Non-invasive neuromodulation combined with rehabilitation therapy improves balance and gait speed in patients with stroke: A Systematic Review and Network Meta-analysis.

OBJECTIVE:This study aimed to determine repetitive transcranial magnetic stimulation [rTMS], transcranial direct current stimulation [tDCS], and cranial nerve noninvasive neuromodulation [CN-NINM] affect functional balance, gait speed, and walking cadence in stroke patients. METHODS:We searched PUBMED, EMBASE, COCHRANE, and SCOPUS (June 22, 2022) for randomized controlled trials. Three reviewers independently performed data extraction and assessed the risk of bias. Network and pair-wise meta-analyses were performed to assess indirect and direct comparisons. RESULTS:We included 34 studies (n = 915 patients). Sixty percent had moderate-to-high methodological quality. The meta-analyses showed positive effects of rTMS combined with rehabilitation therapy compared to sham on gait speed, walking cadence, and balance function with weighted mean differences and 95% confidence interval of 0.08, [0.03-0.13]; 7.16, [3.217-11.103]; and 3.05, [0.52-5.57], respectively. tDCS showed improvement on the time up and go (TUG) test (-0.88, [-1.68--0.08]). From the SUCRA analyses, rTMS is the best ranked treatment for gait speed and functional balance improvement compared to tDCS and sham interventions. There were not enough studies to include CN-NINM in the meta-analysis. CONCLUSIONS:Walking cadence and speed, functional balance significantly improved after rTMS with short-term effects, which were superior to that of tDCS and sham treatments. tDCS showed short-term beneficial effects on the TUG test.