Highlights
- •Noninvasive brain stimulation improved deficits in functional balance and postural control poststroke.
- •The treatment effects on postural imbalance were significant following repetitive transcranial magnetic stimulation (rTMS).
- •The improvements after rTMS appeared in patients with history of acute, subacute, and chronic stroke.
- •A higher number of rTMS sessions significantly increased the treatment effects.
Abstract
Objectives
The postural imbalance poststroke limits individuals’ walking abilities as well as
increase the risk of falling. We investigated the short-term treatment effects of
noninvasive brain stimulation (NIBS) on functional balance and postural control in
patients with stroke.
Data Sources
We started the search via PubMed and the Institute for Scientific Information’s Web
of Science on March 1, 2019 and concluded the search on April 30, 2019.
Study Selection
The meta-analysis included studies that used either repetitive transcranial magnetic
stimulation (rTMS) or transcranial direct current stimulation (tDCS) for the recovery
of functional balance and postural control poststroke. All included studies used either
randomized controlled trial or crossover designs with a sham control group.
Data Extraction
Three researchers independently performed data extraction and assessing methodological
quality and publication bias. We calculated overall and individual effect sizes using
random effects meta-analysis models.
Data Synthesis
The random effects meta-analysis model on the 18 qualified studies identified the
significant positive effects relating to NIBS in terms of functional balance and postural
control poststroke. The moderator-variable analyses revealed that these treatment
effects were only significant in rTMS across patients with acute, subacute, and chronic
stroke whereas tDCS did not show any significant therapeutic effects. The meta-regression
analysis showed that a higher number of rTMS sessions was significantly associated
with more improvements in functional balance and postural control poststroke.
Conclusions
Our systematic review and meta-analysis confirmed that NIBS may be an effective option
for restoring functional balance and postural control for patients with stroke.
Keywords
List of abbreviations:
CI (confidence interval), M1 (primary motor cortex), NIBS (noninvasive brain stimulation), PEDro (the Physiotherapy Evidence Database), rTMS (repetitive transcranial magnetic stimulation), SMA (supplementary motor area), SMD (standardized mean difference), tDCS (transcranial direct current stimulation)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Archives of Physical Medicine and RehabilitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Heart disease and stroke statistics-2017 update: a report from the American Heart Association.Circulation. 2017; 135: e146-e603
- Rehabilitation of sensorimotor integration deficits in balance impairment of patients with stroke hemiparesis: a before/after pilot study.Neurol Sci. 2008; 29: 313-319
- Gait disturbances in patients with stroke.PM & R. 2014; 6: 635-642
- Balance disability after stroke.Phys Ther. 2006; 86: 30-38
- Efficiency of physical therapy on postural imbalance after stroke: study protocol for a systematic review and meta-analysis.BMJ Open. 2017; 7e013348
- Balance and gait impairment in transient ischemic attack and minor stroke.J Stroke Cerebrovascular Dis. 2015; 24: 2291-2297
- Balance is associated with quality of life in chronic stroke.Top Stroke Rehabil. 2013; 20: 340-346
- Effects of exercise therapy on balance capacity in chronic stroke: systematic review and meta-analysis.Stroke. 2016; 47: 2603-2610
- Effect of virtual reality training on balance and gait ability in patients with stroke: systematic review and meta-analysis.Phy Ther. 2016; 96: 1905-1918
- Noninvasive neuromodulation in poststroke gait disorders: rationale, feasibility, and state of the art.Neurorehabil Neural Repair. 2016; 30: 71-82
- Non-invasive brain stimulation for the lower limb after stroke: what do we know so far and what should we be doing next?.Disabil Rehabil. 2017; 39: 714-720
- Noninvasive human brain stimulation.Annu Rev Biomed Eng. 2007; 9: 527-565
- Noninvasive brain stimulation to enhance functional recovery after stroke: studies in animal models.Neurorehabil Neural Repair. 2018; 32: 927-940
