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ORIGINAL RESEARCH ARTICLE Comparison of Different Rehabilitation Techniques of Traditional Chinese and Western Medicine in the Treatment of Motor Dysfunction After Stroke Based on Frequency Method A Network Meta-analysis Ruo Yang Li, MD, Ke-Yu Chen, MM, Xiao-Rong Wang, MM, Qian Yu, MD, and Li Xu, MM Objective: The aim of the study is to evaluate the effect of different What Is Known traditional Chinese and western medicine rehabilitation techniques � As one of the most common sequelae after stroke, on motor dysfunction after stroke using a network meta-analysis. motor dysfunction after stroke (MDAS) has troubled Methods: CNKI, Wanfang, PubMed, Embase, and Cochrane databases many stroke patients. Therefore, rehabilitation tech- were searched from inception to September 2022. We independently nology, as a complementary treatment of conven- searched and screened randomized controlled trials of rehabilitation tional rehabilitation therapy, is gradually favored by techniques for poststroke motor dysfunction treatment, evaluated the the clinical field. However, the advantages and disad- quality, and analyzed the data using Stata 14.0. vantages of different technologies are rarely men- Results: Seventy-four randomized controlled trials involving nine re- tioned. habilitation techniques and 5128 patients were included. The results of What Is New network meta-analysis showed the following orders regarding improve- ment of the total scores of Fugl-Meyer Assessment, Action Research � The findings of the network meta-analysis provide ev- Arm Test, and Berg Balance Scale: biofeedback therapy > mirror ther- idence support that rehabilitation technology is bene- apy > repetitive transcranial magnetic stimulation > acupuncture therapy ficial to patients with MDAS. The results suggest that BT had the best comprehensive effect, while VR was > transcranial direct current stimulation > Taichi > common therapy, the best intervention for improving Action Research virtual reality > transcranial direct current stimulation > repetitive Arm Test and Fugl Meyer Assessment–lower extrem- transcranial magnetic stimulation > mirror therapy > common therapy, ity, and acupuncture therapy has the greatest advan- and acupuncture therapy > virtual reality > neuromuscular electrical tage in improving lower limb balance function. The stimulation > mirror therapy > common therapy > transcranial direct research results may provide some guidance for reha- current stimulation, respectively. bilitation doctors in the treatment of MDAS patients. Conclusions: Biofeedback therapy had the best comprehensive effect, while virtual reality was the best intervention for improving the index of action research arm test and Fugl-Meyer Assessment–lower extrem- and swallowing dysfunction. Motor dysfunction is the most ity. Acupuncture therapy improved lower limb balance function. common sequela of stroke. Undoubtedly, motor dysfunction Key Words: Rehabilitation Techniques, Stroke, after stroke seriously affects the quality of life of patients. Re- Network Meta-analysis ducing patients’ dysfunction, improving their quality of life, and making them return to their families and even to society (Am J Phys Med Rehabil 2023;102:504–512) are issues that should be addressed at the early stage of rehabil- itation medicine, which also conforms to the function-oriented troke is one of the most common diseases in the world, research direction of contemporary rehabilitation medicine. With S causing sequelae and affecting the family life of countless the deepening of clinical research, the excellent efficacy of patients. Dysfunction after stroke includes motor, cognitive, traditional Chinese medicine and western medicine in the From the Hospital of Chengdu University of Traditional Chinese Medicine, Sichuan Province [2021YFS0132], and Department of Science and Chengdu, China (RYL, QY); Department of Rehabilitation Medicine, Sichuan Technology of Sichuan Province [2020YFS0415]) from the Foundation of Academy of Medical Sciences, Sichuan Provincial People’s Hospital, Chengdu, Basic Research. China (RYL, QY, LX); Department of Traditional Chinese Medicine, Chengdu Financial disclosure statements have been obtained, and no conflicts of interest have