Effect of Different Modalities of Repetitive Transcranial Magnetic Stimulation on Post-stroke Upper Limb Motor Dysfunction: a Network Meta-analysis

doi:10.12114/j.issn.1007-9572.2022.0535

Abstract

Abstract:

Background

Upper limb motor dysfunction is a common complication after stroke that seriously affects daily living skills of patients. As a common neuroelectrohysiological technique, repetitive transcranial magnetic stimulation (rTMS) has a good effect on post-stroke upper limb motor dysfunction. However, there is still no practice-based evidence on the selection of modalities of rTMS.

Objective

To evaluate the clinical efficacy of four rTMS modalities in post-stroke upper limb motor dysfunction by a network meta-analysis.

Methods

Randomized controlled trials (RCTs) about rTMS for treating upper limb motor dysfunction after stroke were searched with subject words combined with free words as searching terms in PubMed, Embase, Cochrane Library, Web of Science, CBM, CNKI, Wanfang Data, and VIP from inception to February 2022, supplemented by references from retrospective meta-analysis. Two researchers performed literature screening, data extraction, and quality evaluation separately. RevMan 5.0 and Stata 16.0 were used for statistical analysis.

Results

A total of 17 RCTs with 790 cases were included. Six interventions were involved: high frequency-rTMS (HF-rTMS), low frequency-rTMS (LF-rTMS), intermittent theta burst stimulation (iTBS), continuous theta burst stimulation (cTBS), sham stimulation and conventional therapy. Network meta-analysis results showed that HF-rTMS and LF-rTMS had better effects on increasing the FMA-UE score than sham stimulation and conventional therapy (P<0.05). cTBS increased the FMA-UE score more significantly than conventional therapy (P<0.05). LF-rTMS increased the MBI and BI scores more notably than sham stimulation and conventional therapy (P<0.05). HF-rTMS and LF-rTMS reduced the MEP latency more significantly than sham stimulation (P<0.05). The SUCRA ranking of the six interventions in terms of increasing the FMA-UE score showed the following: LF-rTMS (79.9%) >cTBS (75.3%) >HF-rTMS (71.1%) >iTBS (45.8%) >sham stimulation (20.2%) >conventional therapy (7.7%). The SUCRA ranking of decreasing the MAS score revealed the following: iTBS (77.0%) >LF-rTMS (64.1%) >cTBS (61.0%) >HF-rTMS (38.0%) >sham stimulation (30.6%) >conventional therapy (29.2%). The SUCRA ranking of increasing the MBI and BI scores showed the following: LF-rTMS (96.4%) >iTBS (74.9%) >HF-rTMS (38.6%) >sham stimulation (30.7%) >conventional therapy (9.4%). The SUCRA ranking of reducing the MEP latency showed the following: HF-rTMS (80.0%) >LF-rTMS (78.9%) >conventional therapy (58.8%) >iTBS (24.9%) >sham stimulation (7.5%) .

Conclusion

The available evidence indicates that, among four modalities producing better effects than sham stimulation and conventional therapy, namely LF-rTMS, HF-rTMS, iTBS, and cTBS, LF-rTMS was superior to the other three in improving upper limb motor function and daily living skills of stroke patients, iTBS performed best in decreasing upper limb muscle tension, and HF-rTMS did best in intervening the corticospinal excitability.

Key words: Stroke, Repetitive transcranial magnetic stimulation, Theta burst stimulation, Upper limb motor dysfunction, Network meta-analysis, Randomized controlled trials

摘要：

背景

上肢运动功能障碍是脑卒中后常见的后遗症之一，严重影响患者日常生活能力。重复经颅磁刺激（rTMS）作为常见的神经电生理技术对治疗脑卒中后上肢运动功能障碍有较好的疗效，但临床对不同rTMS干预模式的选择仍缺乏循证依据。

目的

采用网状Meta分析方法比较rTMS的4种模式对脑卒中后上肢运动功能障碍患者的临床疗效。

方法

计算机检索PubMed、Embase、Cochrane Library、Web of Science、中国生物医学文献数据库、中国知网、万方数据知识服务平台、维普网中有关rTMS治疗脑卒中后上肢运动功能障碍的随机对照试验，并通过追溯Meta分析的参考文献作为补充。检索时间均为建库至2022年2月，采用主题词和自由词结合方式进行。2名研究者进行文献筛选、资料提取及质量评价。采用RevMan 5.0软件和Stata 16.0软件进行统计学分析。

