Transcranial direct current stimulation (tDCS) for improving capacity in activities and arm function after stroke: a network meta-analysis of randomised controlled trials

Bernhard Elsner, Gert Kwakkel, Joachim Kugler, Jan Mehrholz, Bernhard Elsner, Gert Kwakkel, Joachim Kugler, Jan Mehrholz

Abstract

Background: Transcranial Direct Current Stimulation (tDCS) is an emerging approach for improving capacity in activities of daily living (ADL) and upper limb function after stroke. However, it remains unclear what type of tDCS stimulation is most effective. Our aim was to give an overview of the evidence network regarding the efficacy and safety of tDCS and to estimate the effectiveness of the different stimulation types.

Methods: We performed a systematic review of randomised trials using network meta-analysis (NMA), searching the following databases until 5 July 2016: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, and four other databases. We included studies with adult people with stroke. We compared any kind of active tDCS (anodal, cathodal, or dual, that is applying anodal and cathodal tDCS concurrently) regarding improvement of our primary outcome of ADL capacity, versus control, after stroke.

Prospero id: CRD42016042055.

Results: We included 26 studies with 754 participants. Our NMA showed evidence of an effect of cathodal tDCS in improving our primary outcome, that of ADL capacity (standardized mean difference, SMD = 0.42; 95% CI 0.14 to 0.70). tDCS did not improve our secondary outcome, that of arm function, measured by the Fugl-Meyer upper extremity assessment (FM-UE). There was no difference in safety between tDCS and its control interventions, measured by the number of dropouts and adverse events.

Conclusion: Comparing different forms of tDCS shows that cathodal tDCS is the most promising treatment option to improve ADL capacity in people with stroke.

Keywords: Meta-analysis; Recovery of function; Review; Stroke; Transcranial direct current stimulation.

Conflict of interest statement

Ethics approval and consent to participate

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Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Study flow diagram
Fig. 2
Fig. 2
Network graph of tDCS for improving ADL capacity after stroke. The thicker the edge, the lower the standard error of this comparison. Colored polygons indicate multi-arm studies
Fig. 3
Fig. 3
Network graph of tDCS for improving arm function (measured by UE-FM) after stroke. The thicker the edge, the lower the standard error of this comparison. Colored polygons indicate multi-arm studies. UE-FM: Upper Extremity Fugl-Meyer Assessment
Fig. 4
Fig. 4
Network graph of the safety of tDCS (measured by number of dropouts and adverse events) after stroke. The thicker the edge, the lower the standard error of this comparison. Colored polygons indicate multi-arm studies
Fig. 5
Fig. 5
Forest plot of tDCS for improving ADL capacity after stroke (12 studies with 284 participants). Treatments are listed in order of relative ranking. SMD = standardized mean difference, CI = confidence interval. Sham is the reference category
Fig. 6
Fig. 6
Forest plot of tDCS for improving arm function after stroke (16 studies with 302 participants). Treatments are listed in order of relative ranking. MD = mean difference [UE-FM points], CI = confidence interval. Sham is the reference category
Fig. 7
Fig. 7
Forest plot of the safety of tDCS for improving ADL capacity or arm function after stroke (26 studies with 754 participants). Treatments are listed in order of relative ranking. RD = Risk Difference, CI = confidence interval. Sham is the reference category

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