Second People’s Hospital, Chengdu, China (K-YC); and Second Department been reported by the authors or by any individuals in control of the content of of Geriatrics, Yaan People’s Hospital, Yaan, China (X-RW). this article. All correspondence should be addressed to: Qian Yu, MD, Sichuan Provincial Supplemental digital content is available for this article. Direct URL citations appear People’s Hospital: Sichuan Academy of Medical Sciences and Sichuan People’s in the printed text and are provided in the HTML and PDF versions of this article Hospital, 89669; Li Xu, MM, Sichuan Provincial People’s Hospital: Sichuan on the journal’s Web site (www.ajpmr.com). Academy of Medical Sciences and Sichuan People’s Hospital, No. 32, Section 2, Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. This is West 1st Ring Rd, Qingyang District, Chengdu, Sichuan, 610072, China. an open-access article distributed under the terms of the Creative Commons RYL and QY contributed equally to the study. Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), RYL and X-RW prepared the manuscript. QYand LX revised the manuscript. K-YC where it is permissible to download and share the work provided it is properly and X-RW participated in the data collection. All the authors have read and cited. The work cannot be changed in any way or used commercially without approved the final version of the manuscript. permission from the journal. All relevant data are within the article and its supporting information files. The study was supported by grants (Sichuan Administration of Traditional ISSN: 0894-9115 Chinese Medicine [2016Z001], Department of Science and Technology of DOI: 10.1097/PHM.0000000000002130 504 www.ajpmr.com American Journal of Physical Medicine & Rehabilitation � Volume 102, Number 6, June 2023 Volume 102, Number 6, June 2023 Techniques on MDAS: A Network Meta treatment of motor dysfunction after stroke (MDAS) has been included FMA and its upper extremity motor function scale widely recognized. (FMA-UE), lower extremity motor function (FMA-LE), BBS, To date, some degree of consensus on rehabilitation ther- and ARAT scores. apy for MDAS at home and abroad, which is mainly divided into physical exercise and occupational therapies, has been estab- Study Exclusion lished. In addition, in recent years, many emerging rehabilitation Studies that met the following criteria were excluded: liter- therapies have been developed in modern medicine, such as acu- ature on nonclinical patients, studies with no FMA-related out- puncture therapy (AT), exercise therapy (eg, Baduanjin and Taichi), come indicators, conference papers and master’s and doctoral virtual reality (VR), mirror therapy (MT), biofeedback therapy theses, and repeated published literature. (BT), neuromuscular electrical stimulation (NMES), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS). Several clinical studies and meta- Data Extraction 2–6 analyses have confirmed that the application of these rehabilita- Two staff members conducted an independent evaluation tion therapies can significantly promote the recovery of MDAS, but and cross-comparison of the included studies. The different most relevant trials involve only the clinical treatment research of a opinions were assessed by a third investigator. The basic infor- single rehabilitation therapy, and the advantages and disadvantages mation of the extracted literature included the study’sname, of different therapies are rarely mentioned. Therefore, we con- name and year of publication of the first author, various sample ducted this meta-analysis and adopted the Fugl-Meyer Assessment sizes, patient ages, intervention measures of each group, random (FMA) score, Berg Balance Scale (BBS) score, and Action Re- grouping method, blind method, and outcome data. All outcome search Arm Test (ARAT) score as evaluation indicators and ranked data were included in the difference between before and after their related efficacy based on the surface under the cumulative treatment (ie, the difference between indicators after and before ranking (SUCRA) to comprehensively study the effectiveness of treatment). If the original text is not calculated, we will calculate various physical adjuvant therapies in treating MDAS. This pro- it. The formula is as follows, where