Effects of non-invasive brain stimulation on motor function after spinal cord injury: a systematic review and meta-analysis

Abstract

Background: In recent years, non-invasive brain stimulation (NIBS) has been used for motor function recovery. However, the effects of NIBS in populations with spinal cord injury (SCI) remain unclear. This study aims to conduct a meta-analysis of the existing evidence on the effects and safety of NIBS against sham groups for motor dysfunction after SCI to provide a reference for clinical decision-making.

Methods: Two investigators systematically screened English articles from PubMed, MEDLINE, Embase, and Cochrane Library for prospective randomized controlled trials regarding the effects of NIBS in motor function recovery after SCI. Studies with at least three sessions of NIBS were included. We assessed the methodological quality of the selected studies using the evidence-based Cochrane Collaboration's tool. A meta-analysis was performed by pooling the standardized mean difference (SMD) with 95% confidence intervals (CI).

Results: A total of 14 randomized control trials involving 225 participants were included. Nine studies used repetitive transcranial magnetic stimulation (rTMS) and five studies used transcranial direct current stimulation (tDCS). The meta-analysis showed that NIBS could improve the lower extremity strength (SMD = 0.58, 95% CI = 0.02-1.14, P = 0.004), balance (SMD = 0.64, 95% CI = 0.05-1.24, P = 0.03), and decrease the spasticity (SMD = - 0.64, 95% CI = - 1.20 to - 0.03, P = 0.04). However, the motor ability of the upper extremity in the NIBS groups was not statistically significant compared with those in the control groups (upper-extremity strength: P = 0.97; function: P = 0.56; and spasticity: P = 0.12). The functional mobility in the NIBS groups did not reach statistical significance when compared with the sham NIBS groups (sham groups). Only one patient reported seizures that occurred during stimulation, and no other types of serious adverse events were reported.

Conclusion: NIBS appears to positively affect the motor function of the lower extremities in SCI patients, despite the marginal P-value and the high heterogeneity. Further high-quality clinical trials are needed to support or refute the use and optimize the stimulation parameters of NIBS in clinical practice.

Keywords: Motor function; Non-invasive brain stimulation; Repetitive transcranial magnetic stimulation; Spinal cord injuries; Transcranial direct current stimulation.

Fig. 1

Flow of studies through the review

Fig. 2

Cochrane risk of bias assessment of the included studies. a Risk of bias graph; b Risk of bias summary

Fig. 3

Weighted mean difference (95% CI) of the effect of NIBS compared with sham on (a) lower extremity strength by pooling data from 5 trials (LEMS), upper extremity strength by pooling data from 3 trials (UEMS) and upper extremity function by pooling data from 2 trails (JTHFT) in people with SCI; (b) Balance from 2 tails

Fig. 4

A subgroup analysis based on different SCI stages for the NIBS effects compared with sham on (a) upper extremity strength, (b) lower extremity strength, (c) LMAS, (d) H/M, (e) 6MWT and (10) TUG

Fig. 5

Weighted mean difference (95% CI) of the effect of NIBS compared with sham on (a) upper extremity spasticity by pooling data from 2 trials (UMAS) and lower extremity strength by pooling data from 7 trials (LMAS) in people with SCI; (b) H/M ratio from3 tails

Fig. 6

Weighted mean difference (95% CI) of the effect of NIBS compared with sham on mobility by pooling data from (a) 3 trials of 6MWT, (b) 2 trials of 10MWT in speed, (c) 2 trials of 10MWT in time- to-complete, (d) 4 trials of TUG