- A coil design for transcranial magnetic stimulation of deep brain regions.J Clin Neurophysiol. 2002; 19: 361-370
- Effects of transcranial direct current stimulation on the excitability of the leg motor cortex.Exp Brain Res. 2007; 182: 281-287
- Influence of interhemispheric interactions on motor function in chronic stroke.Ann Neurol. 2004; 55: 400-409
- Relationships between functional and structural corticospinal tract integrity and walking post stroke.Clin Neurophysiol. 2012; 123: 2422-2428
- Effects of repetitive transcranial magnetic stimulation on walking and balance function after stroke: a systematic review and meta-analysis.Am J Phy Med Rehabil. 2018; 97: 773-781
- Effects of transcranial direct current stimulation on walking ability after stroke: a systematic review and meta-analysis.Restor Neurol Neurosci. 2018; 36: 59-71
- Noninvasive brain stimulation combined with other therapies improves gait speed after stroke: a systematic review and meta-analysis.Top Stroke Rehabilitation. 2019; 26: 201-213
- Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.J Cli Epidemiol. 2009; 62: 1006-1012
- Effects of different montages of transcranial direct current stimulation on the risk of falls and lower limb function after stroke.Neurol Res. 2017; 39: 1037-1043
- The effect of low-frequency (1 Hz) rTMS on the cerebellar cortex in patients with ataxia after a posterior pirculation stroke : randomized control trial.J Magn. 2017; 22: 625-629
- Therapeutic efficacy of low frequency transcranial magnetic stimulation in conjunction with mirror therapy for subacute stroke patients.J Magn. 2015; 20: 52-56
- Enhancement of cortical excitability and lower limb motor function in patients with stroke by transcranial direct current stimulation.Brain Stimul. 2015; 8: 561-566
- Effects of repetitive transcranial magnetic stimulation over trunk motor spot on balance function in stroke patients.Ann of Rehabil Med. 2016; 40: 826-834
- Brain stimulation paired with novel locomotor training with robotic gait orthosis in chronic stroke: a feasibility study.NeuroRehabilitation. 2013; 33: 67-76
- The effect of repetitive transcranial magnetic stimulation on postural stability after acute stroke: a clinical trial.Basic Clin Neurosci. 2017; 8: 405-411
- Immediate effect of transcranial direct current stimulation combined with functional electrical stimulation on activity of the tibialis anterior muscle and balance of individuals with hemiparesis stemming from a stroke.J Phys Ther Sci. 2017; 29: 2138-2146
- Priming with 1-Hz repetitive transcranial magnetic stimulation over contralesional leg motor cortex does not increase the rate of regaining ambulation within 3 months of stroke a randomized controlled trial.Am J Phys Med Rehabil. 2018; 97: 339-345
- The effects of repetitive transcranial magnetic stimulation on balance ability in acute stroke patients.J Korean Soc Phys Med. 2016; 11: 11-17
- Effect of repetitive transcranial magnetic stimulation over the cerebellum on patients with ataxia after posterior circulation stroke: A pilot study.J Rehabil Med. 2014; 46: 418-423
- Effects of repetitive transcranial magnetic stimulation of the unaffected hemisphere leg motor area in patients with subacute stroke and substantial leg impairment: a pilot study.J Rehabil Med. 2015; 47: 305-310
- Effects of transcranial direct current stimulation over the supplementary motor area body weight-supported treadmill gait training in hemiparetic patients after stroke.Neurosci Lett. 2018; 662: 302-305
- Transcranial direct current stimulation in the recovery of postural control after stroke: a pilot study.Disabil Rehabil. 2015; 37: 1857-1863
- Robotic-assisted gait training combined with transcranial direct current stimulation in chronic stroke patients: a pilot double-blind, randomized controlled trial.Restor Neurol Neurosci. 2017; 35: 527-536
- Effect of transcranial direct current stimulation on postural stability and lower extremity strength in hemiplegic stroke patients.Ann Rehabil Med. 2013; 37: 759-765
- Assessment of the interest of inhibitory repetitive transcranial magnetic stimulation (rTMS) on unaffected motor cortex in balance disorders in chronic stroke patients.Ann Phys Rehabil Med. 2015; 585: e117-e122
- Short-term effects of cerebellar tDCS on standing balance performance in patients with chronic stroke and healthy age-matched elderly.Cerebellum. 2018; 17: 575-589