corr is usually 0.5: vides strong evidence for the clinical efficacy of physical adjuvant qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi therapy in treating MDAS. 2 2 SD ¼ SD þ SD ðÞ 2 Corr SD SD Echange Ebaseline Efinal Ebaseline Efinal MATERIALS AND METHODS Mean ¼ Mean −Mean Echange Efinal Ebaseline Registration This meta-analysis is registered on international pro- Statistical Analysis spective register of systematic reviews (registration number STATA 14.0 (Stata Corporation, Lakeway, TX) was used CRD42022320020). This study conforms to all Preferred for network meta-analysis. In this study, the outcome indicators Reporting Items for Systematic Reviews and Meta-Analyses (FMA, FMA-UE, FMA-LE, BBS, and ARAT scores) were all guidelines and reports the required information accordingly measured with a unified standard and were continuous vari- (see Supplementary Checklist, Supplemental Digital Content 1, ables; hence, mean difference (MD) and 95% confidence inter- http://links.lww.com/PHM/B872). val (CI) were used as the effect quantity indicators. Stata was used to draw a network diagram of different outcome indica- Literature Search tors. The dots in the evidence network diagram represented The retrieval strategy adopted a combination of subject an intervention, the size of the dots represented the number and free words. Retrieval databases used were PubMed, Embase, of samples finally included in the intervention, lines between Cochrane Library, CNKI, and WANFANG. The retrieval time the two points represented a direct comparison between the ranged from the establishment of the database to September two interventions, and the thickness of the lines represented 2022. Search terms include the following: clinical, motor func- the number of randomized controlled trials using two interven- tion, stroke, acupuncture, mirror therapy, tDCS, Baduanjin, tions simultaneously. The node analysis was used for inconsis- Yijinjing, Tai Chi, etc. See the Supplementary Document (Ap- tency test. If P > 0.05, it indicated that there was no overall in- pendix, Supplemental Digital Content 2, http://links.lww.com/ consistency, and the consistency model was used for analysis. PHM/B873) for detailed retrieval strategy. To evaluate the local inconsistency, this study calculated the in- conformity factors and 95% CI of each closed loop in the net- Study Selection work. This calculation method used the ifplot command in The inclusion criterion was randomized controlled trials. Stata to detect loop inconformity. If the lower limit between The study participants were patients who were clinically diag- 95% confidence regions contained or was close to 0, it indi- nosed with stroke, met the stroke diagnostic criteria of relevant cated that the local comparison, that is, the direct comparison societies, or were identified as having stroke by imaging evi- evidence, was very consistent with the indirect comparison dence. Regarding treatment plan, the control group was treated evidence. Network meta-analysis was performed using Stata, with common therapy (CT) (including routine physical therapy with both direct and indirect estimates. It provided a simultaneous and routine occupational therapy) or single rehabilitation ther- comparison of multiple treatments even if a head-to-head compar- apy, and the treatment group was treated with rehabilitation ison between the two treatment arms was unavailable. The rank- therapies based on routine rehabilitation training, such as AT, ingindex was reflectedbythe SUCRA, where0 ≤ SUCRA Taichi, VR, MT, BT, NMES, rTMS, and tDCS. Outcome measures ≤100%; 100% represented the most effective treatment, and 0 © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. www.ajpmr.com 505 Li et al. Volume 102, Number 6, June 2023 represented the worst and ineffective treatment. Similarly, the mentioned the allocation concealment, 33 studies mentioned larger the area under the curve of the SUCRA chart, the better the single- or double-blind method between participants and sub- the effect of the intervention. jects, one study mentioned that the blind method was not used between participants and subjects, 27 studies described the blind Methodologic Quality method when evaluating data, and 27 studies defined the quantity of