Critically appraised paper: Non-invasive brain stimulation does not enhance the effect of robotic-assisted upper limb training on arm motor recovery after stroke [synopsis]

摘要

Summary of: Reis SB. Bernardo WM. Oshiro CA, Krebs HI. Conforto AB. Effects of robotic therapy associated with noninvasive brain stimulation on upper-limb rehabilitation after stroke: systematic review and meta-analysis of randomized clinical trials. Neurorehabil Neural Repair. 2021 ;35:256-266. Objective: To review the evidence as to whether adding non-invasive brain stimulation enhances the effects of robotic-assisted upper limb training on upperlimb motor recovery in individuals with stroke. Data sources: MEDLINE, EMBASE, CEI^TRAL, LILACS, CINAHL, DORIS, and PEDro were searched up to July 2019. This search was supplemented by searching online archives of theses and trial registries. Study selection: Randomised controlled trials (parallel or crossover) involving people with upper limb paresis due to stroke, in which non-invasive brain stimulation before, during or after robotic-assisted upper limb rehabilitation was compared with sham non-invasive brain stimulation or robotic-assisted upper limb rehabilitation without non-invasive brain stimulation. Outcome measures were upper limb performance in either impairment-level and/or activity-level domains. Data extraction: Two reviewers extracted data and discrepancies were resolved by consensus. For crossover designs, only the first-phase intervention data were extracted. Risk of bias for individual studies was assessed according to specified criteria by two reviewers and quality of the body of evidence was rated according to GRADEpro. Data synthesis: Of 1.176 articles identified by the search, eight unique trials with a total of 324 participants (161 active.163 control) met the selection criteria and were included in the review. The quality of evidence was high for both impairment-level and activity-level outcome measures. Based on the quantitative pooling of the available data, there was no effect of non-invasive brain stimulation on upper limb performance on the Fug卜Meyer Assessment (seven studies. MD 0.15.95% Cl -3.10 to 3.40) or on upper limb activity limitation (five studies, SMD 0.03, 95% Cl -0.28 to 0.33). Planned subgroup analyses demonstrated similar results for both subacute and chronic stroke, robotic device characteristics (end-effector and exoskeleton), upper limb joints involved in training, and unimanual and bimanual training. Tliere was no evidence that non-invasive brain stimulation paradigms (increased or decreased cortical excitability), timing of stimulation (before, after and during robotic-assisted therapy), or number of sessions influenced the results. Conclusion: At present, there is high-quality evidence to suggest that the effects of robotic-assisted upper limb training on upper limb motor impairment or motor activity for individuals with stroke are not enhanced by existing non-invasive brain stimulation approaches.