Herseninfarct en hersenbloeding

Initiatief: NVN Aantal modules: 63

tDCS Bovenste extremiteit

Uitgangsvraag

Wat is het effect van tDCS op functies van de bovenste exremiteit?

Aanbeveling

Pas geen tDCS toe ter bevordering van herstel van arm-handvaardigheid na een herseninfarct of hersenbloeding.

Overwegingen

Voor- en nadelen van de interventie en de kwaliteit van het bewijs

Er is onvoldoende wetenschappelijk bewijs voor effectiviteit van tDCS in welke vorm en op welk moment dan ook ter bevordering van de arm-handvaardigheid bij patiënten met een herseninfarct of hersenbloeding. Slechts 1 trial met 32 patiënten, suggereert een gunstig effect van bihemisferale tDSC toegepast > 3 maanden na herseninfarct of hersenbloeding op dagelijkse activiteiten gemeten met de Barthel Index. Omdat deze kleine trial niet in overeenstemming is met de andere onderzoeken, en omdat arm-hand functie slechts weinig bijdraagt aan de scores van de Barthel Index, trekt de werkgroep deze resultaten in twijfel.   

 

Waarden en voorkeuren van patiënten (en eventueel hun verzorgers)

Voor patiënten is het belangrijk dat de behandeling met tDCS veilig is en een positief resultaat oplevert. Echter op dit moment lijkt het bewijs voor de effectiviteit van de behandeling met tDCS nog zeer gering. Ook zijn er geen afzonderlijke subgroepen bekend waarbij meer effect te verwachten is. Als er toch vragen zijn van patiënten over deze behandeling dan moet duidelijk aangegeven worden dat het effect van deze behandeling op dit moment nog onduidelijk is en dat er meer onderzoek nodig is.

 

Rationale van de aanbeveling: weging van argumenten voor en tegen de interventies

De werkgroep is van mening dat er onvoldoende wetenschappelijk bewijs is voor effect van tDCS ter bevordering van herstel van patiënten met een herseninfarct of hersenbloeding. Kwalitatief hoogwaardige fase 3 trials ontbreken.

Onderbouwing

1. Conclusions rTMS 3 months after stroke onset

1.1 Upper limb capacity (crucial)

Low

GRADE

Anodal tDCS may result in little to no difference in patients’ upper limb capacity within three months after stroke.

 

Sources: (Mazzoleni, 2017)

 

Very low GRADE

The evidence is very uncertain about the effect of cathodal tDCS on patients’ upper limb capacity within three months after stroke.

 

Sources: (Nicolo, 2018; Yao, 2020)

 

Very low GRADE

The evidence is veryis uncertain about the overall effect of tDCS on patients’ upper limb capacity within three months after stroke.

 

Sources: (Mazzoleni, 2017; Nicolo, 2018; Yao, 2020)

 

1.2 Upper limb muscle synergies (important)

Low

GRADE

Anodal tDCS may result in little to no difference in patients’ upper limb muscle synergies within three months after stroke.

 

Sources: Hesse, 2011; Mazzoleni, 2017

 

Very low GRADE

The evidence is very uncertain about the effect of cathodal tDCS on patients’ upper limb muscle synergies within three months after stroke.

 

Sources: (Hesse, 2011; Nicolo, 2018)

 

Low

GRADE

Overall, tDCS results may result in little to no difference in patients’ upper limb muscle synergies within three months after stroke.

 

Sources: (Hesse, 2011; Mazzoleni, 2017; Nicolo, 2018)

 

1.3 Muscle Strength (important)

Very low GRADE

The evidence is very uncertain about the effect of cathodal tDCS on patients’ muscle strength within three months after stroke.

 

Sources: (Nicolo, 2018)

 

1.4 Activities of daily living (important)

Low

GRADE

Anodal tDCS may result in little to no clinical difference in patients’ activities of daily living within three months after stroke.

 

Sources: (Hesse, 2011)

 

Low

GRADE

Cathodal tDCS may result in little to no difference in patients’ activities of daily living within three months after stroke.

 

Sources: (Hesse, 2011)

 

Low

GRADE

Overall, tDCS may result in little to no difference in patients’ activities of daily living within three months after stroke.

 

Sources: (Hesse, 2011)

 

2. Conclusions tDCS >3 months after stroke onset

2.1 Upper limb capacity (crucial)

Low

GRADE

Anodal tDCS may result in little to no difference in patients’ upper limb capacity beyond three months after stroke.

 

Sources: (Allman, 2016; Edwards, 2019; Sik, 2015)

 

Low

GRADE

Cathodal tDCS may result in little to no difference in patients’ upper limb capacity beyond three months after stroke.

 

Sources: (Figlewski, 2017)

 

Low

GRADE

Bihemispheric tDCS may result in little to no difference in patients’ upper limb capacity beyond three months after stroke.

 

Sources: (Sik, 2015; Straudi, 2016)

 

Low

GRADE

Overall, tDCS may result in little to no difference in patients’ upper limb capacity beyond three months after stroke.

 

Sources: (Allman, 2016; Edwards, 2019, Figlewski, 2017; Sik, 2015; Straudi, 2016)

 

2.2. Upper limb muscle synergies (important)

Low

GRADE

Anodal tDCS may result in little to no difference in patients’ upper limb upper limb muscle synergies beyond three months after stroke.

 

Sources: (Allman, 2016)

 

Very low GRADE

The evidence is very uncertain about the effect of tDCS on patients’ upper limb upper limb muscle synergies beyond three months after stroke.

 

Sources: (Alisar, 2020; Shahweiwola, 2018; Salazar, 2020)

 

2.3 Muscle Strength (important)

Low

GRADE

Anodal tDCS may result in little to no difference in patients’ muscle strength beyond three months after stroke.

 

Sources: (Figlewski, 2017)

 

Low

GRADE

Cathodal tDCS may result in little to no difference in patients’ muscle strength beyond three months after stroke.

 

Sources: (Salazar, 2020)

 

2.4 Activities of daily living (important)

Low

GRADE

Bihemispheric tDCS may improve patients’ activities of daily living beyond three months after stroke.

 

Sources: (Alisar, 2020)

Description of studies

As a starting point, we included studies from the review from Bai (2019). This systematic review and meta-analysis describes the effect of transcranial direct current stimulation (tDCS) on upper and lower limb recovery of stroke patients with motor dysfunction. In total, 29 RCTs including those with a crossover design, comprising 664 participants, were included in a meta-analysis. To answer our clinical question, and based on our inclusion criteria, data from six RCTs (Mazzoleni, 2017; Figlewski, 2017; Straudi, 2016; Hesse, 2011; Allman, 2016; Hamoudi, 2018) were extracted from this review. 17 studies did not include enough participants, three studies did not describe the upper limb motor function as an outcome measure and one study was not referenced correctly. The type of intervention (polarity, density and treatment sessions) varied between studies. The effects were evaluated on upper limb motor function and motor dysfunction, using the following outcomes: finger acceleration, upper extremity Fugl-Meyer Motor (FM-UE) score, action research arm test (ARAT), Wolf motor function test-functional ability scale (WMFT-FAS), Jebsen Taylor test (JTT), motor assessment scale (MAS), Jebsen Taylor hand function test (JHFT) and 9-hole peg test (9HPT). Funnel plots in the review showed a very small publication bias.

 

1. Start of treatment ≤ 3 months after stroke onset

Two RCTs included in the review (Bai, 2019) and two additional RCTs described the effect of tDCS treatment in patients who were treated ≤ 3 months after stroke onset. Mazzoleni (2017) assessed upper limb capacity by the BBT score and upper limb synergy by the Fugl Meyer Assessment of the Upper Extremity (FM-UE) (n=24). Hesse (2011) assessed upper limb synergy with the FM-UE and activities of daily living by the Barthel Index (BI) (n=84).

 

Apart from the studies included in the review, two separate RCTs described the effects of rTMS treatment in patients who were treated within 3 months after stroke onset (Nicolo, 2018; Yao, 2020).

 

 

Nicolo (2018) performed a double-blinded, randomized, placebo-controlled study and evaluates the effects of cathodal tDCS and continuous theta burst stimulation (cTBS) on neural network connectivity and motor recovery in individuals with subacute stroke. A total of 41 adult ischaemic or haemorrhagic stroke patients, aged 28 to 85 years (mean, 65y; 18 women; 12 with left hemispheric stroke), were allocated to three groups. The cathodal tDCS group (n=14) received 25 minutes stimulation (1mA) to the C3-C4 area of the ipsilesional supraorbital region and the contralesional M1. The rTMS group (n=14) received two spaced neuronavigated cTBS applications, separated by 15 minutes. In the sham group (n=13) the current was ramped up for 30 seconds and then slowly tapered down to zero (sham tDCS) or the coil produced no magnetic field (sham rTMS). After five minutes, physical therapy was started in all groups. To answer our clinical question, only the cathodal tDCS group and the sham group were compared. All groups received three sessions per week over three weeks and all sessions were combined with 30 minutes of active functional motor practice. The effects were evaluated on patients’ upper limb capacity, assessed by the box and block test (BBT), upper limb synergy (FM-UE) and Strength (Jamar dynamometer). The study was limited by the small sample size, the fact that not all participants of the sham group received sham tDCS, but some received sham rTMS. Furthermore, the researchers administering the treatment were not blinded.

 

Yao (2020) described a single-blind randomized controlled trial and evaluated the effect of cathodal tDCS, combined with virtual reality (VR) on patients with ischaemic stroke. A total of 42 adult subjects, aged 18 to 80 years (mean, 65y; 9 women; 22 left hemispheric stroke), were allocated to two groups. The intervention group (n=22) received a cathodal tDCS (2mA) for 20 minutes. Two patients in this group discontinued intervention and were not included in the analyses. The control group (n=20) received a sham tDCS (current increase to 2 mA and ramp-down to 0 mA). Both groups were simultaneously treated in virtual reality, with a powerful feedback sensing manipulator and large screen providing VR scenes showing different game forms aiming to help patients with exercise control training. The duration of the therapy was 20 minutes and was performed five times a week for two weeks. Effects were evaluated on patients’ upper limb capacity, assessed by the Action Research Arm Test (ARAT), upper limb synergy (FM-UE) and activities of daily living (BI). The study was limited by the small sample size and the unability to blind the researchers administering the treatment.  

 

2. Start of treatment beyond three months after stroke onset

Four RCTs included in the review (Bai, 2019) and five additional RCTs described the effect of tDCS treatment in patients who were treated > 3 months after stroke onset. Figlewski (2017) assessed upper limb capacity by the WMFT score and strength by the handgrip force (n=44). Straudi (2016) assessed upper limb capacity by the BBT score and upper limb synergy by the FM-UE score (n=23). Allman (2016) assessed upper limb capacity by the ARAT and upper limb synergy by the FM-UE score (n=26). Hamoudi (2018) assessed upper limb capacity by the JTT and upper limb synergy by the FM-UE score (n=36).

 

Apart from the studies included in the review, four separate RCTs described the effects of rTMS treatment in patients who were treated > 3 months after stroke onset (Alisar, 2020; Edwards, 2019; Sik, 2015; Salazar, 2020).

 

Alisar (2020) described a double-blind sham-controlled study of bihemispheric tDCS combined with conventional rehabilitation techniques in stroke patients on upper extremity motor function and activities of daily living. A total of 38 adult stroke patient, aged  18 to 75 years (mean, 64y; 19 women; 16 with left hemispheric stroke) were allocated in two groups. All patients received conventional upper extremity rehabilitation (three weeks, five days a week, 15 sessions total). The intervention group (n=18) received 30 minutes of tDCS simultaneously to occupational therapy. The control group (n=20) received 30 minutes of sham tDCS simultaneously to occupational therapy. Th effects were evaluated on patients’ upper limb upper limb synergy (FM-UE) and activities of daily living (FIM). The study was limited by the small sample size and presence of heterogeneity in lesion location.

 

Edwards (2019) describes a dual-site, randomized controlled trial of anodal tDCS and robotic upper-limb training in chronic ischaemic stroke patients. A total of 82 adult stroke patients, aged 42 to 90 (mean, 68y; 32 women) were allocated in two groups: The anodal tDCS group (n=41) received 20 minutes of anodal tDCS. The sham ticks group (n=41) received 20 minutes of sham tDCS, comprising a 30 sec current ramp to 2 mA, then 30 sec ramp down to 0 mA. Both groups received 36 sessions of shoulder-elbow robot or wrist robot therapy in 12 weeks. The effects were evaluated on patients’ upper limb capacity (WMFT) and upper limb synergy (FM-UE). The study was limited by the small sample size.

 

Sik (2015) describes a prospective, randomized, sham-controlled study and evaluates the effectiveness of anodal or bihemispheric tDCS applications on the upper extremity motor functions of patients with stroke. A total of 36 adult stroke patients, aged 55 to 67 (mean, 60y; 16 women; 15 with left hemispheric stroke) were allocated in three groups: The anodal tDCS group (n=12) received 20 minutes of tDCS stimulation to the C3-C4 area of the affected hemisphere and the reference electrode to the opposite supraorbital region. The bihemispheric tDCS group (n=12) received 40 minutes of tDCS stimulation to the C3-C4 area of the unaffected hemisphere in addition to its anodal application. In the sham tDCS group (n=12), electrodes were placed as in the anodal group, with the first tingling sensation for one minute. All groups received occupational therapy simultaneously with the tDCS application, which included a total of 15 sessions for three weeks. This therapy included range of motion exercises, strengthening, exercises, outreach activities, activities to increase supination and grip-release activities. The effects were evaluated on patients’ upper limb capacity (WMFT) and upper limb synergy (FM-UE) after the final treatment session and after six months follow-up. The study was limited by the small sample size.

 

Shahweiwola (2018) describes a randomized controlled study and evaluates the effect of bilateral tDCS combined with functional electrical stimulation (FES) therapy on patients with severe chronic stroke. A total of 30 adult subjects, aged 35 to 70 (mean, 51y; 3 women; 14 left hemispheric stroke) were allocated in two groups. The intervention group (n=15) received 20 minutes of active anodal tDCS followed by one hour of FES therapy, using a bio-feedback Neuromuscular Stimulator. Five sessions per week on workdays and a total of 20 sessions were carried out on four weeks. The control group (n=15) received sham tDCS combined with FES. The effects were evaluated on patients’ upper limb capacity (WMFT), and upper limb synergy (FM-UE) after overall therapy. The study was limited by the skewed population towards males at baseline and small sample size.

 

Salazar (2020) describes a double-blind randomized controlled trial and evaluated the effect of concurrent bi-cephalic tDCS and FES therapy on chronic post-stroke subjects with moderate and severe compromise. A total of 30 adult subjects, aged 18 to 80 (mean, 58y; 10 women; 16 with left hemispheric stroke) were allocated in two groups. The intervention group (n=15) received 10 sessions of concurrent tDCS and FES. The control group received 10 sessions of concurrent sham tDCS and FES at the same time. Both groups were treated for 30 minutes, 5 times a week for 2 weeks (excluding weekends). The effects were evaluated on patients’ strength (handgrip force) after treatment. The study was limited by the small sample size.

 

Results

1. Start of treatment ≤ 3 months after stroke onset

1.1 Upper Limb Capacity

Three RCT’s described upper limb capacity in patients who were treated within three months after stroke onset (Mazzoleni, 2017; Nicolo, 2018; Yao, 2020).

 

1.1.1 Anodal tDCS

Mazzoleni (2017) assessed upper limb capacity by using the BBT score (a higher score means better outcome) in patients who received anodal tDCS (n=44). The intervention group showed a mean score of 27.67 (SD 15.89) and the control group 25.58 (SD 5.99). This corresponds to a standardized mean difference (SMD) of 0.17 (95% CI -0.63 to 0.97). This effect was neither statistically different nor clinically relevant. Results are shown in figure 1.1.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limb capacity started at high because it was based on a RCT, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of anodal tDCS within three months after stroke onset regarding the outcome upper limb capacity is low.

 

1.1.2 Cathodal tDCS

Nicolo (2018) and Yao (2020) assessed upper limb capacity in patients who received cathodal tDCS (n=67). Nicolo (2018) presented results by using BBT ratio (%), resulting in a mean ratio of 13% (SD 30) in the tDCS group (n=14) and 0% (SD 11.5%) in the sham group (n=13). Yao (2020) presented the ARAT scale score (0 to 57, a higher score means better outcome), resulting in a mean score of 24.8 (SD 19.9) in the tDCS group (n=20) and 18.8 (SD 15.9) in the sham group (n=20). These effects were neither statistically different nor clinically relevant. Standardized results are shown in figure 1.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limp capacity started at high because it was based on randomised controlled trials, but was downgraded by three levels due to inadequate blinding of healthcare providers (risk of bias, -1) and limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of cathodal tDCS within three months after stroke onset regarding the outcome upper limb capacity is very low.

 

Figure 1. Forest plot summarizing the effect of anodal and cathodal tDCS on upper limb capacity in stroke patients who were treated within 3 months after stroke onset

 

1.2 Upper limb muscle synergies

Three RCT’s described upper limb muscle synergies in patients who were treated within three months of stroke onset (Hesse, 2011; Mazzoleni, 2017; Nicolo, 2018).