abscission. There was a difference in the number of cases The quality of the included studies was evaluated accord- before and after. The remainder of the literature has not been ing to the quality evaluation scale recommended in the Cochrane clearly described. The risk assessment of bias included in the Handbook 5.1.0, including six parts: reporting, detection, per- literature is shown in Figure 1B. formance, selection, loss to follow-up, and other biases. The evaluation content of each part can be judged as high, medium, or low risk according to the standard. Evidence Network A total of 20 studies reported FMA, involving seven reha- RESULTS bilitation therapies. A total of 48 rehabilitation protocols in- volving FMA-UE were reported. A total of 24 studies reported FMA-LE, involving seven rehabilitation therapies. Eight stud- Characteristics of the Included Trials ies reported BBS, involving six rehabilitation therapies. A total A total of 4153 relevant studies were obtained in the pre- of seven studies reported ARAT, involving five therapies. The liminary search, including 385 from CNKI, 770 from Wanfang, line between the two points represented the evidence of a direct 493 from PubMed, 1081 from EMBASE, and 1424 from the comparison between the two therapies. If there was no connec- Cochrane Library. After exclusion of duplicate studies and strictly tion, this indicated that there was no direct comparison, and the adherence to the inclusion and exclusion criteria, 74 randomized 8–81 results could be obtained through indirect comparison. The thick- controlled trials were included. Except for a three-arm ex- 52 ness of the line indicated the number of studies using the two re- periment, all double-arm experiments with a total of 5128 habilitation therapies in all included studies, and the size of the patients. Nine rehabilitation treatment schemes were involved, dots indicated the sample size of the included cases (Fig. 1C). namely, CT, AT,rTMS, Taichi,tDCS, BT,NMES, MT,and VR. The document screening process and results are shown in Figure 1A, and the basic information of the included docu- Inconsistency Test ments is shown in Supplemental Digital Content 3 and 4 (http:// Seven rehabilitation therapies using FMA formed a closed links.lww.com/PHM/B874, http://links.lww.com/PHM/B875, ba- loop. The overall consistency result was P = 0.7639, suggest- sic characteristics of trials included). ing that there was no overall inconsistency. The results showed that the inconsistency factor was 6.13. After treatment, the Risk of Bias eight rehabilitation treatment schemes with FMA-UE formed The included studies were evaluated using the Cochrane two closed loops. The overall consistency results showed Manual 5.1.0 Bias Risk Assessment Tool. All the included P = 0.3320, suggesting that there was no overall inconsistency. studies of bias risk assessment mentioned random allocation, The results showed that the inconsistency factors were 12.07 of which 43 studies described the allocation method, 31 studies and 3.18, respectively. After treatment, the seven rehabilitation FIGURE 1. A, Flow chart of literature screening. B, Risk of bias graph (Ba: risk of bias summary; Bb: risk of bias graph). C, Network diagram (Ca: FMA; Cb: FMA-UE; Cc: FMA-LE; Cd: BBS; Ce: ARAT). 506 www.ajpmr.com © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. Volume 102, Number 6, June 2023 Techniques on MDAS: A Network Meta therapies with FMA-LE formed a closed loop. The overall Fugl-Meyer Assessment–Upper Extremity consistency result was P = 0.7516, suggesting no overall incon- Eight therapies were compared directly and indirectly, and sistency. The results showed an inconsistency factor of 1.68. The four comparisons showed statistically significant differences. 