Original Title: Efectividad y Seguridad de las Técnicas de Estimulación Cerebral no Invasiva en la Neurorrehabilitación del Ictus

Authors' objectives: The primary objective is to assess the evidence on the utility and role of these brain stimulation therapies, using magnetic or electric waves, in the neurorehabilitation of stroke patients with stroke-related deficits.

Authors' results and conclusions: After conducting the systematic search and removing duplicates, the titles and abstracts of 565 records were evaluated, and of these, 106 were then full text screened. In the end, 63 reviews were included in the analysis. Based on the outcomes assessed, the findings were as follows: i) for dysphagia: anodal tDCS and rTMS both probably improve dysphagia recovery (moderate certainty); ii) for aphasia: tDCS may have little or no benefit on improving functional communication, although the evidence was uncertain (very low certainty), while low frequency rTMS probably improves the severity of aphasia after stroke (low certainty) though the effect of high frequency rTMS is very limited or uncertain (very low certainty); iii) for gait: tDCS probably has little or no effect on postural balance (very low certainty), gait speed or resistance recovery (low certainty), although it probably improves functional recovery (very low certainty); and rTMS may improve postural balance (low certainty) and gait speed (low certainty); iv) for lower limbs: tDCS probably improves the recovery of lower-limb motor function (moderate certainty), and stimulation using intermittent theta burst stimulation (iTBS) and rTMS in patients with established spasticity probably improves lower limb motricity (low certainty); v) for upper limbs: tDCS probably has little or no benefit for upper limb motor recovery (moderate certainty), while high frequency rTMS (10 Hz) probably improves the motor function recovery (moderate certainty), but low frequency rTMS may have little or no benefit (low certainty); vi) for activities of daily living: it probably improves recovery for these activities (moderate certainty); but outcomes of stimulation with rTMS or iTBS vary depending on the scale used; vii) for cognition and memory: tDCS may improve cognitive function and memory in patients with stroke (very low certainty), while rTMS can improve cognitive function (moderate certainty) and memory (low certainty) of these patients; viii) for visual hemi spatial neglect: the evidence was uncertain for tDCS and rTMS (very low certainty in both cases); ix) for depression: tDCS probably improves depression (low certainty), and srTMS probably improves the symptoms of depression after stroke, including a significant effect on remission (low certainty); and x) for spasticity: tDCS probably improves spasticity after stroke (low certainty), and rTMS probably improves lower-limb spasticity (low certainty) and spasticity in general (low certainty). In patients with stroke, our review found that tDCS may have clinical benefit for dysphagia, lower- and upper-limb motor recovery and activities of daily living. Repetitive TMS probably has benefits for alleviating dysphagia, upper-limb motor recovery (at a high frequency of 10Hz) and memory. For other outcomes, the evidence was of low or very low certainty, although in most indications, there were potential improvements with the use of NIBS. The report of subgroup analysis by type of intervention protocol was inconsistent between studies. There is a need for RCTs that include more patients, evaluate various types of protocols (intensity, frequency, and duration) and ensure blinding in the evaluation of outcomes.

Authors' methods: A review of systematic reviews (SRs) that might have performed a systematic search in at least two biomedical databases and had evaluated the risk of bias of the included individual studies, was conducted. The SRs included randomised controlled trials (RCTs) on adult participants with stroke who received TMS, in particular repetitive TMS (rTMS), or tDCS compared to placebo, conventional rehabilitation or a simulated intervention, and assessed the following outcomes: dysphagia, aphasia, gait, upper and lower limb motricity, functioning for activities of daily living, cognition and memory, hemispatial neglect, depression and spasticity. Systematic searches were performed in MEDLINE (via PubMed, January 2023), EMBASE (via Ovid, January 2023) and the Cochrane Central Register of Controlled Trials (via The Cochrane Library, January 2023). Potential overlap between individual studies was assessed by indication and type of NIBS technique used, and the SRs that provided the largest number of unique individual studies were prioritised. The quality of the SRs included was appraised by applying the Measurement Tool to Assess Systematic Reviews (AMSTAR)-2 criteria. The risk assessment of the individual studies performed in the SRs themselves was used to assess the risk of bias of the RCTs. The certainty of evidence for each outcome was evaluated following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, which classifies the certainty of evidence as high, moderate, low, or very low.

Project Status: Completed

Year Published: 2025

URL for published report: https://www.euskadi.eus/contenidos/informacion/osteba_publicacion/eu_def/adjuntos/Estimulacion_Cerebral_no_Invasiva_del_Ictus.pdf

English language abstract: An English language summary is available

Publication Type: Mini HTA

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government</p>