 

1.2.1 Anodal tDCS

Hesse (2011) and Mazzoleni (2017) assessed upper limb muscle synergies by using the FM-UE score (scale 0 to 66, a higher score means better outcome) in patients who received anodal tDCS (n=72). Hesse (2011) reported a MD of -0.10 (95% CI 8.98 to 9.78) in favour of sham tDCS. Mazzoleni (2017) reported a MD of -5.33 (95% CI -15.94 to 5.28) in favour of sham tDCS. These effects were neither statistically different nor clinically relevant. Results are shown in figure 2.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limb muscle synergies started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of anodal tDCS within three months after stroke onset regarding the outcome upper limb muscle synergies is low.

 

Figure 2 Forest plot summarizing the effect of anodal tDCS on upper limb muscle synergies in stroke patients who were treated within 3 months after stroke onset

1.2.2 Cathodal tDCS

Hesse (2011) and Nicolo (2018) assessed upper limb muscle synergies by using the FM-UE score and the FM-UE ratio (%) respectively in patients who received cathodal tDCS (n=75). Hesse (2011) reported a mean score 18.9 (SD 10.5) in the tDCS group (n=32) compared to 19.2 (SD 15.0) in the sham tDCS group (n=16). Nicolo (2018) reported a mean ratio of 15.7% (SD 14.6%) in the tDCS group (n=14) and 12.8% (SD 14.4%) in the sham group (n=13). Both effects were neither statistically different nor clinically relevant. Standardized results are shown in figure 3.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limb muscle synergies started at high because it was based on randomised controlled trials, but was downgraded by three levels due to inadequate blinding of healthcare providers (risk of bias, -1) and limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of cathodal tDCS within three months after stroke onset regarding the outcome upper limb muscle synergies is very low.

 

Figure 3 Forest plot summarizing the effect of cathodal tDCS on upper limb muscle synergies in stroke patients who were treated within 3 months after stroke onset

 

1.3 Muscle strength

One RCT described muscle strength in patients who were treated within three months of stroke onset (Nicolo, 2018). Strength was measured with the Jamar dynamometer and presented as ratio between the affected and unaffected limb.

 

1.3.1 Cathodal tDCS

Nicolo (2018) assessed muscle strength by the Jamar dynamometer test ratio (%) in patients who were treated with cathodal tDCS (n=41). Data resulted in no difference between the two groups, corresponding to a MD of 0.0% (95% CI: -4.99% to 4.99%).

 

The level of evidence in the literature

The level of evidence regarding the outcome muscle strength started at high because it was based on randomised controlled trials, but was downgraded by three levels due to, inadequate blinding of healthcare providers (risk of bias, -1) and limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of cathodal tDCS within three months after stroke onset regarding the outcome muscle strength is very low.

 

1.4 Activities of Daily Living

One RCT described activities of daily living in patients who were treated within three months of stroke onset (Hesse, 2011).

 

1.4.1 Anodal tDCS

Hesse (2011) assessed activities of daily living by using the BI (0 to 100, a higher score means better outcome) in patients who were treated with anodal tDCS (n=49). Data resulted in a MD of -2.70 (95% CI: -10.05 to 4.65), favouring sham treatment. This effect was neither statistically different nor clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome activities of daily living started at high because it was based on a randomised controlled trial, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of anodal tDCS within three months after stroke onset regarding the outcome activities of daily living is low.

 

1.4.2 Cathodal tDCS

Hesse (2011) assessed activities of daily living by using the BI in patients who were treated with cathodal tDCS (n=49). Data resulted in a MD of 2.90 (95% CI: -3.98 to 9.78), favouring tDCS treatment. This effect was neither statistically different nor clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome activities of daily living started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of cathodal tDCS within three months after stroke onset regarding the outcome is low.

 

2. Start of treatment > 3 months after stroke onset

2.1 Upper limb capacity

Seven RCTs described upper limb capacity in patients who were treated after three months of stroke onset (Figlewski, 2017; Allman, 2016; Hamoudi, 2018; Sik, 2015; Shahweiwola, 2018; Straudi, 2016; Edwards, 2009).

2.1.1 Anodal tDCS

Allman (2016) and Edwards (2019) assessed upper limb capacity by the WMFT(-FAS) score (0 to 75, a higher score means better outcome) in patients who received anodal tDCS (n=93). Both effects were neither statistically different nor clinically relevant. Results are shown in figure 4 Furthermore, Sik (2015) assessed upper limb capacity by the WMFT performance time of each domain of the test (median 25. to 75. Percentile). After summing up the performance times of each domain, data resulted in a median time of 126 seconds (IQR 5 to 10,25) in the tDCS group, compared to 162.8 (IQR 6.5 to 12.38) seconds in the sham tDCS group. Hamoudi (2018) also assessed upper limb capacity by the percentage of improved speed during the JTT (n=37). Data (estimated from figure 4) resulted in a MD of 2.0% (95% CI: 0.39 to 3.61), also favouring tDCS. All effects were neither statistically significant nor clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limb capacity started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of anodal tDCS beyond three months after stroke onset regarding the outcome upper limb capacity is low.

 

2.1.2 Cathodal tDCS

Figlewski (2017) assessed upper limb capacity by the WMFT-FAS (0 to 75) in patients who received cathodal tDCS (n=22). Data resulted in a MD of 0.70 (95% CI -5.24 to 6.64), favouring tDCS. This effect was neither statistically different nor clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limb capacity started at high because it was based on a randomised controlled trial, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of cathodal tDCS beyond three months after stroke onset regarding the outcome upper limb capacity is low.

 

2.1.3 Bihemispheric tDCS

Shahweiwola (2018) and Straudi (2016) assessed upper limb capacity respectively by the WMFT-FAS (0 to 75, a higher score means better outcome) and the BBT (a higher score means better outcome) respectively in patients who received bihemispheric tDCS (n=53). Both effects were neither statistically different nor relevant. Results are shown in figure 4. Furthermore, Sik (2015) assessed upper limb capacity by the WMFT performance time of each domain of the test (median 25. to 75. Percentile) (n=36). After summing up the performance times of each domain, data resulted in a median time of 125 seconds (IQR 4.5 to 4.75) in the tDCS group, compared to 162.8 seconds (IQR 5.1 to 6.5) in the sham tDCS group. This effect was neither statistically significant nor clinically relevant.

 

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limb capacity started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of bihemispheric tDCS beyond three months after stroke onset regarding the outcome upper limb capacity is low.

 

Figure 4 Forest plot summarizing the effect of anodal and bihemispheric tDCS on upper limb capacity in stroke patients who were treated > 3 months after stroke onset

 

2.2 Upper limb muscle synergies

Four RCTs described upper limb upper limb muscle synergies in patients who were treated after three months of stoke onset (Allman, 2016; Alisar, 2020; Shahweiwola, 2018; Salazar, 2020).

 

2.2.1 Anodal tDCS

Allman (2016) assessed upper limb upper limb muscle synergies by the FM-UE score (0 to 66) in patients who received anodal tDCS (n=24). The tDCS group showed a mean score of 50.26 (SD 11.16), compared to 45.53 in the sham tDCS group. This effect was neither statistically different nor clinically relevant. Standardized results are shown in figure 5.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper upper limb muscle synergies started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of anodal tDCS beyond three months after stroke onset regarding the outcome upper limb muscle synergies is low.

 

2.2.2 Bihemispheric tDCS

Alisar (2020) and Shahweiwola (2018) assessed upper limb upper limb muscle synergies by the FM-UE (0-66) in patients who received bihemispheric tDCS (n=92). Alisar (2020) showed a mean score of 35 (SD 20.73) in the tDCS group (n=16) and 28.12 (SD 23.5) in the sham group (n=16). Shahweiwola showed a mean score of 25.4 (SD 9.19) in the tDCS group (n=15) and 22.1 (SD 13.16) in the sham group (n=15). These effects were neither statistically different nor clinically relevant. Standardized results are shown in figure 5. Furthermore, Salazar (2020) showed a median FM-UE score of 26.66 (IQR 22.23 to 31.97) in the tDCS group (n=15) and 31.21 (IQR 26.58 to 36.65) in the control group (n=15). This difference was neither statistically significant nor clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome upper limb muscle synergies started at high because it was based on randomised controlled trials, but was downgraded by three levels due to inconsistent results (inconsistency, -1) and limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of bihemispheric tDCS beyond three months after stroke onset regarding the outcome upper limb muscle synergies is very low.

 

Figure 5 Forest plot summarizing the effects of anodal and bihemispheric tDCS on upper limb muscle synergies in stroke patients who were treated >3 months after stroke onset.

2.3 Muscle Strength

Two RCTs described muscle strength in patients who were treated after three months of stroke onset (Figlewski, 2017; Salazar, 2020).

 

2.3.1 Cathodal tDCS

Figlewski (2017) assessed muscle strength by grip strength (kg) in patients who were treated with cathodal tDCS (n=44), showing a mean score of 21.1 kg (SD 10.8 kg) in the tDCS group (n=22) and 19.7 kg (SD 9.3 kg) in the sham group. This data resulted in a MD of 1.4 kg (95% CI: -4.56 to 7.36), favouring tDCS treatment. This difference was neither statistically different nor clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome muscle strength started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of cathodal tDCS beyond three months after stroke onset regarding the outcome muscle strength is low.

 

2.3.2 Bihemispheric tDCS

Salazar (2020) assessed muscle strength by grip strength (kg.) in patients who were treated with bilateral tDCS (n=30). Data resulted in a median grip strength of 6 kg (IQR: 9 to 56) in the tDCS group and 10 kg (IQR: 0 to 20) in the sham group (p=0.134). This effect was neither statistically different nor clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome muscle strength started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of efficacy of bihemispheric tDCS beyond three months after stroke onset regarding the outcome muscle strength is low.

 

2.4 Activities of daily living

One RCT described activities of daily living in patients who were treated after three months of stroke onset (Alisar, 2020).

 

2.4.1 Bihemispheric tDCS

Alisar (2020) assessed activities of daily living by the FIM (18 to 126, a higher score means better outcome) in patients who were treated with bihemispheric tDCS (n=32). The tDCS group (n=16) showed a mean score of 88.19 (SD 24.61) and the control group (n=16) of 58.37 (SD 27.24). This data resulted in a MD of 29.82 points (95% CI: 11.83 to 47.81), favouring tDCS treatment. This effect was statistically significant and clinically relevant.

 

The level of evidence in the literature

The level of evidence regarding the outcome activities of daily living started at high because it was based on randomised controlled trials, but was downgraded by two levels due to limited number of included patients (imprecision, -2). The final GRADE level of evidence of bihemispheric tDCS beyond three months after stroke onset regarding the outcome activities of daily living is low.

A systematic review of the literature was performed to answer the following question:

What is the effect of tDCS on upper limb capacity in patients after stroke?

 

P:        patients with ischaemic/haemorrhagic stroke with persisting upper limb dysfunction;

I:         non-invasive brain stimulation with transcranial direct-current stimulation (tDCS);

C:        sham tDCS;

O:        upper limb capacity, upper limb muscle synergies, muscle strength and activities of daily living (ADL).

 

In the literature, tDCS treatment was applied at different time points after stroke onset. On the basis of a critical time window of spontaneous neurological recovery of maximal 3 months (Bernhardt, 2017), we decided to distinguish between treatment ≤ 3 months after stroke onset and treatment > 3 months after stroke onset. Within this distinguishment, the effects were evaluated per intervention type. This resulted in the following (sub-)groups:

 

a.        Start of treatment at or within three months after ischaemic/haemorrhagic stroke:

  • Anodal tDCS;
  • Cathodal tDCS;
  • Bihemispheric tDCS.

b.        Start of treatment beyond three months after ischaemic/haemorrhagic stroke:

  • Anodal tDCS;
  • Cathodal tDCS;
  • Bihemispheric tDCS.

 

Relevant outcome measures

The working group considered ‘upper limb capacity’ as a critical outcome measure for decision-making; and ‘upper limb muscle synergies’, ‘strength’ and ‘activities of daily living’ as important outcome measures for decision-making.

 

Definitions

The working group classified the used outcome measures following the codes of the International Classification of Functioning, Disability and Health (ICF) in the following groups: (Steiner, 2002):

1.        Upper limb capacity (d430, d440, d445): Jebsen Taylor Hand Function Test (JTT), Wolf Motor Function Test (WMFT), Box and Block Test (BBT), 9-Hole Peg Test (9HPT), Action Research Arm Test (ARAT).

2.        Upper limb muscle synergies (b760): Fugl-Meyer Upper Extremity (FM-UE) and Brunnstrom Stages of Stroke Recovery (BSSR).

3.        Strength (b739): Jamar Dynanometer Test and Handgrip Force.

4.        Activities of daily living: Functional Independence Measure (FIM) and Barthel Index (BI).

 

The working group defined a difference of 10% on each test scale as a clinically important difference. For standardized mean differences (SMD), results were clinically relevant if they were smaller than -0.5 or higher than 0.5. 

 

Search and select (Methods)

The databases Medline (via OVID) and Embase (via Embase.com) were searched with relevant search terms until 22-10-2020. The detailed search strategy is depicted under the tab Methods. The systematic literature search resulted in 798 hits. Studies were selected based on the following criteria:

•          Patients with ischaemic/haemorrhagic stroke.

•          RCTs and SRs about non-invasive brain stimulation with tDCS.

•          Subgroups with anodal, cathodal or bihemispheric tDCS.

•          A control group receiving sham tDCS.

•          More than 10 patients per treatment arm.

•          For cross-over studies: a baseline measurement and at the first cross-over point.

•          A description of at least one outcome measure, as described in the PICO.

 

14 studies were initially selected based on title and abstract. After reading the full-text, six studies were excluded (see table with reasons for exclusion under the tab Methods) and seven studies were included, including one systematic review and six RCTs.

 

Results

Seven studies were included in the analysis of the literature, including one SR and six RCTs. Important study characteristics and results are summarized in the evidence tables. The assessment of the risk of bias is summarized in the risk of bias tables.

