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Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke.

Abstract

BACKGROUND

Stroke is one of the leading causes of disability worldwide. Functional impairment resulting in poor performance in activities of daily living (ADLs) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance and function after stroke, but a possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability and hence to improve ADL performance and function.

OBJECTIVES

To assess the effects of tDCS on generic activities of daily living (ADLs) and motor function in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, May 2013), MEDLINE (1948 to May 2013), EMBASE (1980 to May 2013), CINAHL (1982 to May 2013), AMED (1985 to May 2013), Science Citation Index (1899 to May 2013) and four additional databases. In an effort to identify further published, unpublished and ongoing trials, we searched trials registers and reference lists, handsearched conference proceedings and contacted authors and equipment manufacturers.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) and randomised controlled cross-over trials (from which we analysed only the first period as a parallel-group design) that compared tDCS versus control in adults with stroke for improving ADL performance and function.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality (JM and MP) and extracted data (BE and JM). If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports.

MAIN RESULTS

We included 15 studies involving a total of 455 participants. Analysis of six studies involving 326 participants regarding our primary outcome, ADL, showed no evidence of an effect in favour of tDCS at the end of the intervention phase (mean difference (MD) 5.31 Barthel Index (BI) points; 95% confidence interval (CI) -0.52 to 11.14; inverse variance method with random-effects model), whereas at follow-up (MD 11.13 BI points; 95% CI 2.89 to 19.37; inverse variance method with random-effects model), we found evidence of an effect. However, the confidence intervals were wide and the effect was not sustained when only studies with low risk of bias were included. For our secondary outcome, upper limb function, we analysed eight trials with 358 participants, which showed evidence of an effect in favour of tDCS at the end of the intervention phase (MD 3.45 Upper Extremity Fugl-Meyer Score points (UE-FM points); 95% CI 1.24 to 5.67; inverse variance method with random-effects model) but not at the end of follow-up three months after the intervention (MD 9.23 UE-FM points; 95% CI -13.47 to 31.94; inverse variance method with random-effects model). These results were sensitive to inclusion of studies at high risk of bias. Adverse events were reported and the proportions of dropouts and adverse events were comparable between groups (risk difference (RD) 0.00; 95% CI -0.02 to 0.03; Mantel-Haenszel method with random-effects model).

AUTHORS' CONCLUSIONS

At the moment, evidence of very low to low quality is available on the effectiveness of tDCS (anodal/cathodal/dual) versus control (sham/any other intervention) for improving ADL performance and function after stroke. Future research should investigate the effects of tDCS on lower limb function and should address methodological issues by routinely reporting data on adverse events and dropouts and allocation concealment, and by performing intention-to-treat analyses.

Authors+Show Affiliations

Department of Public Health, Dresden Medical School, Technical University Dresden, Fetscherstr. 74, Dresden, Sachsen, Germany, 01307.No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

Language

eng

PubMed ID

24234980

Citation

Elsner, Bernhard, et al. "Transcranial Direct Current Stimulation (tDCS) for Improving Function and Activities of Daily Living in Patients After Stroke." The Cochrane Database of Systematic Reviews, 2013, p. CD009645.
Elsner B, Kugler J, Pohl M, et al. Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. Cochrane Database Syst Rev. 2013.
Elsner, B., Kugler, J., Pohl, M., & Mehrholz, J. (2013). Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. The Cochrane Database of Systematic Reviews, (11), CD009645. https://doi.org/10.1002/14651858.CD009645.pub2
Elsner B, et al. Transcranial Direct Current Stimulation (tDCS) for Improving Function and Activities of Daily Living in Patients After Stroke. Cochrane Database Syst Rev. 2013 Nov 15;(11)CD009645. PubMed PMID: 24234980.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. AU - Elsner,Bernhard, AU - Kugler,Joachim, AU - Pohl,Marcus, AU - Mehrholz,Jan, Y1 - 2013/11/15/ PY - 2013/11/16/entrez PY - 2013/11/16/pubmed PY - 2014/5/21/medline SP - CD009645 EP - CD009645 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev IS - 11 N2 - BACKGROUND: Stroke is one of the leading causes of disability worldwide. Functional impairment resulting in poor performance in activities of daily living (ADLs) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance and function after stroke, but a possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability and hence to improve ADL performance and function. OBJECTIVES: To assess the effects of tDCS on generic activities of daily living (ADLs) and motor function in people with stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, May 2013), MEDLINE (1948 to May 2013), EMBASE (1980 to May 2013), CINAHL (1982 to May 2013), AMED (1985 to May 2013), Science Citation Index (1899 to May 2013) and four additional databases. In an effort to identify further published, unpublished and ongoing trials, we searched trials registers and reference lists, handsearched conference proceedings and contacted authors and equipment manufacturers. SELECTION CRITERIA: We included only randomised controlled trials (RCTs) and randomised controlled cross-over trials (from which we analysed only the first period as a parallel-group design) that compared tDCS versus control in adults with stroke for improving ADL performance and function. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality (JM and MP) and extracted data (BE and JM). If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports. MAIN RESULTS: We included 15 studies involving a total of 455 participants. Analysis of six studies involving 326 participants regarding our primary outcome, ADL, showed no evidence of an effect in favour of tDCS at the end of the intervention phase (mean difference (MD) 5.31 Barthel Index (BI) points; 95% confidence interval (CI) -0.52 to 11.14; inverse variance method with random-effects model), whereas at follow-up (MD 11.13 BI points; 95% CI 2.89 to 19.37; inverse variance method with random-effects model), we found evidence of an effect. However, the confidence intervals were wide and the effect was not sustained when only studies with low risk of bias were included. For our secondary outcome, upper limb function, we analysed eight trials with 358 participants, which showed evidence of an effect in favour of tDCS at the end of the intervention phase (MD 3.45 Upper Extremity Fugl-Meyer Score points (UE-FM points); 95% CI 1.24 to 5.67; inverse variance method with random-effects model) but not at the end of follow-up three months after the intervention (MD 9.23 UE-FM points; 95% CI -13.47 to 31.94; inverse variance method with random-effects model). These results were sensitive to inclusion of studies at high risk of bias. Adverse events were reported and the proportions of dropouts and adverse events were comparable between groups (risk difference (RD) 0.00; 95% CI -0.02 to 0.03; Mantel-Haenszel method with random-effects model). AUTHORS' CONCLUSIONS: At the moment, evidence of very low to low quality is available on the effectiveness of tDCS (anodal/cathodal/dual) versus control (sham/any other intervention) for improving ADL performance and function after stroke. Future research should investigate the effects of tDCS on lower limb function and should address methodological issues by routinely reporting data on adverse events and dropouts and allocation concealment, and by performing intention-to-treat analyses. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/24234980/Transcranial_direct_current_stimulation__tDCS__for_improving_function_and_activities_of_daily_living_in_patients_after_stroke_ L2 - https://doi.org/10.1002/14651858.CD009645.pub2 DB - PRIME DP - Unbound Medicine ER -