EVIDENCE BASED

APPROACH FOR USE

OF NIBS IN STROKE
REHABILITATION

ARPAN DOBARIYA [MPT-II]

GUIDE - Dr. AARTI
PANCHAL
 INTRODUCTION

OBJECTIVE

CONTENT
METHODOLOGY & APPRAISAL

CONCLUSION & TAKE HOME MESSAGE

 Part One

INTRODUCTION
 NON INVASIVE BRAIN STIMULATION
REPETITIVE TRANSCRANIAL
MAGNETIC STIMULATION
TMS provides a way to induce electrical current in the
brain without the need for invasive surgery. It involves
passing an electric current through conductive wires of
an insulated coil to induce a local magnetic field, which
transfers energy across the skull to induce a secondary
electric current in the brainuse of TMS as a therapeu-
tic tool is the development of repetitive TMS (rTMS)
When TMS pulses are applied in rapid succession, the
underlying cortex has a more sustained alteration in
excitability
TRANSCRANIAL DIRECT CURRENT
STIMULATION
tDCS involves the application of a low-amplitude,
direct current (typically 0.5–2 mA) to the scalp via
electrodes. Electric current flows from the negatively
charged cathode to the positively charged anode,
penetrating the skull and modifying neuronal trans-
membrane potentials in the current path. The effect is
to modulate the excitability of a given region and alter
the probability of firing an action potential
Part Two

OBJECTIVE
 Reserch
question
 OBJECTIVE

To compare effectiveness of rTMS and

tDCS on motor function in patients with
stroke
 Part Three
METHODOLOGY &
APPRAISAL
 Methodology

Database Keywords
PUBMED NIBS or Brain Stimulation AND
COCHRANE stroke or hemiplegia
SCHOLAR

P - STROKE
O- motor component I - tDCS and rTMS
both
 SELECTION CRITERIA

STUDY TYPE
PUBLISHED YEAR
Meta analysis
2018-2022
ANALYSIS
Individual rTMS and tDCS
analysis

APPRAISAL TOOL - AMSTAR -II CHECKLIST

 Appraisal - I

Title Functional Balance and Postural Control Improvements in Patients with Stroke after
Non-Invasive Brain Stimulation: A Meta-Analysis

Methodology The meta-analysis included 18 (n-503) studies that used either repetitive transcranial
magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) for the
recovery of functional balance and postural control post stroke. All included studies used
either randomized control trial or crossover designs with a sham control group. 9 studies used rTMS and
9 studies used tDCS. Meta analysis done for tDCS and rTMS separately. For acute , subacute and
chronic condition, analysis done separately.

Result - these treatment

effects were only significant in rTMS across acute/subacute and chronic stroke patients
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 post stroke. rTMS can be use for improvement
in functional balance and Postural Control. High definition tDCS can be also use for same but
Conventional tDCS is not having significant effect.
 Appraisal - II

Title Non-invasive brain stimulation for fine motor improvement after

stroke: a meta-analysis (2018)

Methodology Twenty-nine studies (351 patients &152 healthy subjects) were reviewed which had outcome measure
of hand function. 14 studies used tDCS and 10 studies used rTMS. 5 studies was on healthy individual.
Effect size calculation done by hedge's g.

Result effect size for tDCS is 0.31 and for rTMS is 0.46. results show that NIBS is associated with gains in fine
motor performance in chronic stroke patients and healthy subjects. This supports the effects of NIBS on
motor learnings
 Appraisal - III

Title Noninvasive brain stimulation combined with other therapies improves gait speed after stroke: a
systematic review and meta-analysis (2019)

Methodology Eligibility criteria were randomized controlled trials that reported the effects of tDCS and
rTMS combined with other therapies for improving gait speed, walking cadence after stroke. Risk of
bias was assessed by Cochrane
risk of bias assessment tool. Mean differences (MD) and 95% confidence intervals were
calculated.quaity of evidence was assessed by GRADE tool. Ten studies (226 subjects) were included in
the meta-analysis. 3 studies used rTMS while 7 studies used tDCS as intervention.

Result rTMS is having significant effect on gait speed and cadance combined with other intervention while
tDCS is not having significant effect on same.
 Appraisal - IV

Title Short-term Effect of Noninvasive Brain Stimulation Techniques on Motor Impairment in

Chronic Ischemic Stroke: A Systematic Review with Meta-Analysis

Methodology four studies included in this study out of which 2 had tDCS and 2 had rTMS as intervention. Outcome
measure was upper extremity or hand functionality. Both international meta analysis done separately.

Result tDCS shows non significant improvement as compare to sham tDCS. rTMS Shows significant
improvement . Both study had high homogeneity.
 Appraisal - V

Title Non-invasive brain stimulation for improving

gait, balance, and lower limbs motor function
in stroke (2022)
Methodology 25 studies (n-657) selected for this study. 16 studies used tDCS as intervention while 9 studies used
rTMS as intervention. Gait, balance and lower limb function was outcome measure. Meta analysis done
for tDCS and rTMS separately with post intervention and follow up duration along with type of
stimulation.

Result study concluded tDCS is having batter effect then rTMS and both hemisphere stimulation gives batter
effect then one side cortex stimulation on gait and balance.
 AMSTAR - II

CA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

I ✅ ✅ ✅ ✅ ✅ ❌ ✅ ✅ ✅ ❌ ✅ ✅ ✅ ❌ ✅ ✅

II ✅ ✅ ✅ ✅ ✅ ❌ ✅ ✅ ❌ ❌ ✅ ✅ ✅ ✅ ✅ ✅

III ✅ ✅ ✅ ✅ ✅ ✅ ✅ ✅ ✅ ❌ ✅ ❌ ✅ ✅ ❌ ✅

IV ✅ ✅ ✅ ✅ ❌ ❌ ✅ ✅ ❌ ❌ ✅ ❌ ❌ ❌ ❌ ✅

V ✅ ✅ ✅ ✅ ✅ ❌ ✅ ✅ ❌ ❌ ✅ ❌ ❌ ✅ ❌ ✅
 Part Four
Conclusion & Take
Home Message
A Effectiveness

B
Cost efficiency

C
Usability
THANK YOU

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