  1. Alisar DC, Ozen S, Sozay S. Effects of Bihemispheric Transcranial Direct Current Stimulation on Upper Extremity Function in Stroke Patients: A randomized Double-Blind Sham-Controlled Study. J Stroke Cerebrovasc Dis. 2020 Jan;29(1):104454. doi: 10.1016/j.jstrokecerebrovasdis.2019.104454. Epub 2019 Nov 4. PMID: 31699572.
  2. Allman C, Amadi U, Winkler AM, Wilkins L, Filippini N, Kischka U, Stagg CJ, Johansen-Berg H.Ipsilesional anodal tDCS enhances the functional benefits of rehabilitation in patients after stroke. Sci Transl Med. 2016 Mar 16;8(330):330re1. doi: 10.1126/scitranslmed.aad5651. Epub 2016 Mar 16. PMID: 27089207; PMCID: PMC5388180.
  3. Bai X, Guo Z, He L, Ren L, McClure MA, Mu Q. Different Therapeutic Effects of Transcranial Direct Current Stimulation on Upper and Lower Limb Recovery of Stroke Patients with Motor Dysfunction: A Meta-Analysis. Neural Plast. 2019 Nov 16;2019:1372138. doi: 10.1155/2019/1372138. PMID: 31827495; PMCID: PMC6881758.
  4. Bernhardt J, Hayward KS, Kwakkel G, Ward NS, Wolf SL, Borschmann K, Krakauer JW, Boyd LA, Carmichael ST, Corbett D, Cramer SC. Agreed Definitions and a Shared Vision for New Standards in Stroke Recovery Research: The Stroke Recovery and Rehabilitation Roundtable Taskforce. Neurorehabil Neural Repair. 2017 Sep;31(9):793-799. doi: 10.1177/1545968317732668. PMID: 28934920.
  5. Edwards DJ, Cortes M, Rykman-Peltz A, Chang J, Elder J, Thickbroom G, Mariman JJ, Gerber LM, Oromendia C, Krebs HI, Fregni F, Volpe BT, Pascual-Leone A. Clinical improvement with intensive robot-assisted arm training in chronic stroke is unchanged by supplementary tDCS. Restor Neurol Neurosci. 2019;37(2):167-180. doi: 10.3233/RNN-180869. PMID: 30932903.
  6. Figlewski K, Blicher JU, Mortensen J, Severinsen KE, Nielsen JF, Andersen H. Transcranial Direct Current Stimulation Potentiates Improvements in Functional Ability in Patients With Chronic Stroke Receiving Constraint-Induced Movement Therapy. Stroke. 2017 Jan;48(1):229-232. doi: 10.1161/STROKEAHA.116.014988. Epub 2016 Nov 29. PMID: 27899754.
  7. Hamoudi M, Schambra HM, Fritsch B, Schoechlin-Marx A, Weiller C, Cohen LG, Reis J. Transcranial Direct Current Stimulation Enhances Motor Skill Learning but Not Generalization in Chronic Stroke. Neurorehabil Neural Repair. 2018 Apr-May;32(4-5):295-308. doi: 10.1177/1545968318769164. Epub 2018 Apr 22. PMID: 29683030; PMCID: PMC6350256.
  8. Hesse S, Waldner A, Mehrholz J, Tomelleri C, Pohl M, Werner C. Combined transcranial direct current stimulation and robot-assisted arm training in subacute stroke patients: an exploratory, randomized multicenter trial. Neurorehabil Neural Repair. 2011 Nov-Dec;25(9):838-46. doi: 10.1177/1545968311413906. Epub 2011 Aug 8. PMID: 21825004.
  9. Mazzoleni S, Tran VD, Iardella L, Dario P, Posteraro F. Randomized, sham-controlled trial based on transcranial direct current stimulation and wrist robot-assisted integrated treatment on subacute stroke patients: Intermediate results. IEEE Int Conf Rehabil Robot. 2017 Jul;2017:555-560. doi: 10.1109/ICORR.2017.8009306. PMID: 28813878.
  10. Nicolo P, Magnin C, Pedrazzini E, Plomp G, Mottaz A, Schnider A, Guggisberg AG. Comparison of Neuroplastic Responses to Cathodal Transcranial Direct Current Stimulation and Continuous Theta Burst Stimulation in Subacute Stroke. Arch Phys Med Rehabil. 2018 May;99(5):862-872.e1. doi: 10.1016/j.apmr.2017.10.026. Epub 2017 Dec 7. PMID: 29223708.
  11. Saeys W, Vereeck L, Lafosse C, Truijen S, Wuyts FL, Van De Heyning P. Transcranial direct current stimulation in the recovery of postural control after stroke: a pilot study. Disabil Rehabil. 2015;37(20):1857-63. doi: 10.3109/09638288.2014.982834. Epub 2015 Jul 9. PMID: 25401406.
  12. Salazar AP, Cimolin V, Schifino GP, Rech KD, Marchese RR, Pagnussat AS. Bi-cephalic transcranial direct current stimulation combined with functional electrical stimulation for upper-limb stroke rehabilitation: A double-blind randomized controlled trial. Ann Phys Rehabil Med. 2020 Jan;63(1):4-11. doi: 10.1016/j.rehab.2019.05.004. Epub 2019 May 31. PMID: 31158553.
  13. Shaheiwola N, Zhang B, Jia J, Zhang D. Using tDCS as an Add-On Treatment Prior to FES Therapy in Improving Upper Limb Function in Severe Chronic Stroke Patients: A Randomized Controlled Study. Front Hum Neurosci. 2018 Jun 19;12:233. doi: 10.3389/fnhum.2018.00233. PMID: 29970994; PMCID: PMC6018756.
  14. Sik, B.Y.. Dursun, N., Sade, I., Sahln, E. (2015). Transcranial Direct Current Stimulation: The Effects on Plegic Upper Extremity Motor Function of Patients With Stroke. Journal of Neurological Sciences, 2015, 32: 320 – 224.
  15. Straudi S, Fregni F, Martinuzzi C, Pavarelli C, Salvioli S, Basaglia N. tDCS and Robotics on Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke. Biomed Res Int. 2016;2016:5068127. doi: 10.1155/2016/5068127. Epub 2016 Mar 31. PMID: 27123448; PMCID: PMC4830702.
  16. Weir CJ, Butcher I, Assi V, Lewis SC, Murray GD, Langhorne P, Brady MC. Dealing with missing standard deviation and mean values in meta-analysis of continuous outcomes: a systematic review. BMC Med Res Methodol. 2018 Mar 7;18(1):25. doi: 10.1186/s12874-018-0483-0. PMID: 29514597; PMCID: PMC5842611.
  17. Yao X, Cui L, Wang J, Feng W, Bao Y, Xie Q. Effects of transcranial direct current stimulation with virtual reality on upper limb function in patients with ischaemic stroke: a randomized controlled trial. J Neuroeng Rehabil. 2020 Jun 15;17(1):73. doi: 10.1186/s12984-020-00699-x. PMID: 32539812; PMCID: PMC7296643.

 

Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

Follow-up

Outcome measures and effect size

Comments

Bai, 2019

SR and meta-analysis of RCTs and cross-over studies.

 

Literature search up to January 2019

 

A: Mazzoleni, 2017

B: Figlewski, 2017

C: Straudi, 2016

D: Hesse, 2011

E: Allman, 2016

F: Hamoudi, 2018

I: Saeys, 2015

 

Study design:

A: RCT

B: RCT

C: RCT

D: RCT

E: RCT

G: RCT
I:
Crossover

Setting and Country:

Department of Radiology and Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China

 

Source of funding and conflicts of interest:

The authors declare that they have no conflicts of interest.

Inclusion criteria SR:

(1) all patients were adults (≥18 years)

and were diagnosed with a first stroke; (2) the articles were

focused on the effect of tDCS on the recovery of motor function

in stroke patients; (3) the stimulation sites were located

in the primary motor cortex (M1); (4) all experiments were

randomized control trials including crossover and parallel

design; (5) ≥5 patients were enrolled, and all control groups

were sham tDCS; (6) all included articles were peer reviewed

and published in English; and (7) the results were

measured with scales.

 

Exclusion criteria SR:

(1) patients who had other diseases that could cause motor

dysfunction; (2) articles that had been published but did

not provide raw data, such as reviews, meta-analysis, or case

reports; (3) animal experiments; and (4) results that were not

expressed as mean ± standard deviation or mean ± standard

error, but as median or interquartile range.

 

29 studies included

 

 

Important patient characteristics at baseline:

 

N, mean age

A: 24 patients, 72.6 yrs

B: 44 patients, 60.5 yrs

C: 23 patients, 58.2 yrs

D: 95 patients, 65.5 yrs

E: 24 patients, 63.5 yrs.

F: 22 patients, 63.4 yrs.

G: 36 patients, 61.8 yrs

yrs.
I:
31 patients, 63.2 yrs

 

Groups comparable at baseline?

Describe intervention:

 

A: wrist robot assisted therapy + tDCS (0.057 mA/cm2)

B: training + anodal tDCS (0.043 mA/cm2)

C: robot assisted training + tDCS (0.029 mA/cm2)

D: arm robot therapy + tDCS (0.057 mA/cm2) Anodal & Cathodal

E: tDCS (anodal, 0.029 mA/cm2) + motor training

G: tDCS (0.04 mA/cm2)

I: tDCS (0.043 mA/cm2)

Describe control:

 

A: wrist robot assisted therapy + tDCS

B: training + sham tDCS (1.5mA)

C: Robot Assisted training + Sham tDCS

D: Arm robot therapy + sham tDCS

E: Sham tDCS + motor training

G: Sham tDCS

I: Sham tDCS

End-point of follow-up:

 

A: after treatment (30 sessions)

B: after treatment (9 sessions)

C: one week after treatment (10 sessions)

D: after treatment and 3 months after treatment (30 sessions)

E: Day 10 / 1 Week / 1 Month / 3 Month (9 sessions)

G: n.r.

I: 4 weeks / 8 weeks after treatment (5 sessions)

 

For how many participants were no complete outcome data available?

(intervention/control)

A: n.r.

B: 3/1

C: 0

D: 4/3/4

E: 1/1

G: n.r.

I: n.r.

 

 

 

Treatment ≤ 3 months

Upper Limb motor function

Effect measure: standardized mean difference (95% CI):

 

Anodal

A: 0.17 (-0.63 – 0.97)

B: n.r.

C: n.r.

D: n.r.
E:
n.r.
G:
n.r.
I:
n.r.

 

Upper limb synergy

Effect measure: standardized mean difference (95% CI):

Anodal

A: -0.39 (-0.53 – 0.31)
B:
n.r.
C:
n.r.
D:
-0.39 (-1.20 -0.42)
E:
n.r.
G:
n.r.
I:
n.r.

 

Pooled effect (random effects model): -0.11 (95% CI: -0.53 to 0.31) favoring sham

Heterogeneity (I2): 0%

 

Cathodal

A: n.r.
B:
n.r.
C:
n.r.
D:
-0.02 (-0.51 – 0.47)
E:
n.r.
G:
n.r.
I:
n.r.

 

Strength

A: n.r.

B: n.r.

C: n.r.

D: n.r.
E:
n.r.
G:
n.r.
I:
n.r.

 

 

Activities of daily living

Effect measure: mean difference (95% CI):

 

Anodal

A: n.r.

B: n.r.

C: n.r.

D: -2.7 (-11.62 – 6.22)
E:
n.r.
G:
n.r.
I:
n.r.

 

Cathodal

A: n.r.

B: n.r.

C: n.r.

D: 2.90 (-5.63 – 11.43)
E:
n.r.
G:
n.r.
I:
n.r.

 

Treatment > 3 months

Upper Limb motor function

Effect measure: standardized mean difference (95% CI):

Anodal

A: n.r.

B: n.r.

C: n.r.

D: n.r.
E:
0.17 (-0.64 – 0.97)
G:
n.r.
I:
n.r.

 

Cathodal

A: n.r.

B: 0.07 (-0.52 – 0.66)

C: n.r.

D: n.r.
E:
n.r.
G:
n.r.
I:
n.r.

 

Bihemispheric

A: n.r.

B: n.r.

C: 0.27 (-0.55 – 1.09)

D: n.r.
E:
n.r.
G:
n.r.
I:
n.r.

 

Upper limb synergy

Effect measure: standardized mean difference (95% CI):

 

Anodal

A: n.r.

B: n.r.

C: n.r.

D: n.r.
E:
0.35 (-0.46 – 1.16)
G:
n.r.
I:
n.r.

 

Bihemispheric

A: n.r.

B: n.r.

C: n.r.

D: n.r.
E:
0.35 (-0.46 – 1.16)
G:
n.r.
I:
n.r.

 

Strength

Effect measure: mean difference (95% CI):

 

Cathodal

A: n.r.

B: 1.40 (-4.56 – 7.36

C: n.r.

D: n.r.
E:
n.r.
G:
n.r.
I:
n.r.

 

Activities of daily living

 

A: n.r.

B: n.r.

C: n.r.

D: n.r.
E:
n.r.
G:
n.r.
I:
n.r.

Facultative:

 

tDCS is effective for the recovery of stroke patients with limb dysfunction after the first unilateral stroke, but the optimal parameters of tDCS for the upper and lower limbs are different. tDCS has a great impact on the recovery of upper limb function in chronic stroke patients. In addition, stroke

patients with upper limb hemiplegia recover better by using anode or cathode tDCS with above 0.029mA/cm2 current density and ≤10 sessions of treatment. But for the recovery of lower limb function, subacute stroke patients benefit more

from bilateral tDCS.

 

Tien, 2020

SR and meta-analysis of  RCTs and cross-over studies.

 

Literature search up to January 2019

A: Chang, 2015
B: Manji, 2018

 

Study design:

A: RCT
B: Crossover

 

Setting and Country:
Department of Physical Therapy, Far Eastern Memorial Hospital, New Taipe City.

 

Source of funding and conflicts of interest:

There are no conflicts of interest.

Inclusion criteria SR:

(1) application of tDCS in patients with stroke who were over 18 years of age; (2) outcome assessments including gait parameters, walking speed and endurance, functional mobility test or questionnaire for walking ability and balance; (3) pre-post and randomized controlled clinical study design; (4) active tDCS versus sham tDCS and could combine other  rehabilitation

treatments in two groups; (5)  published in English or Chinese language.

 

Exclusion criteria SR:

(1) patients had other types of neurological or musculoskeletal diseases or subjects were non-human subjects; (2) treatment combined other types of stimulation; (3) the articles were non-clinical trials including review, case report, editorial comment, and meta-analysis.

 

14 studies included

 

Important patient characteristics at baseline:

 

N, mean age

A: 24 patients, 62,8 yrs.
B: 30 patients, 63.0 yrs

 

Stroke type
Ischaemic/Hemiparetic

A: 24/0
B:
17/13

 

Groups comparable at baseline?

Yes

Describe intervention:

 

A: 10 sessions of anodal tDCS and conventional physical therapy.
B: Combined therapy body weight-supported treadmill training (BWSTT) and tDCS (anode: front of Cz, cathode: inion, 1 mA, 20 min).

 

Describe  control:

 

A: Sham group, in which patients received 10 sessions of sham stimulation and conventional physical therapy.
B: sham stimulation



End-point of follow-up:

 

A: after treatment
B: n.r.

 

For how many participants were no complete outcome data available?

(intervention/control)

A: 0
B: n.r.

 

 

Treatment ≤ 3 months
Walking ability
Defined as FAC

Effect measure: mean difference (95% CI):

Anodal
A: 0.42 (-0.05 – 0.89)
B:
n.r.

Standing balance
Defined as BBS

Effect measure: mean difference (95% CI):

Anodal
A: -2.50 (-6.07 – 1.07)
B:
n.r.

Strength and Muscle Synergy
Defined as FMA-LE

Effect measure: mean difference (95% CI):

Anodal
A: 2.20 (-0.17 – 4.57)
B:
n.r.

Siting balance
n.r.

Sitting and standing balance
n.r.

Walking distance
n.r.

Walking speed
Defined as the speed during gait analysis (m/s)

Effect measure: mean difference (95% CI):

Anodal
A: 0.05 (-0.15 – 0.25)
B:
n.r.

Falling
n.r.

Treatment > 3 months
Walking ability
n.r.

Standing balance
n.r.

Strength and Muscle Synergy
n.r.

Sitting Balance
n.r.

Sitting and standing balance
Defined as TUG

Effect measure: mean difference (95% CI):

Anodal
A: n.r.
B: -0.90 (6.34 – 4.54)

Walking distance
Defined was 10MWT

Effect measure: mean difference (95% CI):

Anodal
A: n.r.
B: 1 wk: 2.30 (-6.17 – 1.57)
2 wk: 1.20 (-4.64 – 2.24)

Walking speed
n.r.

 

 

 

 

 

 

Facultative:

In conclusion, this meta-analysis suggests that tDCS improves walking ability with an exception of walking speed and endurance in patients with stroke. Both anodal and dual- hemispheric tDCS exert positive effects on promoting walking-related performances after stroke. However, difficulty in improving balance performance by tDCS may limit the effects of tDCS on walking speed and/or walking distance.

 

Level of evidence: PEDro scale (per study)
A: Excellent
B:
Good

 

 

Elsner, 2019

SR and meta-analysis of RCTs

 

Literature search up to July 2018

 

A: Fridriksson, 2018

B: Meinzer, 2016

C: Spielmann, 2018

 

Study design:

A: RCT
B:
RCT
C:
Multi-centre RCT

 

Setting and Country:

A: USA
B:
Germany
C:
the Netherlands


 

 

Source of funding and conflicts of interest:

 

A: None
B:
None
C:
This work was funded by Erasmus MC Cost-Effectiveness Research and the Dutch Brain Foundation. No conflicts of interests present.


 

(commercial / non-commercial / industrial co-authorship)

 

Inclusion criteria SR:

- RCTs, cross-over trials

 

Exclusion criteria SR:

- Quasi-randomised controlled trials

- Aged 18 years or above

- Stroke patients (WHO definition)

- tDCS alone or with SLTH

 

21 studies included

 

 

Important patient characteristics at

N, mean age

A: 74, 59.8y
B:
26. 60y
C:
58, 58y

 

 

Sex:

A: 69.7% Male
B:
69.2% Male
C:
69.0% Male


 

Groups comparable at baseline?

Describe intervention:

 

A: A-tDCS (1 mA) for 20 minutes over the left scalp over the individually most active cortex region identified by naming tasks fMRI during 45 minutes of computerised naming treatment

B: A-tDCS over the leftM1 (1 mA for 20 minutes) at the beginning of computer-assisted

naming treatment session with the ’vanishing cues’ approach (2 times for 90 minutes a day, 4 days per week for 2 weeks)

C: A-tDCS for 1 mA for the first 20 minutes and word-finding therapy for 45minutes per day on 5 consecutive sessions; 225 minutes per week.

 

Describe control:

 

A: S-tDCS for 20minutes over the left scalp over the individually most active cortex region identified by naming tasks fMRI during 45 minutes of computerised naming treatment

B: S-tDCS over the leftM1 (1 mA for 30 seconds) at the beginning of computer-assisted

naming treatment session with the ’vanishing cues’ approach (2 times for 90 minutes a day, 4 days per week for 2 weeks)

C: S-tDCS for the first 20 minutes and word-finding therapy for 45minutes per day on 5 consecutive

sessions; 225 minutes per week.

 

End-point of follow-up:

 

A: 1 week after treatment

B: After treatment and after 6 months follow-up

C: After treatment and after 6 months follow-up

 

 

For how many participants were no complete outcome data available?

(intervention/control)

A: n.r.

B: n.r.

C: n.r.

 

 

 

 

Treatment ≤ 3 months

 

Functional communication

Measured with ANELT (0-50). Effect measure: MD (95% CI)

 

Anodal:

A: n.r.
B:
n.r.
C:
1.00 (-5.15 to 7.15) in favour of tDCS.

