REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION FOR UPPER LIMB REHABILITATION IN PEOPLE WITH STROKE: A SYSTEMATIC REVIEW

S. Lampropoulou¹, A. Berlemi¹, E. Billis¹, V. Sakellari², E. Trachani¹, A. Nowicky³

¹University of Patras, Department of Physiotherapy, Rio, Greece, ²University of West Attica, Department of Physiotherapy, Athens, Greece, ³Brunel University, Department of Health Sciences, London, United Kingdom

Background: Repetitive transcranial magnetic stimulation (rTMS) has been increasingly used the last years to stroke survivors, as a feasible intervention modifying the excitability of the motor areas of the brain and thus promoting post-stroke clinical recovery. However, the evidence about its efficacy on upper arm rehabilitation is not concluded.

Purpose: The main purpose, therefore, of the present study was to systematically review the literature about the effects of rTMS on enhancing motor and functional recovery of the upper limb post-stroke. A further aim of this research was to summarize the current evidence on the ways and protocols that the rTMS is been used in rehabilitation of the hemiplegic upper limb.

Methods: A systematic review of randomized controlled trials (RCTs) published in the PubMed, Web of Science and Medline databases, was conducted for the period from January 2007 to October 2021. Evidence was gathered in regards the effectiveness of rTMS (as monotherapy or in combination with upper extremity rehabilitation programs) in the improvement of functional and motor skills of the upper limb in adult patients with stroke, up to one year from the onset of the episode. Specifically, data were extracted in terms of outcome measures for muscle tone (Motor Assessment Scale), muscle strength (Grip Strength), mobility (Fugl Meyer Assessment Scale, Action Research Arm Test, Wolf Motor Function Test), functionality in daily activities (Functional Ambulation Scale, Barthel Index, Functional Independence Measure), hand limb dexterity (Box and Block Test, Pardue Pegboard Test, Finger tapping test), quality of life and severity of stroke (Brunnstrom Stages, Modified Rank Score, National Institutes of Health Stroke Scale), and were evaluated by two (2) independent judges. The methodological quality of the studies was completed based on Pedro criteria and the level of research evidence with the Best Evidence Synthesis ranking system respectively.

Results: Ten (10) randomized clinical studies (n=617 patients) were finally included in this review and highlighted the use of rTMS both as a monotherapy (3 studies, n=261 patients) and in combination with a conventional physical therapy program (7 studies, n=80 patients). The rTMS was equally effective when it was applied on both the affected (7 studies) and the non-affected hemisphere (8 studies) using high (5 to 10 Hz) (HF) and low (1 Hz) frequency (LF) protocols, respectively. Strong evidence was found for the effectiveness of HF, LF, and their combination rTMS on muscle strength, muscle tone, mobility, hand dexterity, activities of daily living, and quality of life. Findings were unclear as to whether rTMS intervention is superior to conventional rehabilitation programs.

Conclusions: The literature strongly supports the positive effects of both HF and LF rTMS in upper limb rehabilitation. However, further research is needed to explore the long-term therapeutic effects of rTMS and its superiority to other conventional therapies.

Implications: The definite evidence of the efficacy of the rTMS on motor and functional improvement of the hemiplegic upper limb gives new promises to stroke survivors, as well as to clinicians for a safe, nonpharmacological tool that enhances the clinical recovery and promote functional independence.

Funding acknowledgements: None

Keywords:
stroke
upper limb
rTMS

Topics:
Disability & rehabilitation
Neurology: stroke

Did this work require ethics approval? No

Reason: This is a systematic review of the literature, as such, no participants or any personal data were required. In addition no intervention was applied