Network Meta-Analysis of 4 Rehabilitation Methods With rTMS on Upper Limb Function and Daily Activities in Patients...

Stroke is one of the leading causes of disability and death worldwide, often leading to physical paralysis and cognitive dysfunction, seriously affecting patients' quality of life, and increasing economic burden. Repetitive transcranial magnetic stimulation (rTMS), a noninvasive brain stimulation technique, has been used in stroke rehabilitation, but the difference in efficacy among rehabilitation methods combined with rTMS is unclear. In this study, we compared the effects of 4 rehabilitation methods, namely, clinical routine rehabilitation therapy, smart rehabilitation therapy, behavioral rehabilitation therapy, and Chinese traditional rehabilitation therapy (CTRT) combined with rTMS on the upper limb function and activities of daily living of patients with stroke through a reticulated meta-analysis, which provided a basis for clinical optimization of rehabilitation strategies.

Six databases, namely, PubMed, Embase, Web of Science, Cochrane, EBSCO, and China National Knowledge Infrastructure, were systematically searched, and 24 randomized controlled trials with a total of 868 patients with stroke were finally included. The primary outcome indicators were upper limb Fugl-Meyer assessment and activities of daily living (Barthel index, modified Barthel index, and functional independence measure were included). Network meta-analysis was performed using Stata 17.0 to assess the relative effect of each combined intervention and examine the consistency of direct and indirect evidence.

In this study, a total of 24 randomized controlled trials involving 868 patients with stroke were included. CTRT combined with rTMS had the most significant upper limb Fugl-Meyer assessment improvement CTRT (standardized mean difference [SMD], 1.23 [95% CI, 0.95-1.52]; P<0.0001), and smart rehabilitation therapy combined with rTMS was the most effective in improving activities of daily living (SMD, 1.74 [95% CI, 1.31-2.18]; P<0.0001). Clinical routine rehabilitation therapy combined with rTMS had the most significant effect that improved action research arm test (SMD, 3.19 [95% CI, 1.70-4.69]; P<0.0001) and the combination of the 4 rehabilitation methods with rTMS improved box and block test, but none of them exerted significant effects (P>0.05). The combination of smart rehabilitation therapy with rTMS had the most significant improvement effect on the wolf motor function test (SMD, 0.78 [95% CI, 0.39-1.16]; P<0.0001), CTRT combined with rTMS had the most significant effect that improved upper limb modified Ashworth scale (SMD, -0.67 [95% CI, -0.99 to -0.36]; P<0.0001), and behavioral rehabilitation therapy combined with rTMS had the most significant effect that improved grip strength (SMD, 1.21 [95% CI, 0.42-2.00]; P<0.01).

This meta-analysis shows varied efficacy of 4 rehabilitation methods combined with rTMS in improving body functions and structures along with activities and participation in patients with stroke. Behavioral rehabilitation therapy combined with rTMS enhances hand strength, and CTRT and clinical routine rehabilitation therapy combined with rTMS improve upper limb Fugl-Meyer assessment and reduce upper limb modified Ashworth scale, while smart rehabilitation therapy combined with rTMS boosts activities of daily living. These results highlight the need for personalized rehabilitation strategies based on individual patient needs to optimize outcomes. Future research should explore the mechanisms underlying these differences.