 

Verbal comprehension

n.r.

 

Expressive naming

Measured with the BNT (60 items)

Effect measure: SMD (95% CI)

 

Anodal:
A: n.r.
B:
n.r.
C:
-0.99 (-1.54 to -0.44) in favour of sham.

 

Treatment >3 months

 

Functional communication

Measured with the CETI

Effect measure: MD (95% CI):

 

Anodal:

A: n.r.

B:  9.40 (-6.18 to 24.98) in favour of tDCS.

C: n.r.

 

Verbal comprehension

n.r.

 

Expressive naming

Measured with naming ability of trained and untrained items or the picture naming test. Effect measure SMD (95% CI):

 

Anodal:

A: 0.41 (-0.06 to 0.87) in favour of tDCS.

B: 0.69 (-0.10 to 1.49) in favour of tDCS.

C: n.r.

 

Pooled effect (random effects model:
0.48 (95% CI 0.08 to 0.88) favoring tDCS

Heterogeneity (I2): 0%

Risk of Bias:
A: Unclear (selective reporting)

B: Unclear (allocation concealment)

C: High (selective reporting)

D: Unclear (allocation concealment, blinding, elective outcome reporting), High (incomplete outcome data)

 

Author’s conclusion

There is no evidence of the effectiveness of tDCS (A-tDCS, CtDCS, Dual-tDCS) versus control (S-tDCS) for improving functional

communication in people with aphasia (low quality of evidence), accuracy in naming verbs (very low quality of evidence), and cognition in stroke patients with aphasia at the present time. However, tDCS improves the accuracy in naming nouns (moderate

quality of evidence), measured at the end of the intervention period and possibly also at follow-up (moderate quality of

evidence). Current evidence does not support the routine use of tDCS for aphasia after stroke.

Van Lieshout, 2019

SR and meta-analysis of  RCTs, cross-over design trials, case studies and mixed design studies.

 

Literature search up to January 2018

 

A: Ládavas, 2015

B: Yun, 2015

 

Study design:

A: RCT
C:
RCT

 

Setting and Country:

A: Italy
B:
Korea

 

Source of funding and conflicts of interest:

The authors declared no potential conflicts of interest with respect

to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support

for the research, authorship, and/or publication of this article: This

work was supported by the Netherlands Organization for Scientific

Research (VICI 016.130.662).

Inclusion criteria SR: 1) patients

with ischaemic or haemorrhagic stroke; (2) age ≥ 18 years;

(3) the use of NIBS (TMS, TBS, or tDCS); (4) objective,

standardized tests or test batteries for assessment of cognitive

function; and (5) baseline measurement and posttreatment

measurement(s)

 

Exclusion criteria SR:

(1) nonhuman

studies and (2) studies that only tested effects on motor, language

functions and perception.

 

40 studies included

 

Important patient characteristics at baseline:

 

N, mean age

A: 30 patients, 68.9 yrs

B: 30 patients, 62.1 yrs

C: 45 patients, 62.8 yrs



Sex:

A: 53.3% Male

B: 70% Male

C: 44.4% Male

 

Stroke
A: n.r.

B: n.r.

C: n.r.

 

comparable at baseline?

Yes

Describe intervention:

 

A: a-tDCS + prism adaptation, c-tDCS + prism adaptation, 20 minutes x 10 sessions, x5/wk, 2 weeks.

B: a-tDCS + cognitive rehabilitation, 30 minutes x 15 sessions, x5/wk x 3 wks

 

Describe  control:

 

A: Sham a/c tDCS + prism adaptation, 20 minutes x 10 sessions, x5/wk, 2x weeks.

B: sham tDCS + cognitive rehabilitation, 30 minutes, x 15 sessions, x 5/wk, x3 weeks.

 

End-point of follow-up:

 

A: first week after PA treatment.

B: Post-treatment

 

 

For how many participants were no complete outcome data available?

(intervention/control)

A: n.r.

B: n.r.

 

 

 

Treatment ≤ 3 months

Visual and spatial attention

n.r.

 

Global cognitive functioning

Defined by the Korean version of the MMSE test (B1=left side; B2=right side)

 

Effect measure: Mean difference (95% Confidence Interval):
Anodal

A: n.r.
B1:
2.20 (-1.20 – 5.60) in favour of tDCS

B2: 1.40 (-1.87 – 4.67 in favour of tDCS)

 

Memory

Defined by the ViLT-R/VeLT-R (B1=left side; B2=right side).

Effect measure: Mean difference (95% Confidence Interval):
Anodal

A: n.r.
B1:
4.50 (-9.40 – 18.40) favouring tDCS / -0.10 (-13.67 – 13.47) favouring sham

B2: 1.80 (-11.91 – 15.51) favouring tDCS / -2.70 (-14.31 – 8.91) favouring sham.

 

Executive functioning

n.r.

 

Treatment ≤ 3 months

Visual and spatial attention

Defined by the behavioral inattention test.

 

Effect measure:

Mean Difference (95% Confidence Interval).

Anodal
A: 9.00 (2.64 – 15.36) in favour of tDCS
B: n.r.

 

Global cognitive functioning

n.r.

 

Memory

n.r.

 

Executive functioning

n.r.

 

 

 

 

 

 

 

 

 

 

Author’s conclusion:

Our review suggests that NIBS is

able to alleviate neglect after stroke. However, the results are still inconclusive and preliminary for the effect of NIBS on other cognitive domains. A standardized core set of outcome measures of cognition, also at the level of daily life activities and participation, and international agreement on treatment protocols, could lead to better evaluation of the efficacy of NIBS and comparisons between studies.

 

Risk-of-bias:

A: n.r.

B: n.r.

 

 


 

Study reference

Study characteristics

Patient characteristics 2

Intervention (I)

Comparison / control (C) 3

 

Follow-up

Outcome measures and effect size 4

Comments

 

Sik, 2015

Type of study:

Double-Blind Sham-Controlled Study

 

Setting and country:

Physical

Medicine and Rehabilitation (PMR) Department of Baskent

University Faculty of Medicine, Turkey

 

Funding and conflicts of interest:

This study was approved by Baskent University Institutional

Review Board and Ethics Committee (Project no: KA15/271)

and supported by Baskent University Research Fund. The authors have no financial conflicts of interest.

Inclusion criteria:

Patients with a history

of subacute or chronic stroke (disease duration of at least three months) and

hand-wrist dorsiflexion of at least 10 degrees (90 degrees wrist palmar flexion posture) due to involvement of the middle

cerebral artery were included in our study.

 

Exclusion criteria:

Patients with severe cognitive deficits, history of epileptic convulsion, severe depression, neglect syndrome, aphasia,

severe spasticity, static deformity in the upper

extremity, non-ambulated, cerebellar or anterior cerebral artery involvement, brain stem

involvement, basal ganglia involvement, intracranial metallic implant, cardiac

pacemaker, significant visual loss, significant hearing loss, complex regional pain syndrome in plegic upper extremity,

uncontrolled systemic problems, and application of botulinum A toxin to the plegic upper extremity in the past 6 months

were excluded from the study.

 

N total at baseline:

Anodal tDCS: 12

Bihemispheric tDCS: 12

Sham: 12

 

Important prognostic factors2:

Age: mean (25-75 percentile)

A: 62,0 (54,8–70,0)
B: 58,5 (53,8–66,0)
S: 60,0 (55,0–67,0)

 

Sex:

A: 60%

B: 40%

S: 72.7%

 

Groups comparable at baseline?

Yes

In addition to a conventional physiotherapy and

occupational therapy program, anodal tDCS application was used in one group (A) for 20 minutes and 15 sessions in 3 weeks, bihemispheric anodal/cathodal tDCS

application in another group (B) for 40 minutes and 15 sessions in 3 weeks. The anodal tDCS application involved the placement of the active electrode to the C3-C4 area of the affected hemisphere and the reference electrode to the opposite supraorbital

region. The application of bihemispheric anodal-cathodal tDCS was performed by the placement of the active electrode to the C3-C4 area of the unaffected hemisphere in addition to its anodal application, and the placement of the reference electrode to

the opposite supraorbital region with the reversal of the current against the anodal tDCS

In addition to a conventional physiotherapy and

occupational therapy program, sham tDCS application in the third group (S). In the sham tDCS group, electrodes

were placed as in the anodal group, with

the first tingling sensation (1 min) achieved by turning on the device followed

by interruption of the current, performed

carefully so that the patient did not notice.

 

Length of follow-up:

6 months.

 

Loss-to-follow-up:

A: 2 (16.7%)
B: 2 (16.7%)
S: 1 (8.3%)

 

Reasons: Did not continue study because of social reasons.

 

Incomplete outcome data:

A: 0
B: 0
S: 0

 

 

 

Treatment ≤ 3 months

 

Upper limb motor function

n.r.

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

Treatment > 3 months

Upper limb motor function

Effect measure: standardized mean difference (95% Confidence Interval)

 

0.47 (-0.56 – 0.97)

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

 

In conclusion, tDCS is an important non-invasive

brain stimulation technique that can provide additional benefits to plegic upper extremity motor function when coadministered

with a rehabilitation program.

 

Alisar, 2020

Type of study:

prospective, randomized, sham-controlled study

Setting and country:

Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation

Haydarpaşa Numune Educatıon and Research Hospital İstanbul, Turkey

 

Funding and conflicts of interest:

n.r.

Inclusion criteria:

(1) age 18-75 years (2) first time stroke

sufferer (3) stroke of vascular aetiology as determined

by computerised tomography or magnetic resonance

imaging (4) at least 3 months since stroke onset (5) mini

mental state examination score 23 6) stable medical condition.

 

Exclusion criteria:

(1) presence of sensory

aphasia/neglect/significant hearing or visual loss/significant

spasticity (modified Ashworth scale grade 3-4) (2)

history of epilepsy/brain tumour/cranial surgery (3)

presence of a pacemaker/intracranial metallic implant.

 

N total at baseline:

Intervention: 16

Control: 16

 

Important prognostic factors2:

For example

age ± SD:

I: 63.56 ± 10.19

C: 63.50 ± 12.60

 

Sex:

I: 38% M

C: 44% M

 

Groups comparable at baseline?

Yes

tDCS was applied using a double channelled direct current stimulator (ZMI Electronics Ltd. Taiwan 2012). The consistency of the direct current was constantly monitored

and determined by the direct current stimulator.

The current was applied using 5.5 cm £ 4 cm (22 cm2) rectangular electrodes.

 

The electrodes were placed using the same method in the

sham group and the stimulator switched on and current

increased until the patient felt the typical ''tingling'' sensation

on their scalp for a duration of 30 seconds. It is well

known that tDCS does not elicit auditory or somatosensory

perceptions beyond the initial minute of its application,12

therefore, the stimulation was gradually reduced and

switched off after approximately a minute. The electrodes

remained in situ for 30 minutes during the OT session.

 

 

Length of follow-up:

After treatment (15th)

 

Loss-to-follow-up:

Intervention: 0

Control: 0

 

Incomplete outcome data:

Intervention: 2 (11.1%)

Control: 4 (20%)

 

Reasons: Did not receive allocated intervention.

 

 

Treatment ≤ 3 months

 

Upper limb motor function

n.r.

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

Treatment > 3 months

Upper limb motor function

n.r.

 

Upper limb synergy

Effect measure: standardized mean difference (95% Confidence Interval)

 

0.30 (-0.39 – 1.00)

 

Strength

n.r.

 

Activities of daily living

Effect measure: Mean difference (95% Confidence Interval):

 

29.82 (11.83 – 47.81)

 

 

 

In this double-blind randomized controlled study, bihemispheric

tDCS therapy combined with OT and conventional

rehabilitation methods were found to be effective in

improving upper extremity motor functions and ADL in

stroke patients. Functional improvement was greater in

chronic stroke sufferers who received tDCS.

In order for tDCS to routinely enter stroke rehabilitation

practice; optimum duration and intensity of tDCS, ideal

time since stroke onset, and lesion location should be

identified. With this in mind, randomized controlled clinical

trials in larger patient populations with longer follow-up

periods should be conducted.

 

Nicolo, 2018

Type of study:

Double-blinded, randomized, placebo-controlled study.

 

Funding and conflicts of interest:

n.r.

Inclusion criteria:

(1) ischaemic or haemorrhagic

stroke, (2) <10 weeks after stroke, (3) unilateral lesion in the

territory of the middle cerebral artery, and (4) first-ever appearance

of upper extremity motor impairment based on the Fugl-

Meyer upper extremity scale (score<50).

 

Exclusion criteria:

Participants were

excluded if they met any of the following criteria: epileptic seizures,

presence of metallic objects in the brain, skull breach after

craniectomy, presence of implants or neural stimulators, pregnancy,

sleep deprivation, recent traumatic brain injury, delirium or

disturbed vigilance, inability to participate in 1-hour treatment

sessions, severe language comprehension deficits, new stroke lesions

during rehabilitation, or medical complications.

 

N total at baseline:

Intervention: 14

Control: 13

 

Important prognostic factors2:

For example

age ± SD:

I: 68.5 ± 10.8

C: 64.3 ± 17.1

 

Sex:

I: 57.1% M

C: 61.5% M

 

Groups comparable at baseline?

Yes

tDCS was applied for 25 minutes at an intensity of 1mA38 using a

constant-current electrical stimulator. Two 35-cm2 electrodes with sponge surfaces were placed over the ipsilesional supraorbital

region (anodal electrode) and the contralesional M1 (cathodal electrode) using the positions of C3 or C4 electrodes of the international 10-20 electroencephalography system.

 

For sham stimulation, the current was ramped up for 30 seconds and then slowly tapered down to zero. This modus operandi has been used to prevent participants from differentiating between real and sham stimulation. Physical therapy was started after approximately

minutes of tDCS.

Length of follow-up:

After intervention.

 

Loss-to-follow-up:

Intervention: 0

Control: 0

 

Incomplete outcome data:

Intervention: 0

Control: 0

 

 

Treatment ≤ 3 months

 

Upper limb motor function

Effect measure: Standardized mean difference (95% Confidence Interval):

 

0.55 (-0.22 – 1.32)

 

Upper limb synergy

Effect measure: Standardized mean difference (95% Confidence Interval):

 

-0.19 (-0.95 – 0.57)

 

Strength

Effect measure: Mean Difference (95% Confidence Interval):

 

0.00 (-4.99 -4.99)

 

Activities of daily living

n.r.

 

Treatment > 3 months

Upper limb motor function

n.r.

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

 

 

 

This study demonstrates that tDCS and rTMS can target different aspects of stroke plasticity. An inhibition of the contralesional M1or a reduction of interhemispheric interactions did not lead to

improved motor recovery in our sample. Conversely, exploratory subgroup analyses suggest that motor recovery might be enhanced by early interventions that seek to increase FC of ipsilesional

motor nodes. This hypothesis will need to be confirmed in future

trials applying tDCS within the first 4 weeks after stroke.

 

Shahweiwola, 2018

Type of study:

Randomized Controlled Study.

 

Funding and conflicts of interest:

This work was supported by the National Natural Science

Foundation of China (No. 51475292, No. 61761166006), and the Shanghai Municipal Commission of Health and Family lanning

(No. 2017ZZ01006). The authors declare that the research was conducted in the absence of any commercial or financial relationships that could

be construed as a potential conflict of interest.

Inclusion criteria:

(1) age between 35

and 70 years; (2) cerebral haemorrhage or cerebral infraction for the first time; (3) confirmed by head CT or MRI; (4) at least 6 months since stroke onset and an ipsilateral arm Brunnstrom

recovery at stages 0–3; (5) conscious and able to communicate; and (6) able to sign informed consent himself/herself or with the

help of his/her immediate family member.

 

Exclusion criteria:

(1) sequelae after lacunar cerebral infraction; (2) peripheral neuropathy in upper limbs; (3)

unconsciousness, sensory aphasia or mental disorders, that may

lead to failures in coordinating examination and treatment; (4) history of seizure. (5) serious illnesses, such as heart, liver or kidney diseases, or serious coagulation disorders; (6) history of

cognitive disorder, neuropsychiatric disorder, drug or alcohol abuse; (7) organ failure, carcinoma or terminal stroke that

seriously affect quality of life beyond hand dysfunction; (8)

inability to complete basic course, to persist treatment, or difficult

to follow-up; (9) with metal implants or skull defect; (10) existence of skin rash, allergy or wounds at the locations where stimulation electrodes would be placed.

 

N total at baseline:

Intervention: 15

Control: 15

 

Important prognostic factors2:

For example

age ± SD:

I: 49.3 ± 9.4

C: 51.9 ± 11.0

 

Sex:

I: 93.3% M

C: 86.7% M

 

Groups comparable at baseline?