95% CI lower limit of all indicators was 0, indicating that the Compared with CT, AT (MD = 5.96, 95% CI = 3.64 to 8.28), consistency of each closed loop was good, that is, the direct VR (MD = 5.25, 95% CI = 1.89 to 8.62), and BT (MD = 9.45, and indirect comparisons have little difference in the impact of 95% CI = 4.04 to 14.85) could significantly increase the whole mesh meta-analysis results, and the statistical results FMA-UE. Compared with BT, improvement in FMA-UE by of mesh meta-analysis have high reliability. The other two indi- rTMS (MD = −7.31, 95% CI = −14.46 to −0.16) was slightly cators (BBS and ARAT) did not form a closed loop; therefore, worse, and there was no significant difference in other compar- there was no need to conduct a closed-loop inconsistency test isons (Table 2). (Fig. 2A). Fugl-Meyer Assessment–Lower Extremity Network Meta-analysis A total of seven therapies were compared directly and indi- rectly. Acupuncture therapy (MD = 3.35, 95% CI = 1.83 to 4.87) Fugl-Meyer Assessment and VR (MD = 6.05, 95% CI = 1.54 to 10.56) significantly in- Seven rehabilitation therapies were compared directly and creased FMA-LE and had better curative effects than CT. There indirectly, and five were found to be statistically different. were no statistical differences in the other comparisons (Table 2). Compared with the impact on FMA with CT, AT (MD = 8.67, 95% CI = 5.65 to 11.70), rTMS (MD = 10.07, 95% CI = 3.45 Berg Balance Scale to 16.69), BT (MD = 18.45, 95% CI = 8.92 to 27.97), and MT (MD = 12.00, 95% CI = 1.00 to 23.00) could significantly in- Six therapies were compared directly and indirectly, and four crease FMA. Compared with BT, Taichi (MD = −16.58, 95% were found to be statistically different. Compared with CT, AT CI = −30.41 to −2.75) improved the total score of FMA slightly (MD = 9.66, 95% CI = 6.08 to 13.23) and VR (MD = 9.13, less than BT, and there was no statistical difference in other 95% CI = 4.40 to 13.87) could significantly increase BBS. Com- comparisons (Table 1). pared with AT, improvement in BBS by tDCS (MD = −12.16, FIGURE 2. A, Inconsistency (Aa: FMA; Ab: FMA-UE; Ac: FMA-LE). B, Cumulative probability ranking plot (Ba: FMA; Bb: FMA-UE; Bc: FMA-LE; Bd: BBS; Be: ARAT). C, Funnel diagram of FMA-UE (A: CT; B: AT; C: VR; D: MT; E: tDCS; F: BT; G: rTMS; H: NMES). © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. www.ajpmr.com 507 Li et al. Volume 102, Number 6, June 2023 95% CI = −19.66 to −4.66) was slightly worse. Transcranial direct current stimulation (MD = −11.63, 95% CI = −19.75 to −3.52) improved BBS significantly less than did VR. No significant differences were observed in the other comparisons (Table 3). Action Research Arm Test Five rehabilitation therapies were compared directly and in- directly, and one comparison showed a statistical difference. Com- pared with CT, VR (MD = 5.27, 95% CI = 1.96 to 8.58) signif- icantly increased ARAT, and there was no statistical difference in other comparisons (Table 3). Surface Under the Cumulative Ranking According to the results of SUCRA, BT may be the most effective intervention to increase FMA (BT [93.9%] > MT [69.2%] > rTMS [62%] > AT [52.9%] > tDCS [44.4%] > Taichi [19.8%] > CT [7.8%]), BT may be the most effective interven- tion to increase FMA-UE (BT [91.9%] > AT [70.1%] > VR [61.4%] > NMES [59.8%] > tDCS [46.1%] > MT [36.5%] > rTMS [28.5%] > CT [5.7%]), VR may be the most effective intervention to increase FMA-LE (VR [84.8.7%] > NMES [80.5%] > AT [60.6%] > MT [58.5%] > rTMS [28.8%] > tDCS [21.9%] > CT [14.9%]), AT may be the most effective inter- vention to increase BBS (AT [76%] > VR [72.2%] > NMES [66.3%] > MT [50%] > CT [24.2%] > tDCS [11.3%]), and VR may be the most effective intervention to increase ARAT (VR [76.8%] > tDCS [72%] > NMES [43.6%] > MT [39.2%] > CT [18.3%]; Fig. 2B). Publication Bias In this study, the FMA-UE outcome index of the MDAS involved eight different rehabilitation therapies. The dots of dif- ferent colors in the funnel chart represented the direct compari- son between two different therapies, and the number of dots rep- resented the number of studies. Most of the dots in the funnel map of this study were symmetrically distributed on the vertical line and its two sides, which were symmetrical on both sides; however, there may still be a certain degree of publication bias, and 12 control studies were distributed outside the 95% CI in the funnel diagram, suggesting the existence of a small sample effect. There were few experiments of pairwise direct compar- ison between other indexes; hence, bias analysis was not con- ducted (Fig. 2C). DISCUSSION In recent years, bed rehabilitation therapies after stroke have been gradually standardized, and an increasing number of emerg- ing physical technologies have been applied to clinical