结果

最终纳入17篇文献，790例患者，共涉及6种干预措施：高频rTMS（HF-rTMS）、低频rTMS（LF-rTMS）、间断性theta节律刺激（iTBS）、连续性theta节律刺激（cTBS）、假刺激、常规疗法。网状Meta分析结果显示，HF-rTMS、LF-rTMS提高脑卒中后上肢功能障碍患者Fugl-Meyer运动评分量表上肢部分（FMA-UE）评分均高于假刺激、常规疗法（P<0.05），cTBS提高脑卒中后上肢功能障碍患者FMA-UE评分高于常规疗法（P<0.05），LF-rTMS提高脑卒中后上肢功能障碍患者改良Barther指数（MBI）和Barther指数（BI）评分均高于假刺激、常规疗法（P<0.05），HF-rTMS、LF-rTMS缩短脑卒中后上肢功能障碍患者运动诱发电位（MEP）潜伏期高于假刺激（P<0.05）。不同措施提高脑卒中后上肢运动功能障碍患者FMA-UE评分的累积排序概率曲线下面积（SUCRA）排序结果显示，LF-rTMS（79.9%）>cTBS（75.3%）>HF-rTMS（71.1%）>iTBS（45.8%）>假刺激（20.2%）>常规疗法（7.7%），降低改良Ashworth量表（MAS）评分的SUCRA排序结果显示，iTBS（77.0%）>LF-rTMS（64.1%）>cTBS（61.0%）>HF-rTMS（38.0%）>假刺激（30.6%）>常规疗法（29.2%），提高MBI和BI评分的SUCRA排序结果显示，LF-rTMS（96.4）>iTBS（74.9%）>HF-rTMS（38.6%）>假刺激（30.7%）>常规疗法（9.4%），缩短MEP潜伏期的SUCRA排序结果显示，HF-rTMS（80.0%）>LF-rTMS（78.9%）>常规疗法（58.8%）>iTBS（24.9%）>假刺激（7.5%）。

结论

现有证据表明，在假刺激及常规疗法对照的基础上，LF-rTMS在改善脑卒中患者上肢运动功能、日常生活能力方面的效果优于HF-rTMS和iTBS、cTBS；iTBS对上肢肌张力的降低具有明显优势；HF-rTMS对皮质脊髓兴奋性的干预效果更佳。

关键词: 卒中, 重复经颅磁刺激, theta节律刺激, 上肢运动功能, 网状Meta分析, 随机对照试验

XIONG Dan,XIE Haihua,LI Hao, et al. Effect of Different Modalities of Repetitive Transcranial Magnetic Stimulation on Post-stroke Upper Limb Motor Dysfunction: a Network Meta-analysis[J]. Chinese General Practice, 2023, 26(08): 997-1007. DOI: 10.12114/j.issn.1007-9572.2022.0535.
熊丹,谢海花,李浩等. 不同重复经颅磁刺激模式对脑卒中后上肢运动功能障碍干预效果的网状Meta分析[J]. 中国全科医学, 2023, 26(08): 997-1007. DOI: 10.12114/j.issn.1007-9572.2022.0535.

Figures/Tables 16

References 49

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步骤	检索式
#1	Transcranial Magnetic Stimulation[MeSH Terms]
#2	Repetitive Transcranial Magnetic Stimulation^* OR theta burst stimulation OR TMS OR TBS
#3	#1 OR #2
#4	Stroke[MeSH Terms]
#5	Cerebrovascular Accident OR Cerebrovascular Apoplexy OR Brain Vascular Accident OR Cerebrovascular Stroke
#6	#4 OR #5
#7	upper limb[MeSH Terms]
#8	upper limb movement dysfunction OR upper extremity motor dysfunction OR upper extremity movement dysfunction OR upper limb motor impairment
#9	#7 OR #8
#10	randomized controlled trial[MeSH Terms]
#11	randomized controlled study OR randomized clinical trial OR controlled clinical Trial
#12	#10 OR #11
#13	#3 AND #6 AND #9 AND #12