Yes

The active tDCS protocol (intensity: 2.0 mA, time

of ramp-up: 10 s, time of ramp-down: 10 s). We placed the anode electrode (5 cm×5 cm) of tDCS over the hot spot on the lesioned hemisphere and the cathode electrode (5 cm×5 cm) on the contralateral symmetrical area of non-lesioned hemisphere. If MEPs could not be detected on the paralyzed arm,

the hot spot for APB on the non-lesioned hemisphere was first

determined, and then the symmetrical area on the contralateral

hemisphere was regarded as the APB hot spot corresponding

to the paralyzed arm. tDCS intervention was delivered for 20

min via a pair of sponge electrodes moistened with 0.9% NaCl solution. To deliver the FES therapy, we used the Bio-feedback Neuromuscular

Stimulator (MyoNet-BOW-III, NCC Medical Co., LTD, China), a parameter-adjustable transcutaneous stimulator that used selfadhesive surface electrodes. The amplitude of the electric current and the tasks were selected based on patients’ needs and adjusted weekly.

the sham protocol was programmed by a dedicated computer software package and saved on the device ahead of the usage. Regular parameters of tDCS were chosen based on pilot study prior to the

experiment. To deliver

the FES therapy, we used the Bio-feedback Neuromuscular

Stimulator (MyoNet-BOW-III, NCC Medical Co., LTD, China),

a parameter-adjustable transcutaneous stimulator that used selfadhesive surface electrodes. The amplitude of the electric current and the tasks were selected based on patients’ needs and adjusted weekly.

Length of follow-up:

After intervention (4 weeks)

 

Loss-to-follow-up:

Intervention: 0

Control: 0

 

Incomplete outcome data:

Intervention: 0

Control: 0

 

 

Treatment ≤ 3 months

 

Upper limb motor function

n.r.

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

Treatment > 3 months

Upper limb motor function

Effect measure: Standardized mean difference (95% Confidence Interval):

 

0.49 (-0.24 – 1.22)

 

Upper limb synergy

Effect measure: Standardized mean difference (95% Confidence Interval):

0.28 (-1.25 – 0.79)

 

Strength

n.r.

 

Activities of daily living

n.r.

 

 

 

 

 

Our results suggest new trials with combined intervention in both the central nervous system and

the peripheral nervous system. In terms of limitations, since only

stroke patients with unilateral arm paralysis were recruited and

tested, more types and cases of stroke are needed. In addition, due to the demographics of the patients that were available for the study, both groups were skewed toward males. To further investigate in the interaction between the tDCS treatment and

the FES therapy in the protocol, more clinical trials with various intervention conditions and more diverse demographics are also needed.

 

Salazar, 2020

Type of study:

A double-blind randomized controlled trial

 

Funding and conflicts of interest:

This study received financial support from Conselho Nacional de

Pesquisa (CNPq, Brazil) - grant universal 461254/2014-0) and from the

Coordenac¸a˜o de Aperfeic¸oamento de Pessoal de Nı´vel Superior (CAPES,

Brazil) - finance code 001). The authors declare that they have no competing interest.

Inclusion criteria
We included

individuals with ischaemic or haemorrhagic chronic stroke confirmed

by head CT or MRI at least 6 months before recruitment,

aged between 18 and 80 years, with moderate (32-47/66) or severe

hemiparesis (9-31/66) according to the Fugl–Meyer score

(17). Participants had to have minimal cognitive ability on the

Mini Mental State Examination (> 20/30 points (illiterate) or > 24/

30 points (literate) (18) and no history of seizures. Furthermore,

participants had to be able to reach forward with both ULs.

 

Exclusion criteria

Individuals who presented shoulder pain, adhesive capsulitis or

glenohumeral luxation and any contraindications for electrical

stimulation were excluded.

 

N total at baseline:

Intervention: 15

Control: 15

 

Important prognostic factors2:

For example

age ± SD:

I: 49.3 ± 9.4

C: 51.9 ± 11.0

 

Sex:

I: 93.3% M

C: 86.7% M

 

Groups comparable at baseline?

Yes

This group underwent 10 sessions of concurrent tDCS and FES during 30 min, 5 times a week

for 2 weeks (excluding weekends). Before each stimulation session,

participants underwentscapular, shoulder, elbow, wrist and finger

passive mobilization for approximately 10 min.

This group underwent 10 sessions of placebo tDCS (sham tDCS) and FES during 30 min, 5 times a week

for 2 weeks (excluding weekends). Before each stimulation session,

participants underwentscapular, shoulder, elbow, wrist and finger

passive mobilization for approximately 10 min.

Length of follow-up:

After intervention (2 weeks)

 

Loss-to-follow-up:

Intervention: 0

Control: 0

 

Incomplete outcome data:

Intervention: 0

Control: 0

 

 

Treatment ≤ 3 months

 

Upper limb motor function

n.r.

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

Treatment > 3 months

Upper limb motor function

n.r.

 

Upper limb synergy

Effect measure: Standardized mean difference (95% Confidence Interval):

-1.34 (-2.14 - -0.54)

 

Strength

n.r.

 

Activities of daily living

n.r.

 

 

 

 

 

Concurrent bi-cephalic tDCS and FES slightly improved reaching motor performance and

handgrip force of chronic post-stroke individuals with moderate and severe UL impairment.

 

Yao, 2020

Type of study:

a randomized controlled trial.

 

Funding and conflicts of interest:

This work was supported by Shanghai Jiao Tong University School of Medicine

- Institute of Neuroscience, Chinese Academy of Sciences, Leading Startup

Project of Brain Diseases Clinical Research Center (2017NKX002). The funders

had no role in study design, data collection and analysis, decision to publish, or

preparation of the manuscript. The authors declare that they have no competing interests.

Inclusion criteria
aged 18–80 years; had a first-ever ischaemic

stroke (silent infarct is allowed) as diagnosed by computed

tomography or magnetic resonance imaging image

scans; had their first ischaemic stroke between 2 weeks to

12 months; can induce motor evoked potential (MEP) of

contralesional first dorsal interossei muscle (FDI) using

Transcranial magnetic stimulation.

 

Exclusion criteria
intracranial or

orbital metallic implants, pacemakers or artificial cochlea;

previous seizure history; previous history of brain

neurosurgery or cerebral trauma; aphasia, unilateral neglect

or cognitive deficits (Mini-Mental State Examination

score < 20); refused to sign informed consent.

 

N total at baseline:

Intervention: 22

Control: 20

 

Important prognostic factors2:

For example

age ± SD:

I: 63 ± 7.5

C: 66.2 ± 6.2

 

Sex:

I: 70% M

C: 85% M

 

Groups comparable at baseline?

Yes

The electrical stimulation device was a transcranial direct

current stimulation model IS300 manufactured by

Sichuan Intelligent Company of China. Its two conductive

rubber electrodes were placed in a saline-soaked

sponge (5 × 7 cm 2) when used. The cathodal electrode

was placed over the patients’ scalp which corresponded

to the primary motor cortex (M1) of the unaffected

hemisphere, and the region was determined by the induction

of stable MEP response in the FDI using transcranial

magnetic stimulation. The reference electrode

was placed above the contralateral supraorbital region.

The current of the experimental group was constant 2

mA for 20 min. he duration of the

VR therapy was 20 min.

For the control group, the current was

rapidly increased to 2 mA in the beginning and then

slowly tapered down to 0. At the end of the experiment,

the current again rapidly ramp up to 2 mA and then

slowly ramp-down to 0. It created a scalp sensation to

blind the subject. he duration of the

VR therapy was 20 min.

Length of follow-up:

After treatment (2 weeks)

 

Loss-to-follow-up:

Intervention: 0

Control: 0

 

Incomplete outcome data:

Intervention: 2

Control: 0

Reasons: Discontinued intervention.

 

 

Treatment ≤ 3 months

 

Upper limb motor function

Effect measure: Standardized mean difference (95% Confidence Interval):

 

0.33 (-0.07 – 0.90)

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

Treatment > 3 months

Upper limb motor function

n.r.

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

 

 

Our proof-of-concept single-centre phase II study

showed that c-tDCS combined with VR can reduce

motor impairment, improve function, increase ADL in

the affected upper limb in patients with subacute or

chronic ischaemic stroke than VR alone. This study provides

critical preliminary data to plan a future multicentre

clinical trial to systematically investigate the efficacy

of combined intervention.

 

Edwards, 2019

Type of study:

randomized controlled trial

 

Funding and conflicts of interest:

This study was supported by NICHD of the NIH,

under award number R01HD069776. Dr. A. Pascual-

Leone was partly supported by the Sidney R. Baer Jr.

Foundation, the Football Players Health Study at Harvard

University, and Harvard Catalyst | The Harvard

Clinical and Translational Science Centre (NCRR

and the NCATS NIH, UL1 RR025758). Dr. L. Gerberwas

partly supported by the Clinical Translational

Science Center, grant number UL1-TR000457-06.

Dr. B.T. Volpe and J. Chang were supported by the

Feinstein Medical Research Foundation.

Inclusion criteria

a) a first unilateral

ischaemic lesion; b) cognitive function sufficient to

understand the experiments and follow instructions;

and c) Motor Power score 1-4/5 (neither hemiplegic

nor fully recovered motor function in the muscles

of the shoulder and/or elbow and/or wrist).

 

Exclusion criteria

n.r.

 

N total at baseline:

Intervention: 41

Control: 41

 

Important prognostic factors2:

For example

age (mean):
67.8

 

Sex:

61% M

 

Groups comparable at baseline?

No, not in age and cortical versus subcortical stroke.

 

For participants in the RobottDCS group, a 2mA

current was delivered by a battery driven, constant

current stimulator (1×1 tDCS device, Soterix

Medical, New York) using surface rubber-carbon

electrodes (35cm2) with surrounding saline soaked

sponges (0.9% NaCl). Participants received stimulation

for 20 minutes while seated (immediately

prior to robot-assisted motor training), with the anode

centered 5 cm lateral to the vertex (Fig. 3), and

the cathode on the contralateral supraorbital area

(Allman et al., 2016).

 

Participants in the RobotSham

group had a comparable set-up to RobottDCS, with

the stimulation comprising a 30 sec current ramp to

2 mA, then 30 sec ramp down to 0 mA, repeated after

20 mins.

Length of follow-up:

After treatment

 

Loss-to-follow-up:

Intervention: 3

Control: 5

Reasons: unrelated illness, death to spouse, transportation issue.

 

Incomplete outcome data:

Intervention: 4

Control: 1

Reasons: unrelated illness, botox treatment, illness of relative.

 

 

Treatment ≤ 3 months

 

Upper limb motor function

n.r.

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

Treatment > 3 months

Upper limb motor function

Effect measure: Standardized mean difference (95% Confidence Interval):

 

0.03 (-0.44 – 0.51)

 

Upper limb synergy

n.r.

 

Strength

n.r.

 

Activities of daily living

n.r.

 

 

 

We conclude that; 1. Robot-assisted arm training is an effective form of rehabilitation for

chronic post-stroke hemiparesis, 2. Supplementary

ipsilesional-anode tDCS as performed in our

study sample although well tolerated, did not augment

training effects, and 3. Residual corticospinal

integrity (motor evoked potential presence) in the

chronic stroke hemiparetic arm, can be a predictor of

clinically important response to intensive arm rehabilitation.

 

Andrade, 2017

Type of study:

sham-controlled, double-blinded, parallel clinical

trial.

Setting and Country: Cognitive Neuroscience and Behavior Program, Department of Psychology, Federal University of Paraíba, João Pessoa, Brazil; Nursing. Department, State University of Paraíba, Campina Grande, Brazil.

Funding and conflicts of interest:

No potential conflict of interest was reported by the authors.

Inclusion criteria:

(a) between 18 and 75 years of age; (b) diagnosis

of unilateral, non-recurring, acute ischaemic stroke, as defined by the International Classification of Diseases (ICD-10) through Computed Tomography or Magnetic Resonance conducted by neurologists; (c) able to walk 10 m independently (with or without a mobility aid); (d) high risk of falling (fall during hospital admission, leg score on the Step Test lower than 7, or Berg Balance Scale (BBS) score of less than 49).

Exclusion criteria:

(a) score between 25 and 32 points on the National Institute of Health Stroke Scale (11) and degree 5 according to the Rankin Scale (12); (b) Mini Mental State Examination score lower than 20.

N total at baseline:
A: 15
B: 15
C: 15
D: 15

Important prognostic factors2:

Age: mean (SD)
A: 68.86 ± 4.66
B: 69.06 ± 4.43

C: 70.40 ± 2.32
D: 68.00 ± 1.46

Sex (% Male):
A: 53,3%
B: 60%
C: 53,3%
D: 66,7%

Groups comparable at baseline?

Yes

Group A
Patients received 10 sessions (five consecutive

days for two weeks) of anodal tDCS stimulation at 2 mA intensity and current density equivalent to 0.05 A/m2. the active electrode was placed on the affected hemisphere.

Group B
Patients received 10 sessions (five consecutive days for two weeks) of cathodal tDCS stimulation at 2 mA intensity and current density equivalent to 0.05 A/m2. the active electrode was placed on the unaffected hemisphere.

Group C
Patients received 10 sessions (five consecutive days for two weeks) of cathodal tDCS stimulation at 2 mA intensity and current density equivalent to 0.05 A/m2. the active electrode was placed on the unaffected hemisphere. The cathode and anode were positioned as active electrodes in the same way described above.

All participants received the same physical rehabilitation program (1 h daily, three times per week). Therapy included individualized motor task training and activities of daily living training, emphasizing active participation of the affected and  unaffected hemispheres.

 

For sham stimulation, the current was ramped up over 30 seconds and then turned off (15). The current was delivered through two saline-soaked sponge surface electrodes (5 × 7 cm) using a battery-driven constant current stimulator (Trans Cranial Technologies®, Hong Kong, China).

Length of follow-up:

1 day after treatment, one-month and three-month follow-up.

 

Loss-to-follow-up (3 months)

N=3
Reasons: Drop out

 

Incomplete outcome data:
n.r.

 

 

 

Walking ability
n.r.

Standing balance
Defined as BBS

Effect measure: mean difference (95% CI):

Anodal
3.50 (3.32 – 3.68)

Cathodal
4.70 (4.52 – 4.88)

Bihemispheric
9.30 (1.07 – 7.30)

Pooled effect (random effects model): 5.83 (95% CI 2.37 to 9.30) favoring tDCS. Heterogeneity (I2): 100%

Strength and Muscle Synergy
n.r.

Sitting balance
n.r.

Sitting and standing balance
Defined as STS (% change)

Effect measure: mean difference (95% CI):

Anodal:
13.5 (12.16 – 14.84)

Cathodal
9.5 (8.34 – 10.65)

Bihemispheric
24.5 (22.96 – 26.04)

Walking distance
Defined as 6MWT (% change)

Effect measure: mean difference (95% CI):

Anodal
28l3 (27.26 – 29.24)

Cathodal
27 (26.12 – 27.88)

Bihemispheric
33.5 (32.51 – 34.49)

Pooled effect (random effects model): 29.6 (95% CI 27.7 0 – 33.46) favoring tDCS. Heterogeneity (I2): 98%

Falling
Defined as FES-I (% change)

Effect measure: mean difference (95% CI):

Anodal
8 (7.32 – 8.68)

Cathodal
6.3 (5.70 – 6.98)

Bihemispheric
20.7 (19.84 – 21.50)

Pooled effect (random effects model): 11.7 (95% CI 3.50 – 18.80) favoring tDCS. Heterogeneity (I2): 100%

This is the first trial to report the effects of different electrode’s setups in reducing the risk of falls and lower limb function in acute stroke. tDCS resulted in significant motor recovery sustained at least three months beyond the intervention. A consensus on what is the best montage is yet to come (26,29) although studies that investigate the long-term effects can contribute to the experimental point of view, proposing systematic study protocols, as well as provide clinical applicability evidence of tDCS in following these patients.

Cattagni, 2019

Type of study:

sham-controlled, double-blinded, parallel clinical

trial.

Setting and Country: Cognitive Neuroscience and Behavior Program, Department of Psychology, Federal University of Paraíba, João Pessoa, Brazil; Nursing. Department, State University of Paraíba, Campina Grande, Brazil.

Funding and conflicts of interest:

No potential conflict of interest was reported by the authors.

Inclusion criteria:

male or female aged 18 years or older, hemiparesis following uni-lateral hemispheric cerebral lesions of vascular origin more than 6 months previously, able to walk for 10 minutes non-stop without gait aids and able to provide informed consent.

Exclusion criteria:

presence of cardiac pacemaker, aphasia or cognitive difficulties that could interfere with comprehension of instructions, neuro-orthopedic surgery to the lower limbs less than 6 months previously, concomitant progressive disease, one or more epileptic seizures within the year prior to the date of inclusion, an intracerebral metal clip, non-affiliation to the social security regime or being under guardianship.

N total at baseline:
24

Important prognostic factors2:

Age: mean (SD)
57 (13)

Sex (% Male):
79,2%

Groups comparable at baseline?