rehabilita- tion. Based on the analysis method of network meta-analysis, this study summarized the comparative evaluation of the inter- vention effects of eight conventional and emerging rehabilita- tion therapies according to the direct and indirect comparisons between the motor function indices of the upper and lower limbs, combined with the principle of frequency method. Fugl-Meyer Assessment The FMA is a clinical evaluation method that is mainly aimed at determining the degree of poststroke dysfunction. It is a limb function evaluation scale developed by Fugl Meyer, 508 www.ajpmr.com © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. TABLE 1. Network meta-analysis of FMA (MD [95% CI]) Treatment MT tDCS Taichi BT rTMS AT CT MT — tDCS 5.09 (−10.13 to 20.31) — Taichi 10.13 (−4.76 to 25.02) 5.04 (−9.50 to 19.58) — BT −6.45 (−21.00 to 8.11) −11.54 (−25.73to2.66) −16.58 (−30.41 to −2.75) — rTMS 1.93 (−10.91 to 14.77) −3.16 (−15.60to9.28) −8.20 (−20.22 to 3.82) 8.38 (−3.23 to 19.98) — AT 3.33 (−8.08 to 14.74) −1.76 (−12.71to9.19) −6.80 (−17.28 to 3.67) 9.77 (−0.22 to 19.77) 1.40 (−5.77 to 8.57) — a a a a CT 12.00 (1.00 to 23.00) 6.91 (−3.61 to 17.43) 1.87 (−8.16 to 11.90) 18.45 (8.92 to 27.97) 10.07 (3.45 to 16.69) 8.67 (5.65 to 11.70) — The values between the 2 comparisons are statistically significant. Volume 102, Number 6, June 2023 Techniques on MDAS: A Network Meta TABLE 2. Network meta-analysis of FMA-UE and FMA-LE (MD [95% CI]) Network Meta-analysis of FMA-UE Treatment NMES rTMS BT tDCS MT VR AT CT NMES — rTMS 3.46 — (−7.01 to 13.94) BT −3.85 −7.31 — (−14.67 to 6.97) (−14.46 to −0.16) tDCS 1.77 −1.69 5.62 — (−8.53 to 12.07) (−8.03 to 4.64) (−1.27 to 12.51) MT 2.60 −0.86 6.45 0.83 — (−7.47 to 12.67) (−6.80 to 5.08) (−0.08 to 12.98) (−4.26 to 5.92) VR 0.35 −3.12 4.19 −1.43 −2.25 — (−9.62 to 10.31) (−8.89 to 2.65) (−2.18 to 10.56) (−6.86 to 4.01) (−7.23 to 2.73) AT −0.36 −3.82 3.49 −2.13 −2.96 −0.71 — (−10.02 to 9.30) (−8.98 to 1.33) (−2.40 to 9.37) (−6.99 to 2.72) (−7.30 to 1.38) (−4.79 to 3.38) CT 5.60 2.14 9.45 3.83 3.00 5.25 5.96 — a a a (−3.77 to 14.97) (−2.54 to 6.81) (4.04 to 14.85) (−0.44 to 8.10) (−0.67 to 6.67) (1.89 to 8.62) (3.64 to 8.28) The values between the 2 comparisons are statistically significant. according to Brunnstrom’s six-stage theory. The FMA is widely instruments so that patients can intuitively observe the changes used as an outcome index for the recovery of motor function in in muscle potential closely related to their diseases, control patients with stroke. The main limitation of this method is the these physiological changes with their subjective consciousness ceiling effect in patients with stroke with mild hemiplegia. Ac- through intensive training, reduce or increase the corresponding cording to the results of the SUCRA, BTwas the best interven- muscle tension, and relax or strengthen muscle contraction. tion technique for improving the total FMA score. Biofeedback Therefore, it can be used in the clinical treatment of some patients therapy, as a modern physiological scientific instrument, selec- with muscle spasms or paralysis. Although the results of the for- tively converts the normal or abnormal physiological activity est map suggest that except for Taichi therapy, rehabilitation ther- information in the human body into recognizable visual or audi- apies have no significant statistical significance, they still have a tory signals; thus, after a series of intensive training and treat- certain clinical guiding significance. Studies by Zhao et al. ment, it is a new therapy that can consciously self-regulate and and Li et al. have shown that after BT intervention, motor func- control this physiological or pathological information in the tion of the upper and lower limbs of patients with poststroke body, regulate physiological function, eliminate pathological hemiplegia significantly improved. However, as a relatively new state, and restore physical and mental health. It can record rehabilitation technology, BT has limited clinical research. There and display the muscle potential signal through electronic were only two studies involving the total FMA score in the TABLE 3. Network meta-analysis of BBS and ARAT (MD [95% CI]) Network Meta-analysis of BBS Network Meta-analysis of ARAT Treatment