步骤	检索式
#1	Transcranial Magnetic Stimulation[MeSH Terms]
#2	Repetitive Transcranial Magnetic Stimulation^* OR theta burst stimulation OR TMS OR TBS
#3	#1 OR #2
#4	Stroke[MeSH Terms]
#5	Cerebrovascular Accident OR Cerebrovascular Apoplexy OR Brain Vascular Accident OR Cerebrovascular Stroke
#6	#4 OR #5
#7	upper limb[MeSH Terms]
#8	upper limb movement dysfunction OR upper extremity motor dysfunction OR upper extremity movement dysfunction OR upper limb motor impairment
#9	#7 OR #8
#10	randomized controlled trial[MeSH Terms]
#11	randomized controlled study OR randomized clinical trial OR controlled clinical Trial
#12	#10 OR #11
#13	#3 AND #6 AND #9 AND #12

第一作者	发表时间（年）	样本量（试验组/对照组）	年龄（岁）		性别（男/女）	偏瘫侧（右/左）	干预措施		结局指标
第一作者	发表时间（年）	样本量（试验组/对照组）	试验组	对照组	性别（男/女）	偏瘫侧（右/左）	试验组	对照组	结局指标
肖长林^[9]	2019	15/17	63.7±11.0	58.7±10.8	21/11	15/17	HF-rTMS	假刺激	①②③
梁绮婷^[10]	2018	38/38^a	64.3±11.8	65.5±10.5	47/31	—	HF-rTMS	常规疗法	①③
周哲^[11]	2020	30/28	59.7±10.4	61.8±11.4	41/17	28/30	HF-rTMS	假刺激	①②③
王玉琴^[12]	2020	36/36	52.0±6.9	53.1±6.8	41/31	28/44	LF-rTMS	假刺激	①③④
刘阅^[13]	2018	10/13	56.9±9.0	55.4±8.4	14/9	9/14	LF-rTMS	常规疗法	①②③
李冰洁^[14]	2016	20/20	51.5±7.1	51.4±6.6	23/17	25/15	LF-rTMS	常规疗法	①③④
GOTTLIEB^[15]	2021	14/14	63.9±10.9	62.4±11.5	12/16	8/20	LF-rTMS	假刺激	①②
SENIÓW^[16]	2012	20/20	63.5±8.9	63.4±9.2	26/14	23/17	LF-rTMS	假刺激	①
汤昕未^[17]	2018	8/8	53.8±10.8	55.6±14.6	14/2	14/2	iTBS	假刺激	①③
CHEN^[18]	2019	11/11	52.9±11.1	52.6±8.3	14/8	15/7	iTBS	假刺激	①②
CHEN^[19]	2021	12/11	54.4±10.6	48.9±9.6	18/5	18/5	iTBS	假刺激	①②
CHEN^[20]	2021	16/16	57.4±8.0	51.4±9.2	7/25	13/19	iTBS	假刺激	③④
KUZU^[21]	2021	7/6	61.3±9.8	65.3±4.6	8/5	8/5	cTBS	假刺激	①②
CHA^[22]	2021	20/20	67.6±7.2	69.1±6.0	25/15	—	HF-rTMS	LF-rTMS	①
KONDO^[23]	2017	71/32	62.3±12.5	60.0±14.2	73/30	47/56	LF-rTMS	cTBS	①
孟祥民^[24]	2016	14/17/14^b	57.4±13.3/55.1±12.9	51.2±14.1	33/12	30/15	HF-rTMS、LF-rTMS	假刺激	①④
LI^[25]	2016	43/42/42^b	54.0±13.4/57.9±12.9	53.1±13.7	87/40	59/68	HF-rTMS、LF-rTMS	假刺激	①④