- Introduction to meta-analysis.Wiley, New York2009
- A re-evaluation of random-effects meta-analysis.J R Stat Soc Ser A Stat Soc. 2009; 172: 137-159
- Quantifying heterogeneity in a meta-analysis.Stat Med. 2002; 21: 1539-1558
- Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.Biometrics. 2000; 56: 455-463
- Bias in meta-analysis detected by a simple, graphical test.BMJ. 1997; 315: 629-634
- PEDro: a physiotherapy evidence database.Med Ref Serv Q. 2008; 27: 189-198
- Cochrane handbook for systematic reviews of interventions 6.0.(Available at:) (Accessed May 1, 2019)
- Meta-analysis and subgroups.Prev Sci. 2013; 14: 134-143
- Conducting quantitative synthesis when comparing medical interventions: AHRQ and the effective health care program.Rockville: Agency for Healthcare Research and Quality (US), 2008
- Non-invasive brains stimulation improves paretic limb force production: a systematic review and meta-analysis.Brain Stimul. 2016; 9: 662-670
- Non-invasive brain stimulation for fine motor improvement after stroke: a meta-analysis.Eur J Neurol. 2018; 25: 1017-1026
- Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke.Cochrane Database Syst Rev. 2016; 3: CD009645
- Non-invasive brain stimulation: a new strategy in mild cognitive impairment?.Front Aging Neurosci. 2017; 9: 16
- Number of pulses or number of sessions? An open-label study of trajectories of improvement for once-vs. twice-daily dorsomedial prefrontal rTMS in major depression.Brain Stimulation. 2018; 11: 327-336
- Robot-aided neurorehabilitation in sub-acute and chronic stroke: does spontaneous recovery have a limited impact on outcome?.NeuroRehabilitation. 2013; 33: 621-629
- Early rehabilitation after stroke: a narrative review.Curr Atheroscler Rep. 2017; 19: 59
- Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery.Ann Neurol. 2008; 63: 272-287
- Acute and post-acute neuromodulation induces stroke recovery by promoting survival signaling, neurogenesis, and pyramidal tract plasticity.Fron Cell Neurosci. 2019; 13: 144
- Multiple sessions of transcranial direct current stimulation and upper extremity rehabilitation in stroke: a review and meta-analysis.Clin Neurophysiol. 2016; 127: 946-955
- Effectiveness and acceptability of accelerated repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depressive disorder: an open label trial.J Affect Disord. 2015; 173: 216-220
- Accelerated HF-rTMS in treatment-resistant unipolar depression: Insights from subgenual anterior cingulate functional connectivity.World J Biol Psychiatry. 2014; 15: 286-297
- Accelerated repetitive transcranial magnetic stimulation for treatment-resistant depression.Depress Anxiety. 2010; 27: 960-963
- Benefit of multiple sessions of perilesional repetitive transcranial magnetic stimulation for an effective rehabilitation of visuospatial function.Eur J Neurosci. 2013; 37: 441-454
- Effects of multi-session repetitive transcranial magnetic stimulation on motor control and spontaneous brain activity in multiple system atrophy: a pilot study.Front Behav Neurosci. 2018; 12: 90
- Neuroimaging of human balance control: a systematic review.Front Hum Neurosci. 2017; 11: 170
- Noninvasive brain stimulation for motor recovery after stroke: mechanisms and future views.Stroke Res Treat. 2012; 2012: 584727
- Transcranial direct current stimulation facilitates motor learning post-stroke: a systematic review and meta-analysis.J Neurol Neurosurg Psychiatry. 2016; 87: 345-355
- The cerebral sulci and gyri.Neurosurg Focus. 2010; 28: E2
- Focality assessment in transcranial magnetic stimulation with double and cone coils.J Clin Neurophysiol. 2006; 23: 462-471
- Three-dimensional distribution of the electric field induced in the brain by transcranial magnetic stimulation using figure-8 and deep H-coils.J Clin Neurophysiol. 2007; 24: 31-38
- A pilot study on effects of 4x1 high-definition tDCS on motor cortex excitability.Conf proc IEEE Eng Med Biol Soc. 2012; 2012: 735-738
- Exploring the effects of anodal and cathodal high definition transcranial direct current stimulation targeting the dorsal anterior cingulate cortex.Sci Rep. 2018; 8: 4454
Article info
Publication history
Published online: September 27, 2019
Footnotes
Supported by Incheon National University, South Korea (grant no. 2017-0389).
Disclosures: none.
Identification
Copyright
© 2019 by the American Congress of Rehabilitation Medicine