Yes

Anodal tDCS was administered using a constant current electrical stimulator (Eldith DC-stimulator, Ilmenau, Ger-many). Rectangular electrodes (35 cm2; 7 × 5 cm) covered by a saline-soaked sponge were used for the anode and cathode. The anode was placed over the leg area of the motor cortex on the affected side with the medial border of electrode placed laterally to Cz on the international electroencephalogram 10—20 system (30) (Fig. 2A). The cathode was placed above the contralateral orbit. The stimulation intensity was set at 2 mA for 30 minutes. This intensity was reached progressively over a period of 8 seconds at the beginning of tDCS and was reduced to 0 mA over the last 8seconds. A current density of 0.06 mA cm − 2 (2 mA/35 cm2)was used in order to remain below the threshold that can lead to tissue damage.

The electrodes were placed in the same position as for anodal tDCS and the same stimulation procedure as for the effective anodal tDCS was respected (Fig. 2A). However, a current was only delivered for 120 seconds at the begin-ning of the application to reproduce the sensation of an increase in current intensity. This stimulation duration was chosen because it is below the 180 seconds that Nitsche andPaulus (46) showed to be required to induce anodal tDCS post-effects. This sham tDCS administration has been shown to be indistinguishable from effective tDCS (18). To ensure that the session was blinded, an independent physician set-up the tDCS equipment in either anodal or placebo mode; this person was uninvolved in data recording, col-letting or processing.

Length of follow-up:

Directly after treatment.

 

Loss-to-follow-up (3 months)

n.r.

 

Incomplete outcome data:
n.r.

 

 

 

Walking ability
n.r.

 

Standing balance
n.r.

 

Strength and Muscle Synergy
n.r.

 

Sitting Balance
n.r.

 

Sitting and standing balance
n.r.

 

Walking distance
n.r.

 

Walking speed
Defined was gait speed (cm/second)

Effect measure: mean difference (95% CI)

0.20 (-20.88 – 21.28)

 

Falling
n.r.

 

 

 

 

 

Although a single session of anodal tDCS has been shown pre-viously to modify the excitability of neurons in the leg motor area, in the present study it was not found to alter muscle activity patterns during gait in patients with chronic stroke, regardless of their BDNF genotype (Val66Met versus Val66Val).There is currently no evidence for the use of a single session of anodal tDCS on the leg motor cortex of patients with chronic stroke to alter leg muscle activities during gait and improve the gait pattern. Nevertheless, because the current study only focused on the acute effects of anodal tDCS on gait parameters in individuals with chronic stroke, any potential chronic effects of tDCS (i.e., effects following repeated sessions of anodal tDCS) cannot be ruled out.

Zumbansen, 2020

Type of study:

three-armed sham-controlled blinded prospective

proof-of-concept study

 

Setting and country:

Jewish General Hospital, Lady Davis Institute for Medical Research,

Department of Neurology & Neurosurgery, McGill University, Montreal,

Quebec

 

Funding and conflicts of interest:

The author(s) disclosed receipt of the following financial support

for the research, authorship, and/or publication of this

article: This trial was supported by research grants from the

Canadian Institutes for Health Research (CIHR,

MOP#125954), W.-D. Heiss Foundation, and the Lady

Davis Institute at the JGH (CLIPP#2014). AZ was funded

by a CIHR postdoctoral fellowship.

 

The author(s) declared no potential conflicts of interest with

respect to the research, authorship, and/or publication of this

article.

Inclusion criteria:

stroke patients presenting with speech or

language problems.

 

Exclusion criteria:

Withdrawal of consent, patients with very severe aphasia (who most likely

exclusively depend on the right hemisphere) were

excluded from the study.

 

N total at baseline:

Intervention: 24

Control: 19

 

Important prognostic factors2:

For example

age ± SD:

I: 65.3 ± 13.2

C: 67.4 ± 11.7

 

Sex:

I: 58.3% M

C: 36.8% M

 

Groups comparable at baseline?

Yes

 

ctDCS was applied with 5-cm2 sponge electrodes

placed over the target area (cathode) and the forehead

over the right eye (anode). Stimulation with a 2-mA

current started immediately before and lasted throughout

the ST session

 

For sham stimulation, the current

was turned on for 30 s to elicit a typical skin sensation

and then turned off.

Length of follow-up:

After treatment and after one month follow-up.

 

Loss-to-follow-up (after treatment)

Intervention: 1

Control: 1

 

Reasons: Withdrew before starting treatment.

 

Incomplete outcome data:

n.r.

 

 

 

Treatment ≤ 3 months

Functional communication

n.r.

 

Verbal comprehension

Measured with the standardized Z-scores of the token test post-intervention. Effect measure: MD (95% CI):

 

Cathodal:

-0.07 (-1.12 to 0.98) in favour of sham tDCS.

 

Expressive naming

Measured with the standardized Z-scores of the BNT post intervention. Effect measure: MD (95% CI)

 

Cathodal:

0.29 (95% CI -0.34 to 0.92)

 

Treatment > 3 months

n.r.

 

 

 

 

 

Contralesional NIBS is a safe add-on therapy for poststroke

aphasia. Low frequency rTMS improved

naming recovery one month after a 10-day treatment

course. ctDCS effect was not significantly different

from sham stimulation. Our results raise the possibility

that inhibitory NIBS over the right pars triangularis may have negative effects in patients where Broca’s

Area is affected, supporting the view that NIBS presently

should not be applied outside clinical trials.

Future trials should specifically investigate individual

factors for patient stratification (e.g., lesion location)

and include longer-term follow-up outcome measures

(>6months).

 

 

Wang, 2019

Type of study: A Randomized Sham-Controlled Study

 

Setting and country:

Department of Rehabilitation, Wangjing Hospital of China Academy

of Chinese Medical Science, Beijing, China

 

Funding and conflicts of interest:

The authors have declared that no competing interests existed at the time

of publication.

 

Inclusion criteria
(a) 1–4 months after the onset

of a single left hemispheric stroke; (b) absence of a previous

brain injury; (c) a lesion that affected the left frontal lobe;

(d) slow speech, laborious pronunciation; and (e) inability or difficulty in word repetition (monosyllabic and disyllabic

word repetition score < 5/10 (test scores/total scores) to

avoid ceiling effect after treatment).

 

Exclusion criteria:

(a) severely impaired auditory verbal comprehension

(auditory word–picture identification < 6/30), (b) a history

of seizures within 12 months until present hospitalization,

and (c) psychiatric disease or dementia.

 

N total at baseline

A-tDCS-M1: 18
A-tDCS-Broca: 18

S-tDCS: 16

 

Important prognostic factors2:

Mean age

A-tDCS-M1: 52.6 yrs

A-tDCS-Broca: 56.1 yrs
S-tDCS: 52.3 yrs

 

Sex:

A-tDCS-M1: 77.8% Male

A-tDCS-Broca: 61.1% Male
S-tDCS: 75% Male

 

Groups comparable at baseline?

Yes

 

A-tDCS-M1

the location of the lip region of M1 for

the tDCS treatment was selected according to transcranial

magnetic stimulation. The transcranial magnetic stimulation

was administered using a rapid magnetic stimulator

(Magstim Company, P/N: 3013-00) with a figure-of-eight

coil (diameter, 7 cm), a peak intensity of stimulation at 2 T,

and a pulse duration of 250 s. The coil was moved over the

scalp in order to determine the optimal site from which

maximal amplitude motor evoked potentials were elicited

in the unaffected orbicularis oris muscle. Then, the left homologous

area was determined as the A-tDCS site.

 

A-tDCS-Broca
The left Broca’s area was defined in the frontotemporal

region as the crossing point between T3-Fz and F7-Cz according

to the international 10–20 system (Friederici, Hahne,

& von Cramon, 1998). This crossing point was known as left Broca’s point (LBP). The cathodal electrode was placed

over the right shoulder.

For sham stimulation, the stimulator was turned off after 30 s. For both active and sham tDCS treatments,

the intensity of the current was gradually increased and

decreased. The anodal electrode of the S-tDCS group was placed similarly to that of the A-tDCS-M1 group. This

procedure blinded the subjects to the stimulation conditions.

tDCS was delivered immediately before the 30-min speech training.

Length of follow-up:

After treatment.

 

Loss-to-follow-up (after treatment)

A-tDCS-M1: 0

A-tDCS-Broca: 0

S-tDCS: 0

 

Reasons: Withdrew before starting treatment.

 

Incomplete outcome data:

n.r.

Treatment ≤ 3 months

n.r.

 

 

Treatment > 3 months

Functional communication

n.r.

 

Verbal comprehension

n.r.

 

Expressive naming

Measured with the picture naming test. Effect measure: SMD (95% CI)

 

Anodal:

Broca
-0.04 (-0.87 to 0.79) in favour of sham tDCS.

 

M1

0.08 (-0.76 to 0.91) in favour of tDCS.

 

In summary, our study provides the first evidence for the application of tDCS over the left lip region of M1,

improving the articulation performance in patients with

poststroke aphasia and AoS. tDCS, with its potential to enhance cortical activation and network connectivity, offers an exciting novel strategy for recovery from AoS.

 

Hosseinzadeh, 2018

Type of study:

RCT

 

Setting and country:

Iran

 

Funding and conflicts of interest:

 

This work was supported by Kerman Neuroscience

Research Center, Kerman, Iran and Kavoush Research

Center for Behavioral, Cognitive and Addiction,

Guilan University of Medical Sciences, Rasht,

Iran. Also, we thanks the Prof. Vahid Sheibani,

Dr. Mohammad Shabani for those kindness, assistance

and considerations (Ethics code number:

IR.KMU.REC.1395.23).

 

The authors declare no conflict of interest.

Inclusion criteria:

All subjects were patients

with chronic ischaemic stroke who were admitted at the Tolou Clinic, Rasht, Iran. Magnetic resonance

imaging (MRI) was performed to confirm both

lesion locations.

 

Exclusion criteria:

Patients with other types of stroke were not included to reduce the heterogeneity of the study population.

 

N total at baseline:

Anodal: 25

Cathodal: 25

Sham: 25

 

Important prognostic factors2:

age ± SD:

Anodal 58±8

Cahodal: 64±7

Sham: 59±7

 

Sex:

Anodal: 52% M

Cathodal: 48% M

Sham: 48%M

 

Stroke type:
100% ischaemic

 

Groups comparable at baseline?

Yes

 

tDCS was applied by a battery-powered, constant current electrical stimulator (at 2-mA intensity using a pair of surface saline-soaked 35-cm2sponge electrodes

(5 7 cm), for 3 times a week for 1 month, for 30 min per session and at an electric current of 2 mA. We used two different electrode  montages, including an anode and a cathode.

 

In anodal tDCS,

2842 5Department of Psychiatry, Guilan University of Medical Sciences, Shafa Hospital, Rasht, Iran 6Department of Neuroscience, Neuroscience Research Center, Guilan University of Medical Sciences, Rasht, Iran 7Razi Herbal Medicines Research

Center, Lorestan University of Medical Sciences, Khorramabad, Iran

University of Medical sciences, Rasht, Iran

Biomedical Research and Therapy,  (11):2841-2849

the anode electrode was mounted on the left superior temporal gyrus, while the cathode was placed over the contralateral superior region (cp5). The current

was run through the brain and other tissues of the

head, from the anode to the cathodal electrode.

 

In cathodal tDCS, the cathode was used for placement symmetrical to the left gyrus (cp6), while the anode was placed at the contralateral supraorbital region.

 

All patients received the same protocol, 3 times a week for 30 min per session for 1

month. Then, all of these evaluation tests were applied for the patients at 3 months after ending the tDCS sessions

tDCS was applied by a battery-powered, constant current electrical stimulator (at 2-mA intensity using a pair of surface saline-soaked 35-cm2sponge electrodes

(5 7 cm), for 3 times a week for 1 month, for 30 min per session and at an electric current of 2 mA. We used two different electrode  montages, including an anode and a cathode.

 

In sham tDCS, the anode was placed over the left superior temporal gyrus and cathode was placed on the contralateral supraorbital region, but no current was

applied.

 

All patients received the same protocol, 3 times a week for 30 min per session for 1 month. Then, all of these evaluation tests were applied

for the patients at 3 months after ending the tDCS sessions

Length of follow-up:

3 months after the intervention.

 

Loss-to-follow-up:

n.r.

 

 

Incomplete outcome data:

n.r.

 

 

Outcome measures and effect size (include 95%CI and p-value if available):

 

Our results demonstrate that anodic tDCS is beneficial

and safe method for increasing the rehabilitation

of movement and life–related functions in chronic

stroke patients, while cathodic tDCS can enhance executive

memory. The ability of anodic tDCS to modulate

cortical excitability becomes useful, and exploring

the preference indication of the anodic and cathodic

tDCS abilities requires further investigation.

One of the limitations of this study was the number

of patients needed to conduct the research trial,

which took a lot of research time. Among other constraints/

factors were the predictable high cost, and the

provision of help and assistance from various agencies,

such as the Kerman Neuroscience Research Center,

Kerman, Iran and Kavoush Research Center for

Behavioral, Cognitive and Addiction, Guilan University

of Medical Sciences, Rasht, Iran. Moreover, while

the introduction of the tDCS method for patients and

neurologists has garnered greater attention, more research

is necessary to fully explore the advantages of this method.

 

Shaker, 2018

Type of study:

RCT

 

Setting and country:

the outpatient clinic of  Faculty of Physical Therapy, Cairo University, and neurology

outpatient clinic of Cairo University Hospitals.

 

Funding and conflicts of interest:

 

The authors declare that they have no competing interests (financial and non-financial). We declare that the research was conducted in absence of any commercial relationships that could be constructed as a potential conflict

of interest.

Inclusion criteria:

Included in this study were patients with ischaemic cerebrovascular

stroke in the domain of carotid system diagnosed

clinically and confirmed by CT and/or MRI of the brain, their age ranged from 40 to 60 years old to

minimize the effect of age on cognition, duration of illness

at least 6 months from stroke onset, educated patients

at least 10 years of formal education, degree of

spasticity was 1 and 1+ according to Modified Ashworth

Scale, grade of muscle power was 3 according to manual

muscle test, mini mental state examination score ranged

from 19 to 24 (mild cognitive impairment), functional

independence measure score ranged from 84 to 99, Beck

depression inventory score from 0–9, and normal hearing and vision.

 

Exclusion criteria:

Excluded from this study were patients with recurrent

cerebrovascular stroke or concomitant neurological disorders

that may affect cognition, psychiatric disorders,

drug or alcohol abuse, and seizure disorders; patients receiving drugs that may affect cognitive functions (anti-

depressants, anti-epileptics, sedatives, muscle relaxants);

and patients with medical illness that may affect

cognitive functions (thyroid, renal or hepatic disorder)

and a presence of wounds in the skin of the skull.

 

 

N total at baseline:

Intervention: 20

Control: 20

 

Important prognostic factors2:

age ± SD:

I: 54.45 ± 4.68

C: 53.05 ± 6.32

 

Sex:

100% Male

 

Stroke type:
100% ischaemic

 

Groups comparable at baseline?

Yes

in group A, patients received

treatment for 1 month, three sessions per week (every

other day). The duration of each session was 60 min, divided

into 30 min of tDCS (2 mA) application followed

by 30 min of RehaCom training.

 

All patients received RehaCom for cognitive training: RehaCom is a

computerized program instituted in the

International Neurological Restoration Center for

rehabilitation of brain injury.

In group B, patients

received sham tDCS and the same cognitive training

program as group A. In sham tDCS, real stimulation

was applied for 5 s; then, stimulation was turned off.

 

All patients received RehaCom for cognitive training: RehaCom is a

computerized program instituted in the

International Neurological Restoration Center for

rehabilitation of brain injury.

Length of follow-up:

End of treatment

 

Loss-to-follow-up:

n.r.

 

Incomplete outcome data:

n.r.

 

 

Outcome measures and effect size (include 95%CI and p-value if available):

 

In view of the results of this study, it could be concluded

that tDCS is a safe and effective neurorehabilitation

modality that improves cognitive functions in several domains

including attention and concentration, figural

memory, logical reasoning, and reaction behavior. Moreover,

tDCS has a positive impact on performance of daily

activities. So, it is recommended to use it in the rehabilitation

of post stroke cognitive dysfunctions.

 

                       

Notes:

  1. Prognostic balance between treatment groups is usually guaranteed in randomized studies, but non-randomized (observational) studies require matching of patients between treatment groups (case-control studies) or multivariate adjustment for prognostic factors (confounders) (cohort studies); the evidence table should contain sufficient details on these procedures.
  2. Provide data per treatment group on the most important prognostic factors(((potential) confounders).
  3. For case-control studies, provide sufficient detail on the procedure used to match cases and controls.
  4. For cohort studies, provide sufficient detail on the (multivariate) analyses used to adjust for (potential) confounders.