第一作者	发表时间（年）	样本量（试验组/对照组）	年龄（岁）		性别（男/女）	偏瘫侧（右/左）	干预措施		结局指标
第一作者	发表时间（年）	样本量（试验组/对照组）	试验组	对照组	性别（男/女）	偏瘫侧（右/左）	试验组	对照组	结局指标
肖长林^[9]	2019	15/17	63.7±11.0	58.7±10.8	21/11	15/17	HF-rTMS	假刺激	①②③
梁绮婷^[10]	2018	38/38^a	64.3±11.8	65.5±10.5	47/31	—	HF-rTMS	常规疗法	①③
周哲^[11]	2020	30/28	59.7±10.4	61.8±11.4	41/17	28/30	HF-rTMS	假刺激	①②③
王玉琴^[12]	2020	36/36	52.0±6.9	53.1±6.8	41/31	28/44	LF-rTMS	假刺激	①③④
刘阅^[13]	2018	10/13	56.9±9.0	55.4±8.4	14/9	9/14	LF-rTMS	常规疗法	①②③
李冰洁^[14]	2016	20/20	51.5±7.1	51.4±6.6	23/17	25/15	LF-rTMS	常规疗法	①③④
GOTTLIEB^[15]	2021	14/14	63.9±10.9	62.4±11.5	12/16	8/20	LF-rTMS	假刺激	①②
SENIÓW^[16]	2012	20/20	63.5±8.9	63.4±9.2	26/14	23/17	LF-rTMS	假刺激	①
汤昕未^[17]	2018	8/8	53.8±10.8	55.6±14.6	14/2	14/2	iTBS	假刺激	①③
CHEN^[18]	2019	11/11	52.9±11.1	52.6±8.3	14/8	15/7	iTBS	假刺激	①②
CHEN^[19]	2021	12/11	54.4±10.6	48.9±9.6	18/5	18/5	iTBS	假刺激	①②
CHEN^[20]	2021	16/16	57.4±8.0	51.4±9.2	7/25	13/19	iTBS	假刺激	③④
KUZU^[21]	2021	7/6	61.3±9.8	65.3±4.6	8/5	8/5	cTBS	假刺激	①②
CHA^[22]	2021	20/20	67.6±7.2	69.1±6.0	25/15	—	HF-rTMS	LF-rTMS	①
KONDO^[23]	2017	71/32	62.3±12.5	60.0±14.2	73/30	47/56	LF-rTMS	cTBS	①
孟祥民^[24]	2016	14/17/14^b	57.4±13.3/55.1±12.9	51.2±14.1	33/12	30/15	HF-rTMS、LF-rTMS	假刺激	①④
LI^[25]	2016	43/42/42^b	54.0±13.4/57.9±12.9	53.1±13.7	87/40	59/68	HF-rTMS、LF-rTMS	假刺激	①④

第一作者	刺激频率（Hz）	刺激强度	总脉冲数	刺激部位	线圈类型	治疗方案及持续时间
肖长林^[9]	10	90% RMT	900	患侧C3、C4	"8"字形线圈	9 min/次，5次/周，持续2周
梁绮婷^[10]	3	90%~120% AMT	900	患侧C3、C4	"8"字形线圈	20 min/次，持续治疗2周后休息2 d，持续8周
周哲^[11]	5	80% RMT	1 200	患侧M1	"8"字形线圈	5 min/次，5次/周，持续3周
王玉琴^[12]	1	80% AMT	600	健侧M1	"8"字形线圈	10 min/次，5次/周，持续4周
刘阅^[13]	1	90% AMT	1 200	健侧M1	"8"字形线圈	24 min/次，5次/周，持续8周
李冰洁^[14]	1	80% AMT	600	健侧M1	"8"字形线圈	10 min/次，5次/周，持续2周
GOTTLIEB^[15]	1	100% RMT	1 200	健侧M1	"8"字形线圈	10 min/次，5次/周，持续2周
SENIÓW^[16]	1	90% RMT	1 200	健侧M1	"8"字形线圈	30 min/次，5次/周，持续3周
汤昕未^[17]	50-5	70% RMT	600	患侧M1	圆形线圈	200 s/次，5次/周，持续2周
CHEN^[18]	50-5	80% AMT	600	患侧M1	"8"字形线圈	200 s/次，5次/周，持续2周
CHEN^[19]	50-5	80% AMT	1 200	健侧M1	"8"字形线圈	200 s/次，5次/周，持续3周
CHEN^[20]	50-5	80% AMT	600	患侧小脑	"8"字形线圈	200 s/次，5次/周，持续2周
KUZU^[21]	50-5	80% AMT	600	健侧M1	"8"字形线圈	200 s/次，5次/周，持续2周
CHA^[22]	10/1	90% RMT	1 350/1 000	患侧M1/健侧M1	"8"字形线圈	20 min/次，5次/周，持续2周
KONDO^[23]	1/50-5	90% RMT/80% AMT	2 400	运动皮质	"8"字形线圈	20 min/次，6次/周，共2周；160 s/次，6次/周，共2周
孟祥民^[24]	10/1	80% AMT	1 350/1 000	健侧M1/患侧M1	圆形线圈	20 min/次，5次/周，持续2周
LI^[25]	10/1	80% AMT	1 350/1 000	健侧M1/患侧M1	圆形线圈	20 min/次，5次/周，持续2周