The association between upper-limb training and repetitive transcranial magnetic stimulation (rTMS) has provoked controversies and produced inconclusive results.

Objective

The purpose of this study was to investigate the effects of rTMS combined with upper-limb training versus sham rTMS combined with upper-limb training on the upper-limb recovery after a stroke.

Methods

A systematic review with meta-analysis was performed. The eligible studies were randomized controlled trials with stroke subjects, and the outcomes were related to upper-limb motor/functional status and spasticity.

Results

A total of 3234 citations were identified, and 11 studies were included. The meta-analysis included eight studies with 199 participants and did not show any difference between groups, neither for upper-limb function nor for spasticity (upper-limb function [0.03 (95% CI: −0.25 to 0.32; I2 0%)] and Modified Ashworth Scale [ −0.31 (95% CI: −0.78 to 0.17; I2 43%)]).

Conclusion

The current state of the literature is not enough to support the hypothesis that a combination of rTMS and upper-limb training has a stronger effect on upper-limb function than upper-limb training alone.

Source: Effect of transcranial magnetic stimulation combined with upper-limb training for improving function after stroke: A systematic review and meta-analysis – Journal of the Neurological Sciences

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[ARTICLE] Functional electrical stimulation versus ankle foot orthoses for foot-drop: a meta-analysis of orthotic effects – Full Text PDF

ABSTRACT

Objective: To compare the effects on walking of Functional Electrical Stimulation (FES) and Ankle Foot Orthoses (AFO) for foot-drop of central neurological origin, assessed in terms of unassisted walking behaviours compared with assisted walking following a period of use (combined-orthotic effects).

Data Sources: MEDLINE, AMED, CINAHL, Cochrane Central Register of Controlled Trials, Scopus, REHABDATA, PEDro, NIHR Centre for Reviews and Dissemination and clinicaltrials.gov. plus reference list, journal, author and citation searches.

Study Selection: English language comparative Randomised Controlled Trials (RCTs).

Data Synthesis: Seven RCTs were eligible for inclusion. Two of these reported different results from the same trial and another two reported results from different follow up periods so were combined; resulting in five synthesised trials with 815 stroke participants. Meta-analyses of data from the final assessment in each study and three overlapping time-points showed comparable improvements in walking speed over ten metres (p=0.04-0.95), functional exercise capacity (p=0.10-0.31), timed up-and-go (p=0.812 and p=0.539) and perceived mobility (p=0.80) for both interventions.

Conclusion: Data suggest that, in contrast to assumptions that predict FES superiority, AFOs have equally positive combined-orthotic effects as FES on key walking measures for foot-drop caused by stroke. However, further long-term, high-quality RCTs are required. These should focus on measuring the mechanisms-of-action; whether there is translation of improvements in impairment to function, plus detailed reporting of the devices used across diagnoses. Only then can robust clinical recommendations be made.

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[Abstract] The efficacy of Botulinum Toxin A for limb spasticity on improving activity restriction and quality of life: a systematic review and meta-analysis using the GRADE approach.

Abstract

Objectives: A systematic review and meta analysis using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. The aim was to evaluate the efficacy of Botulinum Toxin type A for limb spasticity on improving activity restriction and quality of life outcomes.

Data sources: Pubmed, Cinahl, Amed, Embase and Cochrane databases. English Language. Search to January 2015.

Review methods: All randomized, placebo controlled trials on adults with active function or quality of life measures for the arm and leg relating to spasticity of any origin and treated with a single dose of Botulinum Toxin A. Evidence quality was assessed by GRADE.

Results: Twenty-five studies were reviewed. Meta analysis was carried out on six upper limb and six lower limb studies. Evidence quality for the upper limb was low/very low. A significant result for Botulinum Toxin A was found at four to twelve weeks for the upper limb for active function (SMD 0.32 CI 0.01, 0.62, P=0.04) These effects were maintained for up to six months for Active Research Arm Test (ARAT) only (MD 1.87 CI 0.53, 3.21, P=0.006).

Evidence quality was very low for the lower limb. No significant effect was found. Meta analysis was not possible for quality of life measures.

Conclusion: Botulinum Toxin A may improve active outcomes in the upper limb but further evidence is needed. No conclusion can be drawn about the effect on active outcomes for the lower limb or for quality of life measures in either limb.

Source: The efficacy of Botulinum Toxin A for limb spasticity on improving activity restriction and quality of life: a systematic review and meta-analysis using the GRADE approach

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

Highlights

• tDCS and rTMS improved force production capabilities post stroke

• Increasing cortical activity in the affected hemisphere enhanced force production

• Reducing cortical activity in the unaffected hemisphere increased force production

• Force production capability improved in each of three recovery stages

Abstract

Background

Non-invasive brain stimulation (NIBS) facilitates motor improvements post stroke. Transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) are representative NIBS techniques frequently used in stroke motor rehabilitation. Our primary question is: Do these two techniques improve force production capability in paretic limbs?

Objective

The current systematic review and meta-analysis investigated the effects of tDCS and rTMS on paretic limb force production in stroke survivors.

Methods

Our comprehensive search identified 23 studies that reported changes in force production following tDCS or rTMS interventions. Each used random assignment and a sham control group. The 23 qualified studies in our meta-analysis generated 29 comparisons: 14 tDCS and 15 rTMS comparisons.

Results

Random effects models indicated improvements in paretic limb force after tDCS and rTMS rehabilitation. We found positive effects on force production in the two sets of stimulation protocols: (a) increasing cortical activity in the ipsilesional hemisphere and (b) decreasing cortical activity in the contralesional hemisphere. Moreover, across acute, subacute, and chronic phases, tDCS and rTMS improved force production.

Conclusion

Cumulative meta-analytic results revealed that tDCS and rTMS rehabilitation protocols successfully improved paretic limb force production capabilities.

Source: Non-Invasive Brain Stimulation Improves Paretic Limb Force Production: A Systematic Review and Meta-Analysis – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation

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