NMES MT tDCS VR AT CT Treatment MT VR NMES tDCS CT NMES — MT — MT 2.12 — VR −4.07 — (−3.57 to (−16.13 to 7.81) 7.98) tDCS 10.42 8.30 — NMES −0.86 3.21 — (−8.83 to (−10.09 to (−14.24 to (−4.24 to 29.66) 26.68) 12.52) 10.67) VR −1.22 −3.34 −11.63 — tDCS −3.83 0.25 −2.97 — (−19.91 to (−21.15 to (−19.75 to (−16.79 to (−6.43 to (−11.82 to 17.48) 14.47) −3.52) 9.14) 6.92) 5.89) AT −1.74 −3.86 −12.16 −0.53 — CT 1.20 5.27 2.06 5.03 — (−20.18 to (−21.40 to (−19.66 to (−6.47 to (−10.39 to (1.96 to (−4.62 to (−0.79 to a a 16.69) 13.67) −4.66) 5.42) 12.79) 8.58) 8.74) 10.84) CT 7.92 5.80 −2.50 9.13 9.66 — (−10.17 to (−11.37 to (−9.09 to (4.40 to (6.08 to a a 26.00) 22.96) 4.09) 13.87) 13.23) The values between the 2 comparisons are statistically significant. © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. www.ajpmr.com 509 Li et al. Volume 102, Number 6, June 2023 TABLE 2. (Continued) Network Meta-analysis of FMA-LE Treatment NMES rTMS tDCS VR MT AT CT NMES — rTMS 5.03 — (−2.61 to 12.66) tDCS 6.04 1.01 — (−3.05 to 15.13) (−5.63 to 7.65) VR −0.11 −5.14 −6.15 — (−8.40 to 8.18) (−10.63 to 0.36) (−13.53 to 1.24) MT 2.56 −2.47 −3.48 2.67 — (−3.10 to 8.22) (−7.59 to 2.66) (−10.59 to 3.64) (−3.39 to 8.73) AT 2.59 −2.44 −3.45 2.70 0.03 — (−4.53 to 9.71) (−5.86 to 0.99) (−9.49 to 2.60) (−2.06 to 7.46) (−4.30 to 4.36) CT 5.94 0.91 −0.10 6.05 3.38 3.35 — a a (−1.02 to 12.90) (−2.23 to 4.05) (−5.95 to 5.75) (1.54 to 10.56) (−0.67 to 7.43) (1.83 to 4.87) The values between the 2 comparisons are statistically significant. treatment of MDAS with BT in this study. More high-quality and main index for evaluating upper limb motor function in this large sample size studies are needed to support these results. study (VR was the third-best intervention in terms of improve- ment in FMA-UE), VR had great advantages in improving up- per limb motor function, especially fine motor function. Upper Limbs The results of this study suggest that BT is the best rehabil- itation therapy for improving the FMA-UE score. The FMA-UE Lower Limbs includes 33 items related to proximal and distal movements of the upper limbs. The FMA-UE mainly evaluates reflex activity, mo- The FMA-LE is the most commonly used index for eval- tor control, and muscle strength of the upper limb on the hemiple- uating the motor function of the lower limbs. The scale has 17 gic side. The meta-analysis results of Wang et al. suggested that items and is scored using a three-level scale. The higher the BT is helpful for the functional recovery of the upper limb ner- score, the better the motor function of the lower limb. The vous system in poststroke patients and accelerates their rehabili- SUCRA results in this study suggested that VR was the best in- tation process, which is consistent with the results of this study. tervention method for improving FMA-LE indicators. Some The ARAT is a standard scale for measuring upper limb studies have shown that VR is better than traditional rehabilita- and hand function. The ARAT explains and evaluates upper tion methods for providing the exercise intensity required to in- limb movementsindaily life basedonfourbasic movements. duce neural plasticity. The intervention measures provided by Compared with the movement requirements of FMA-UE, those VR can significantly improve motor function, balance, gait, 69,90–92 of ARAT are more complex, including grasping, kneading, and and depression. gross movement under the shoulder and elbow flexion and ex- The BBS was first reported by Berg. The BBS focuses tension. Therefore, combination evaluation with FMA-UE can more on the evaluation of the balance function of the lower compensate for the ceiling effect of FMA in patients with mild limbs than the FMA-LE. The lower the score, the more serious hemiplegia. In this study, the secondary index for evaluating the balance dysfunction. Therefore, the BBS score is also one upper limb motor function was the ARAT. The results of the of the most commonly used evaluation indices of lower limb SUCRA suggested that VR was the best intervention for improv- function. In this study, AT was an intervention that improved ing this index. The VR game system creates a simulation model BBS score. As one of the representative rehabilitation technol- to make participants feel that the environment