 

Table of quality assessment for systematic reviews of RCTs and observational studies

Based on AMSTAR checklist (Shea, 2007; BMC Methodol 7: 10; doi:10.1186/1471-2288-7-10) and PRISMA checklist (Moher, 2009; PLoS Med 6: e1000097; doi:10.1371/journal.pmed1000097)

Study

 

 

 

 

 

First author, year

Appropriate and clearly focused question?1

 

 

 

 

Yes/no/unclear

Comprehensive and systematic literature search?2

 

 

 

 

Yes/no/unclear

Description of included and excluded studies?3

 

 

 

 

Yes/no/unclear

Description of relevant characteristics of included studies?4

 

 

 

Yes/no/unclear

Appropriate adjustment for potential confounders in observational studies?5

 

 

 

 

 

Yes/no/unclear/notapplicable

Assessment of scientific quality of included studies?6

 

 

 

Yes/no/unclear

Enough similarities between studies to make combining them reasonable?7

 

Yes/no/unclear

Potential risk of publication bias taken into account?8

 

 

 

 

Yes/no/unclear

Potential conflicts of interest reported?9

 

 

 

 

Yes/no/unclear

Bai, 2019

Yes

Yes

No

Yes

Not applicable

Yes

Yes

Yes

Yes

Tien, 2020

Yes

Yes

No

Yes

Not applicable

Yes

Yes

Yes

Yes

Elsner, 2019

Yes

Yes

Yes

Yes

Not applicable

Yes

Unclear

Yes

Yes

Van Lieshout, 2019

Yes

Yes

Yes

Yes

Not applicable

Yes

Yes

Yes

Yes

  1. Research question (PICO) and inclusion criteria should be appropriate and predefined.
  2. Search period and strategy should be described; at least Medline searched; for pharmacological questions at least Medline + EMBASE searched.
  3. Potentially relevant studies that are excluded at final selection (after reading the full text) should be referenced with reasons.
  4. Characteristics of individual studies relevant to research question (PICO), including potential confounders, should be reported.
  5. Results should be adequately controlled for potential confounders by multivariate analysis (not applicable for RCTs).
  6. Quality of individual studies should be assessed using a quality scoring tool or checklist (Jadad score, Newcastle-Ottawa scale, risk of bias table et cetera).
  7. Clinical and statistical heterogeneity should be assessed; clinical: enough similarities in patient characteristics, intervention and definition of outcome measure to allow pooling? For pooled data: assessment of statistical heterogeneity using appropriate statistical tests (for example Chi-square, I2)?
  8. An assessment of publication bias should include a combination of graphical aids (for example funnel plot, other available tests) and/or statistical tests (for example Egger regression test, Hedges-Olken). Note: If no test values or funnel plot included, score “no”. Score “yes” if mentions that publication bias could not be assessed because there were fewer than 10 included studies.
  9. Sources of support (including commercial co-authorship) should be reported in both the systematic review and the included studies. Note: To get a “yes,” source of funding or support must be indicated for the systematic review AND for each of the included studies.

 

Risk of bias tables of the RCTs

Study reference

 

(first author, publication year)

Was the allocation sequence adequately generated? a

 

 

 

 

 

 

 

 

 

 



 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Was the allocation adequately concealed?b

 

 

 

 

 

 

 

 

 

 



 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Blinding: Was knowledge of the allocated

interventions adequately prevented?c

 

Were patients blinded?

 

Were healthcare providers blinded?

 

Were data collectors blinded?

 

Were outcome assessors blinded?

 

Were data analysts blinded?

 

Definitely yes

Probably yes

Probably no

Definitely no

Was loss to follow-up (missing outcome data) infrequent?d

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Are reports of the study free of selective outcome reporting?e

 

 

 

 



 

 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Was the study apparently free of other problems that could put it at a risk of bias?f

 

 

 

 

 

 



 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Overall risk of bias

If applicable/necessary, per outcome measureg

 

 

 

 

 

 



 

 

 

 

 

 

 

LOW

Some concerns

HIGH

 

Alisar, 2020

Definitely yes;

 

Reasons: Patients were allocated a number and randomised into 1 of 2 treatment groups

using the Random Allocation Software programme.

Definitely yes;

 

Reasons: The patients and PMR trainee who performed all patient evaluations were blind

to the treatment received

Definitely no;

 

Reasons: The occupational therapist and PMR specialist involved in the study were not blind to the

treatment received.

Definitely yes;

 

Reasons: There were no dropouts.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably no;

 

Reasons: Limitations

of the study include the heterogeneity in lesion location

and the short post treatment follow-up.

 

Some concerns

Sik, 2015

No information;

 

Reasons: No information was provided about the allocation sequence.

No information;

 

Reasons: No information was provided abaut the concealment of the allocation sequence.

Probably yes;

 

Reasons: The evaluation of

WMFT and KFET was conducted by an

experienced physiotherapist who was blinded to the therapy, but no information was provided about the blinding of patients and data collectors.

Definitely yes;

 

Reasons: Missing outcome data was infrequent.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably yes;

 

Reasons: No other problems noted.

 

LOW

Nicolo, 2018

Definitely yes;

 

Reasons: Randomization was stratified for initial motor impairment and

stroke lateralization, with an allocation sequence based on a block size of 3, generated with a computer random number generator

Definitely yes;

 

Reasons: The allocation sequence was generated by

a researcher not involved in recruitment.

Probably no;

 

Reasons: Subjects

were blinded with respect to the true or sham stimulation

conditions; Motor function was assessed by a trained therapist who was blinded to treatment allocation; The researcher administering

NIBS was unblinded.

Definitely yes;

 

Reasons: Missing outcome data was infrequent.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably yes;

 

Reasons: No other problems noted.

 

LOW

Shaheiwola, 2018

No information;

 

Reasons: No information was provided about the allocation sequence.

No information;

 

Reasons: No information was provided about the allocation concealment.

Probably yes;

 

Reasons: To ensure the reliability of results, there was a baseline

observation period of 4 weeks before the intervention period; No information was provided about the blinding of the patients, data collectors and data analysts.

Definitely yes;

 

Reasons: No patients were excluded from the analysis or lost to follow-up.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably no;

 

Reasons: Only

stroke patients with unilateral arm paralysis were recruited and

tested.

Some concerns

Salazar, 2020

Definitely yes;

 

Reasons: Randomization was done by using a

computer-generated random number of sequences (http://www.

random.com). Concealed randomization was performed in blocks

of 4 to 6 individuals.

Probably yes;

 

Reasons: An investigator who was not involved in the

assessment, treatment or statistical analysis conducted the

randomization.

Definitely yes;

 

Reasons: A trained physiotherapist

delivered the treatment to both groups. The same blinded

examiners performed all assessments; To assess the effective blinding of participants, they were asked

to answer whether they were aware of receiving real or sham tDCS. Participants were allowed to answer only YES or NO. This

assessment was performed at the end of the last evaluation

session; A blinded assessor asked all

participants if they noticed some improvement, no change or

deterioration after the treatment.

Definitely yes;

 

Reasons: Missing outcome data was infrequent.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably yes;

 

Reasons: No other problems noted.

 

LOW

Yao, 2020

Definitely yes;

 

Reasons: The

study used a computer to generate a random number table. The physician designated the random numbers in

the random number table as the experimental group or

the control group according to odd or even numbers.

Definitely yes;

 

Reasons: The generated random distribution sequence was put into the sequentially coded, sealed and opaque envelope.

 

 

Definitely no;

 

Reasons: Only the

patients were blinded to the stimulation condition by creating a scalp sensation to the subjects receiving sham stimulation.

Definitely yes;

 

Reasons: No patients were excluded from the analysis.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Definitely no;

 

Reasons: As the study was conducted in the rehabilitation

inpatient facility in real-world practice, and all of the patients likely received additional rehabilitation

therapy outside of the clinical-trial setting. We could not quantify and control these therapies which may pose

biases to the study.

Some concerns

Edwards, 2019

Definitely yes;

 

Reasons: The randomization was block stratified to ensure our two comparison groups were balanced with respect to this potential prognostic factor.

Definitely yes;

 

Reasons: The allocation was concealed by a predetermined sealed envelope method. Both the patient and tDCS administrator were blind to the randomization.

Probably yes;

 

Reasons: Patients, evaluating therapists, and analysts were

blind to the tDCS randomization.

Probably no;

 

Reasons: 8/77 patients were lost to follow-up due to unrelated illness, botox treatment or illness of relative.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably yes;

 

Reasons: No other problems noted.

 

LOW

Andrade, 2017

Definitely yes;

 

Reasons: Randomization was conducted with randomly permuted blocks, through an online program (www. random.org). After completion of baseline measures.

Definitely yes;

 

Reasons: Blind allocation in the ratio of 1:1:1:1 was carried out with sequentially numbered and sealed opaque envelopes.

Definitely yes;

 

Reasons: Blinding was extended from the person responsible for randomization, allocation, outcome assessing, and trialists

to those who analyzed the data.

Probably yes;

 

Reasons: 2/60 patients were lost to follow-up, which was infrequent and balanced.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably yes;

 

Reasons: No other problems noted.

 

LOW

Cattagni, 2019

Probably yes;

 

Reasons: The order of sessions was randomized in order to ensure that equal numbers (12) of participants began with each type of session (effective anodal tDCS or sham tDCS).

No information;

 

Reasons: Reasons: No information was provided about the concealment of the allocation sequence.

 

Definitely yes;

 

Reasons: To ensure that the session was blinded, an independent physician set-up the tDCS equipment in either anodal or placebo mode; this person was uninvolved in data recording, collecting or processing.

No information;

 

Reasons: No information was provided about lost to follow-up.

Definitely yes;

 

Reasons: All relevant outcomes were reported

Probably yes;

 

Reasons: No other problems noted.

 

Some concerns

Zumbansen, 2020

Definitely yes;

 

Reasons: Computer-generated, non-restricted randomization by

site was performed through an online system located at

the Department of Clinical Epidemiology at the JGH

(Montreal).

Definitely yes;

 

Reasons: Only the technician performing the stimulation

had access to the randomization information when logging into the study platform, on the first day of treatment.

Definitely yes;

 

Reasons: Patients, therapist, principal investigators and

research personnel assessing clinical outcomes were

blinded to the treatment assignment. Therapists did

not attend rTMS sessions and had no access to the tDCS device settings.

Probably yes;

 

Reasons: 1/63 patients were lost to follow-up at the first day after the intervention, which was infrequent.

Definitely yes;


Reasons: All relevant outcomes were reported

Definitely no;

 

Reasons: Patient characteristics were not balanced (in terms of language variability), the recruitment goal was not reached, assessment tools lack validation.

LOW

Wang, 2019

Definitely yes;


Reasons: The subjects were assigned to the groups using a

computer-generated randomization list by a single investigator.

Definitely yes;


Reasons: The subjects were assigned to the groups using a

computer-generated randomization list by a single investigator.

The assigned random number was input into the stimulator device by the same investigator who did not

participate in other sections of the study.

Definitely yes;

 

Reasons: All subjects

and speech-language therapists were blinded to the design.

Definitely yes;

 

Reasons: No patients were lost to follow-up.

Definitely yes;


Reasons: All relevant outcomes were reported

Probably no;

 

Reasons: the inclusion criteria for brain lesion involved in the left frontal lobe, but most participants’ lesion was far beyond the site.

LOW

Hosseinzadeh, 2018

Definitely yes;

 

Reasons: The research groups (of patients) were based on the random selection of envelopes.

Definitely yes;

 

Reasons: In order to observe the double blindness of the research, the patients chose closed envelopes for the rhombus, in which specific codes were inserted. The patients and tDCS-conducting technicians

did not know the content of the envelopes, thus providing a satisfactory classification of the four groups.

Definitely yes;

 

Reasons: In order to observe the double blindness of the research, the patients chose closed envelopes for the rhombus, in which specific codes were inserted.

Probably yes;

 

Reasons: Loss to follow-up was not reported.

Definitely yes;

 

Reasons: All relevant outcomes were reported.

Probably yes;

 

Reasons: No other problems noted.

 

LOW

Shaker, 2018

No information;

 

Reasons: No information was provided about the generation of the allocation sequence.

No information;

 

Reasons: No information was provided about allocation concealment.

 

Definitely no;

 

Reasons: The study was single-blinded but did not specify who was blinded.

Probably yes;

 

Reasons: Loss to follow-up was not reported.

Definitely yes;

 

Reasons: All relevant outcomes were reported.

Probably yes;

 

Reasons: No other problems noted.

 

Some concerns

1.            Randomization: generation of allocation sequences have to be unpredictable, for example computer generated random-numbers or drawing lots or envelopes. Examples of inadequate procedures are generation of allocation sequences by alternation, according to case record number, date of birth or date of admission.

2.            Allocation concealment: refers to the protection (blinding) of the randomization process. Concealment of allocation sequences is adequate if patients and enrolling investigators cannot foresee assignment, for example central randomization (performed at a site remote from trial location). Inadequate procedures are all procedures based on inadequate randomization procedures or open allocation schedules.

3.            Blinding: neither the patient nor the care provider (attending physician) knows which patient is getting the special treatment. Blinding is sometimes impossible, for example when comparing surgical with non-surgical treatments, but this should not affect the risk of bias judgement. Blinding of those assessing and collecting outcomes prevents that the knowledge of patient assignment influences the process of outcome assessment or data collection (detection or information bias). If a study has hard (objective) outcome measures, like death, blinding of outcome assessment is usually not necessary. If a study has “soft” (subjective) outcome measures, like the assessment of an X-ray, blinding of outcome assessment is necessary. Finally, data analysts should be blinded to patient assignment to prevents that knowledge of patient assignment influences data analysis.

4.            If the percentage of patients lost to follow-up or the percentage of missing outcome data is large, or differs between treatment groups, or the reasons for loss to follow-up or missing outcome data differ between treatment groups, bias is likely unless the proportion of missing outcomes compared with observed event risk is not enough to have an important impact on the intervention effect estimate or appropriate imputation methods have been used.

5.            Results of all predefined outcome measures should be reported; if the protocol is available (in publication or trial registry), then outcomes in the protocol and published report can be compared; if not, outcomes listed in the methods section of an article can be compared with those whose results are reported.

6.            Problems may include: a potential source of bias related to the specific study design used (e.g., lead-time bias or survivor bias); trial stopped early due to some data-dependent process (including formal stopping rules); relevant baseline imbalance between intervention groups; claims of fraudulent behavior; deviations from intention-to-treat (ITT) analysis; (the role of the) funding body. Note: The principles of an ITT analysis implies that (a) participants are kept in the intervention groups to which they were randomized, regardless of the intervention they actually received, (b) outcome data are measured on all participants, and (c) all randomized participants are included in the analysis.

7.            Overall judgement of risk of bias per study and per outcome measure, including predicted direction of bias (e.g. favors experimental, or favors comparator). Note: the decision to downgrade the certainty of the evidence for a particular outcome measure is taken based on the body of evidence, i.e. considering potential bias and its impact on the certainty of the evidence in all included studies reporting on the outcome.

 

Tabel Exclusie na het lezen van het volledige artikel voor deelvraag 1 (bovenste extremiteit)

Auteur en jaartal

Redenen van exclusie

Jin, 2019

Te weinig patiënten in de controlegroep.

Liao, 2020

Te weinig patiënten in de controlegroep.

Oveisgharan, 2018

Te weinig patiënten in de interventie- en de controlegroep.

Dehem, 2018

Te weinig patiënten in de interventie- en de controlegroep.

Manji, 2018

Verkeerde uitkomstmaten beschreven.

 

Autorisatiedatum en geldigheid

Laatst beoordeeld  : 12-09-2024

Laatst geautoriseerd  : 28-12-2022

Geplande herbeoordeling  : 01-10-2025

Initiatief en autorisatie

Initiatief:
  • Nederlandse Vereniging voor Neurologie
Geautoriseerd door:
  • Koninklijk Nederlands Genootschap voor Fysiotherapie
  • Nederlandse Vereniging van Revalidatieartsen
  • Nederlandse Vereniging voor Neurologie
  • Nederlandse Vereniging voor Radiologie
  • Harteraad
  • Hartstichting

Algemene gegevens

De ontwikkeling/herziening van deze richtlijnmodule werd ondersteund door het Kennisinstituut van de Federatie Medisch Specialisten (www.demedischspecialist.nl/kennisinstituut) en werd gefinancierd uit de Stichting Kwaliteitsgelden Medisch Specialisten (SKMS). De financier heeft geen enkele invloed gehad op de inhoud van de richtlijnmodule.

Samenstelling werkgroep

Voor het ontwikkelen van de richtlijnmodule is in 2021 een doorstart gemaakt met de multidisciplinaire werkgroep, bestaande uit vertegenwoordigers van alle relevante specialismen (zie hiervoor de Samenstelling van de werkgroep) die betrokken zijn bij de zorg voor patiënten met een herseninfarct of hersenbloeding.

