Transcranial direct current stimulation combined with robotic therapy for upper and lower limb function after stroke: a systematic review and meta-analysis of randomized control trials

Abstract

Background: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation method able to modulate neuronal activity after stroke. The aim of this systematic review was to determine if tDCS combined with robotic therapy (RT) improves limb function after stroke when compared to RT alone.

Methods: A search for randomized controlled trials (RCTs) published prior to July 15, 2021 was performed. The main outcome was function assessed with the Fugl-Meyer motor assessment for upper extremities (FM/ue) and 10-m walking test (10MWT) for the lower limbs. As secondary outcomes, strength was assessed with the Motricity Index (MI) or Medical Research Council scale (MRC), spasticity with the modified Ashworth scale (MAS), functional independence with the Barthel Index (BI), and kinematic parameters.

Results: Ten studies were included for analysis (n = 368 enrolled participants). The results showed a non-significant effect for tDCS combined with RT to improve upper limb function [standardized mean difference (SMD) = - 0.12; 95% confidence interval (CI): - 0.35-0.11)]. However, a positive effect of the combined therapy was observed in the lower limb function (SMD = 0.48; 95% CI: - 0.15-1.12). Significant results favouring tDCS combined with RT were not found in strength (SMD = - 0.15; 95% CI: - 0.4-0.1), spasticity [mean difference (MD) = - 0.15; 95% CI: - 0.8-0.5)], functional independence (MD = 2.5; 95% CI: - 1.9-6.9) or velocity of movement (SMD = 0.06; 95% CI: - 0.3-0.5) with a "moderate" or "low" recommendation level according to the GRADE guidelines.

Conclusions: Current findings suggest that tDCS combined with RT does not improve upper limb function, strength, spasticity, functional independence or velocity of movement after stroke. However, tDCS may enhance the effects of RT alone for lower limb function. tDCS parameters and the stage or type of stroke injury could be crucial factors that determine the effectiveness of this therapy.

Keywords: Neuromodulation; Robotic; Stroke; Transcranial direct current stimulation; tDCS.

Fig. 1

PRISMA_flow_chart

Fig. 2

Risk of bias summary. Review authors' judgements about each risk of bias item for each included study (upper figure). Risk of bias item presented as percentages across all included studies (lower figure)

Fig. 3

Funnel plot of comparison active tDCS + robotic rehabilitation Vs sham tDCS + robotic rehabilitation for the main outcome functionality. The references of the studies are shown in brackets. Asymmetries were not observed

Fig. 4

Forest plot of comparison between experimental group (active tDCS + robotic rehabilitation) and control group (sham tDCS + robotic rehabilitation) for the main outcome functionality. In Hesse et al. study (a) Anodic stimulation arm (b) Cathodic stimulation arm

Fig. 5

Forest plot of comparison between experimental group (active tDCS + robotic rehabilitation) and control group (sham tDCS + robotic rehabilitation) for secondary outcomes. A Effect on strength. B Effect on spasticity. C Effect on functional independence. D Effect on velocity of upper limb movements

Fig. 6

Forest plot of comparison between experimental group (active tDCS + robotic rehabilitation) and control group (sham tDCS + robotic rehabilitation) for adverse event (upper figure A) and lost to follow (lower figure B)