is real and allows ogies of traditional Chinese medicine, its efficacy has been them to interact with the dynamic environment created by a com- confirmed in many clinical studies. Its unique advantage is that puter. By creating a stimulating an entertaining environment it can select different acupoints and meridians for syndrome and ensuring patient interest, these systems support motor re- differentiation and treatment according to the limb function covery by activating new motor projection areas and resting characteristics of patients with stroke. Some scholars evaluated synapses. Sensory stimuli at different levels, such as motor ac- the impact of interactive dynamic scalp acupuncture on lower tivities and cognitive planning of movement, lead to permanent limb motor function and gait in patients with stroke with hemi- cellular, anatomical, physiological, and behavioral remodeling plegia, and the results showed that the effect of interactive dy- of the central nervous system. It has been clinically confirmed namic scalp acupuncture on lower limb motor function and that the Brunnstrom stage of patients with stroke after VR tech- walking ability was better than that of routine therapy. To date, nology intervention are significantly higher than those in the medical institutions in many Asian countries use ATas a routine CT group. Combined with the results of the FMA-UE, the rehabilitation therapy in the poststroke rehabilitation stage. 510 www.ajpmr.com © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. Volume 102, Number 6, June 2023 Techniques on MDAS: A Network Meta 5. Zhang L, Xing G, Fan Y, et al: Short- and long-term effects of repetitive transcranial magnetic Limitations stimulation on upper limb motor function after stroke: a systematic review and meta-analysis. This study had some limitations. First, in this study, patients Clin Rehabil 2017;31:1137–53 6. Xie YJ, Chen Y, Tan HX, et al: Repetitive transcranial magnetic stimulation for lower included in the literature were not analyzed by stage or subgroup extremity motor function in patients with stroke: a systematic review and network analysis. There are acute, subacute, and chronic recovery stages meta-analysis. Neural Regen Res 2021;16:1168–76 after a stroke. The rehabilitation methods adopted in each stage 7. Chaimani A, Higgins JP, Mavridis D, et al: Graphical tools for network meta-analysis in were different according to the limb function; thus, it may also af- STATA. PLoS One 2013;8:e76654 8. Ban YC, Lin XX, Geng XX, et al: Effect of acupuncture combined with rehabilitation fect the inconsistency of this study, mainly because there are few technology on upper limb motor dysfunction in the early stage of stroke and magnetic clinical studies on the application of individual emerging rehabil- resonance diffusion tensor imaging. Mod Med J 2019;47:439–42 itation technologies to the staged treatment of poststroke motor re- 9. Chen AL: Clinical study of EMG biofeedback therapeutic instrument in the treatment of habilitation. We look forward to more high-quality clinical studies upper limb motor dysfunction after stroke. Chin J Community Phys 2017;33:147–8 10. Chen H, Cai Q, Xu L, et al: Effect of transcranial direct current stimulation combined with for further verification. Second, most of the literature in this study mirror therapy on upper limb motor function in patients with stroke. did not mention the blind method, random method, and so on, Chin J Rehabil Theory Pract 2020;26:301–5 which may affect the reliability of the study to some extent. Third, 11. Chen QQ, Zhuo J, Tang YQ: Role of mirror therapy in the rehabilitation of lower limb motor function after stroke. Chin J Clin Res 2019;32:979–82 most of the results in this study were positive and a few were neg- 12. Chen WZ, Jia M, Chen DY: Therapeutic effect of acupuncture and moxibustion on limb motor ative. The possibility of a publication bias cannot be ruled out. dysfunction in patients with stroke. Nei Mongol J Tradit Chin Med 2018;37:68–9 In addition, it is worth noting that MDAS is a movement 13. 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American Journal of Physical Medicine & Rehabilitation – Wolters Kluwer Health
Published: Jun 17, 2023
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