 

Kerngroep

  • Dr. B. (Bob) Roozenbeek (voorzitter), neuroloog, Erasmus MC Rotterdam, namens de Nederlandse Vereniging voor Neurologie (NVN)
  • Prof. dr. R.M. (Renske) van den Berg-Vos, neuroloog, OLVG West Amsterdam, namens de NVN
  • Prof. dr. J. (Jeannette) Hofmeijer, neuroloog, Rijnstate ziekenhuis Arnhem, namens de NVN
  • Prof. dr. J.M.A. Visser-Meilij, revalidatiearts, UMC Utrecht, namens de VRA
  • A.F.E. (Arianne) Verburg, huisarts, namens het Nederlands Huisartsen Genootschap (NHG)
  • Prof. dr. H.B. (Bart) van der Worp, neuroloog, UMC Utrecht, namens de NVN
  • Dr. S.M. (Yvonne) Zuurbier, neuroloog, Amsterdam UMC, namens de NVN
  • Prof. dr. W. (Wim) van Zwam, radioloog, Maastricht UMC, namens de Nederlandse Vereniging voor Radiologie (NVvR)
  • Prof. dr. G. (Gert) Kwakkel, hoogleraar neurorevalidatie, Amsterdam UMC, namens de Koninklijk Nederlands Genootschap foor Fysiotherapie (KNGF)

 

Met ondersteuning van

  • Dr. M.L. Molag, adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • Drs. F. Ham, junior adviseur, Kennisinstituut van de Federatie Medisch Specialisten

Belangenverklaringen

De Code ter voorkoming van oneigenlijke beïnvloeding door belangenverstrengeling is gevolgd. Alle werkgroepleden hebben schriftelijk verklaard of zij in de laatste drie jaar directe financiële belangen (betrekking bij een commercieel bedrijf, persoonlijke financiële belangen, onderzoeksfinanciering) of indirecte belangen (persoonlijke relaties, reputatiemanagement) hebben gehad. Gedurende de ontwikkeling of herziening van een module worden wijzigingen in belangen aan de voorzitter doorgegeven. De belangenverklaring wordt opnieuw bevestigd tijdens de commentaarfase.

 

Een overzicht van de belangen van werkgroepleden en het oordeel over het omgaan met eventuele belangen vindt u in onderstaande tabel. De ondertekende belangenverklaringen zijn op te vragen bij het secretariaat van het Kennisinstituut van de Federatie Medisch Specialisten.

 

Werkgroeplid

Functie

Nevenfuncties

Gemelde belangen

Ondernomen actie

Van den Berg-Vos

Neuroloog

Geen

Voorzitter werkgroep CVA van het Transmuraal Platform Amsterdam (betaald d.m.v. vacatiegelden)

Lid focusgroep CVA ROAZ Noord-Holland (onbetaald)

 ‘Medical lead' Experiment Uitkomstindicatoren VWS (namens Santeon) aandoening CVA, via Santeon betaald voor 4 uur per week

Projectleider “Patient-Reported Outcomes Measurement Information System (PROMIS®) voor waardegedreven zorg" (SKMS-project met subsidie FMS, betaald d.m.v. vacatiegelden)

Projectleider "Regionale auditing voor kwaliteit van zorg bij patiënten met een herseninfarct” (SKMS-project met subsidie FMS , betaald dmv vacatiegelden)

Voorzitterschap (namens de Nederlandse Vereniging voor Neurologie) van werkgroep CVA van het programma Uitkomstgerichte Zorg ‘Meer inzicht in uitkomsten’ (betaald d.m.v. vacatiegelden)

Geen

Hofmeijer

Neuroloog (0,6 fte)

Hoogleraar universiteit Twente (0,4 fte)

Geen

Geen

Kwakkel

Hoogleraar Neurorevalidatie

Europees Editor NeuroRehabilitation and Neural Repair

 

Handling editor Stroke (AHA)

Coordinator Stroke Unit Cursus NPI

Cursusleider mCIMT bij NPI

Cursusleider Neurorebvalidatie-CVA bij NPI

 

Geen

Roozenbeek

Neuroloog

 

Lid van CONTRAST, coördineert onderzoeksprojecten op gebied van acute beroertezorg gefinancierd door Stichting BeterKeten, Stichting THEIA, Erasmus Universiteit en Erasmus MC

Geen

Verburg

Huisarts

Senior wetenschappelijk medewerker NHG

Geen

Geen

Visser-Meily

Revalidatiearts, hoogleraar en afdelingshoofd

Geen

Geen

Geen

Van der Worp

Neuroloog

 

Adviezen aan/consultancy voor Boehringer Ingelheim, producent van onder anderen alteplase en dabigatron.

Adviseur van Bayer en LivaNova; subsidie van Stryker voor stroke trial (gelden via het CONTRAST consortium); mede-onderzoeker B-STARS, een inmiddels afgeronde RCT van rTMS bij patiënten met een beroerte.

Uitsluiting besluitvorming alteplase en dabigatran

Zuurbier

Neuroloog

Geen

Geen

Geen

Van Zwam

Neuro-interventieradioloog

Geen

Consultancy activiteiten voor stryker en Cerenovus, lid CONTRAST, MRCLEAN: ATE

Geen invloed op richtlijnonderwerpen

Inbreng patiëntenperspectief

Er werd aandacht besteed aan het patiëntenperspectief door gebruik te maken van kwaliteitscriteria vanuit patiëntenperspectief voor CVA, ontwikkeld door Harteraad. Verder informeren Harteraad, Hartstichting en Hersenletsel door middel van notulen vergaderingen kerngroep en worden ze betrokken bij relevante onderwerpen. De conceptmodules zijn tevens voor commentaar aan bovengenoemde verenigingen voorgelegd.

 

Wkkgz & Kwalitatieve raming van mogelijke substantiële financiële gevolgen

Kwalitatieve raming van mogelijke financiële gevolgen in het kader van de Wkkgz

Bij de richtlijn is conform de Wet kwaliteit, klachten en geschillen zorg (Wkkgz) een kwalitatieve raming uitgevoerd of de aanbevelingen mogelijk leiden tot substantiële financiële gevolgen. Bij het uitvoeren van deze beoordeling zijn richtlijnmodules op verschillende domeinen getoetst (zie het stroomschema op de Richtlijnendatabase).

 

Uit de kwalitatieve raming blijkt dat er waarschijnlijk geen substantiële financiële gevolgen zijn, zie onderstaande tabel.

 

Submodule

Uitkomst raming

Toelichting

Non-invasieve hersenstimulatie met rTMS

Geen financiële gevolgen

Hoewel uit de toetsing volgt dat de aanbeveling(en) breed toepasbaar zijn (>40.000 patiënten), volgt ook uit de toetsing dat [het overgrote deel (±90%) van de zorgaanbieders en zorgverleners al aan de norm voldoet OF het geen nieuwe manier van zorgverlening of andere organisatie van zorgverlening betreft, het geen toename in het aantal in te zetten voltijdsequivalenten aan zorgverleners betreft en het geen wijziging in het opleidingsniveau van zorgpersoneel betreft]. Er worden daarom geen substantiële financiële gevolgen verwacht.

Non-invasieve hersenstimulatie met tDCS

Geen financiële gevolgen

Hoewel uit de toetsing volgt dat de aanbeveling(en) breed toepasbaar zijn (>40.000 patiënten), volgt ook uit de toetsing dat [het overgrote deel (±90%) van de zorgaanbieders en zorgverleners al aan de norm voldoet OF het geen nieuwe manier van zorgverlening of andere organisatie van zorgverlening betreft, het geen toename in het aantal in te zetten voltijdsequivalenten aan zorgverleners betreft en het geen wijziging in het opleidingsniveau van zorgpersoneel betreft]. Er worden daarom geen substantiële financiële gevolgen verwacht.

 

De kwalitatieve raming volgt na de commentaarfase.

Werkwijze

AGREE

Deze richtlijnmodule is opgesteld conform de eisen vermeld in het rapport Medisch Specialistische Richtlijnen 2.0 van de adviescommissie Richtlijnen van de Raad Kwaliteit. Dit rapport is gebaseerd op het AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II; Brouwers, 2010).

 

Knelpuntenanalyse en uitgangsvragen

Tijdens de voorbereidende fase inventariseerden de werkgroep de knelpunten in de zorg voor patiënten na een herseninfarct of hersenbloeding. Op basis van de uitkomsten van de knelpuntenanalyse zijn door de werkgroep concept-uitgangsvragen opgesteld en definitief vastgesteld.

 

Uitkomstmaten

Na het opstellen van de zoekvraag behorende bij de uitgangsvraag inventariseerde de werkgroep welke uitkomstmaten voor de patiënt relevant zijn, waarbij zowel naar gewenste als ongewenste effecten werd gekeken. Hierbij werd een maximum van acht uitkomstmaten gehanteerd. De werkgroep waardeerde deze uitkomstmaten volgens hun relatieve belang bij de besluitvorming rondom aanbevelingen, als cruciaal (kritiek voor de besluitvorming), belangrijk (maar niet cruciaal) en onbelangrijk. Tevens definieerde de werkgroep tenminste voor de cruciale uitkomstmaten welke verschillen zij klinisch (patiënt) relevant vonden.

 

Methode literatuursamenvatting

Een uitgebreide beschrijving van de strategie voor zoeken en selecteren van literatuur en de beoordeling van de risk-of-bias van de individuele studies is te vinden onder ‘Zoeken en selecteren’ onder Onderbouwing. De beoordeling van de kracht van het wetenschappelijke bewijs wordt hieronder toegelicht.

 

Beoordelen van de kracht van het wetenschappelijke bewijs

De kracht van het wetenschappelijke bewijs werd bepaald volgens de GRADE-methode. GRADE staat voor ‘Grading Recommendations Assessment, Development and Evaluation’ (zie http://www.gradeworkinggroup.org/). De basisprincipes van de GRADE-methodiek zijn: het benoemen en prioriteren van de klinisch (patiënt) relevante uitkomstmaten, een systematische review per uitkomstmaat, en een beoordeling van de bewijskracht per uitkomstmaat op basis van de acht GRADE-domeinen (domeinen voor downgraden: risk of bias, inconsistentie, indirectheid, imprecisie, en publicatiebias; domeinen voor upgraden: dosis-effect relatie, groot effect, en residuele plausibele confounding).

 

GRADE onderscheidt vier gradaties voor de kwaliteit van het wetenschappelijk bewijs: hoog, redelijk, laag en zeer laag. Deze gradaties verwijzen naar de mate van zekerheid die er bestaat over de literatuurconclusie, in het bijzonder de mate van zekerheid dat de literatuurconclusie de aanbeveling adequaat ondersteunt (Schünemann, 2013; Hultcrantz, 2017).

 

GRADE

Definitie

Hoog

  • er is hoge zekerheid dat het ware effect van behandeling dicht bij het geschatte effect van behandeling ligt zoals vermeld in de literatuurconclusie;
  • het is zeer onwaarschijnlijk dat de literatuurconclusie verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Redelijk

  • er is redelijke zekerheid dat het ware effect van behandeling dicht bij het geschatte effect van behandeling ligt zoals vermeld in de literatuurconclusie;
  • het is mogelijk dat de conclusie verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Laag

  • er is lage zekerheid dat het ware effect van behandeling dicht bij het geschatte effect van behandeling ligt zoals vermeld in de literatuurconclusie;
  • er is een reële kans dat de conclusie verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Zeer laag

  • er is zeer lage zekerheid dat het ware effect van behandeling dicht bij het geschatte effect van behandeling ligt zoals vermeld in de literatuurconclusie;
  • de literatuurconclusie is zeer onzeker.

 

Bij het beoordelen (graderen) van de kracht van het wetenschappelijk bewijs in richtlijnen volgens de GRADE-methodiek spelen grenzen voor klinische besluitvorming een belangrijke rol (Hultcrantz, 2017). Dit zijn de grenzen die bij overschrijding aanleiding zouden geven tot een aanpassing van de aanbeveling. Om de grenzen voor klinische besluitvorming te bepalen moeten alle relevante uitkomstmaten en overwegingen worden meegewogen. De grenzen voor klinische besluitvorming zijn daarmee niet één op één vergelijkbaar met het minimaal klinisch relevant verschil (Minimal Clinically Important Difference, MCID). Met name in situaties waarin een interventie geen belangrijke nadelen heeft en de kosten relatief laag zijn, kan de grens voor klinische besluitvorming met betrekking tot de effectiviteit van de interventie bij een lagere waarde (dichter bij het nuleffect) liggen dan de MCID (Hultcrantz, 2017).

 

Overwegingen (van bewijs naar aanbeveling)

Om te komen tot een aanbeveling zijn naast (de kwaliteit van) het wetenschappelijke bewijs ook andere aspecten belangrijk en worden meegewogen, zoals aanvullende argumenten uit bijvoorbeeld de biomechanica of fysiologie, waarden en voorkeuren van patiënten, kosten (middelenbeslag), aanvaardbaarheid, haalbaarheid en implementatie. Deze aspecten zijn systematisch vermeld en beoordeeld (gewogen) onder het kopje ‘Overwegingen’ en kunnen (mede) gebaseerd zijn op expert opinion. Hierbij is gebruik gemaakt van een gestructureerd format gebaseerd op het evidence-to-decision framework van de internationale GRADE Working Group (Alonso-Coello, 2016a; Alonso-Coello, 2016b). Dit evidence-to-decision framework is een integraal onderdeel van de GRADE-methodiek.

 

Formuleren van aanbevelingen

De aanbevelingen geven antwoord op de uitgangsvraag en zijn gebaseerd op het beschikbare wetenschappelijke bewijs en de belangrijkste overwegingen, en een weging van de gunstige en ongunstige effecten van de relevante interventies. De kracht van het wetenschappelijk bewijs en het gewicht dat door de werkgroep wordt toegekend aan de overwegingen, bepalen samen de sterkte van de aanbeveling. Conform de GRADE-methodiek sluit een lage bewijskracht van conclusies in de systematische literatuuranalyse een sterke aanbeveling niet a priori uit, en zijn bij een hoge bewijskracht ook zwakke aanbevelingen mogelijk (Agoritsas, 2017; Neumann, 2016). De sterkte van de aanbeveling wordt altijd bepaald door weging van alle relevante argumenten tezamen. De werkgroep heeft bij elke aanbeveling opgenomen hoe zij tot de richting en sterkte van de aanbeveling zijn gekomen.

 

In de GRADE-methodiek wordt onderscheid gemaakt tussen sterke en zwakke (of conditionele) aanbevelingen. De sterkte van een aanbeveling verwijst naar de mate van zekerheid dat de voordelen van de interventie opwegen tegen de nadelen (of vice versa), gezien over het hele spectrum van patiënten waarvoor de aanbeveling is bedoeld. De sterkte van een aanbeveling heeft duidelijke implicaties voor patiënten, behandelaars en beleidsmakers (zie onderstaande tabel). Een aanbeveling is geen dictaat, zelfs een sterke aanbeveling gebaseerd op bewijs van hoge kwaliteit (GRADE gradering HOOG) zal niet altijd van toepassing zijn, onder alle mogelijke omstandigheden en voor elke individuele patiënt.

 

Implicaties van sterke en zwakke aanbevelingen voor verschillende richtlijngebruikers

 

Sterke aanbeveling

Zwakke (conditionele) aanbeveling

Voor patiënten

De meeste patiënten zouden de aanbevolen interventie of aanpak kiezen en slechts een klein aantal niet.

Een aanzienlijk deel van de patiënten zouden de aanbevolen interventie of aanpak kiezen, maar veel patiënten ook niet. 

Voor behandelaars

De meeste patiënten zouden de aanbevolen interventie of aanpak moeten ontvangen.

Er zijn meerdere geschikte interventies of aanpakken. De patiënt moet worden ondersteund bij de keuze voor de interventie of aanpak die het beste aansluit bij zijn of haar waarden en voorkeuren.

Voor beleidsmakers

De aanbevolen interventie of aanpak kan worden gezien als standaardbeleid.

Beleidsbepaling vereist uitvoerige discussie met betrokkenheid van veel stakeholders. Er is een grotere kans op lokale beleidsverschillen.  

 

Organisatie van zorg

In de knelpuntenanalyse en bij de ontwikkeling van de richtlijnmodule is expliciet aandacht geweest voor de organisatie van zorg: alle aspecten die randvoorwaardelijk zijn voor het verlenen van zorg (zoals coördinatie, communicatie, (financiële) middelen, mankracht en infrastructuur). Randvoorwaarden die relevant zijn voor het beantwoorden van deze specifieke uitgangsvraag zijn genoemd bij de overwegingen. Meer algemene, overkoepelende, of bijkomende aspecten van de organisatie van zorg worden behandeld in de module Organisatie van zorg.

 

Commentaar- en autorisatiefase

De conceptmodule werd aan de betrokken (wetenschappelijke) verenigingen, instanties en (patiënt) organisaties voorgelegd ter commentaar. De commentaren werden verzameld en besproken met de werkgroep. Naar aanleiding van de commentaren werd de conceptmodule aangepast en definitief vastgesteld door de werkgroep. De definitieve module werd aan de deelnemende (wetenschappelijke) verenigingen en (patiënt) organisaties voorgelegd voor autorisatie en door hen geautoriseerd dan wel geaccordeerd. De commentaartabel is op te vragen bij het Kennisinstituut via secretariaat@kennisinstituut.nl.

Zoekverantwoording

Zoekacties zijn opvraagbaar. Neem hiervoor contact op met de Richtlijnendatabase.

Volgende:
Organisatie van zorg