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Optimization of Electrical Stimulation for the Treatment of Lower Limb Dysfunction After Stroke: A Systematic Review and Bayesian Network Meta-Analysis Of Randomized Controlled Trials

Yu Fang, Jiang Li, Shanyu Liu,Yan Wang, Jiaming Li, Dongdong Yang, Qiaoling Wang

Abstract

Objective

To compare the treatment effect of five electrical stimulation methods commonly used in the treatment of stroke patients with lower limb dysfunction.
Methods

We implemented a systematic search of 3915 studies published up to January 2023 from eight databases and two clinical trial registries. First, two independent reviewers critically evaluated trial eligibility according to the inclusion and exclusion criteria. Next, they selected and extracted data. Then, they assessed the risk of bias. Pairwise meta-analysis and Bayesian network meta-analysis were conducted to estimate the effectiveness and ranking of the five electrical stimulation methods.

Introduction

Stroke is a disorder of cerebral blood circulation that can lead to neurological deficits [1, 2]. Previous studies indicated that the proportion of stroke in the global burden of the disease will increase year by year [3]. Stroke holds the characteristics of high incidence rate, high disability rate, high mortality, high recurrence rate, high economic burden and so on [4], which has led to a growing number of elderly people being disabled [5]. Stroke-induced lower limb dysfunction mainly affects the walking ability of patients, 63% of patients lose walking ability in the early post-stroke period and 22% cannot walk independently even after clinical and comprehensive rehabilitative interventions [6]. Lower limb dysfunction not only seriously impacts patients’ daily life but also brings serious mental and economic stress to patients and their families [7]. Therefore, establishing scientific and effective rehabilitation treatment schemes are crucial for such patients.

Materials and methods

This study followed the PRISMA-NMA guidelines [25] (shown in S1 Table). The study has been registered in the Open Science Framework (registration DOI:10.17605/OSF.IO/F3G5Q).

Search strategy

We conducted an exhaustive online search for eligible studies by setting the retrieval time from the establishing date of each database to January 7th, 2023. The literature language was limited within English and Chinese. We searched in eight electronic databases, including China National Knowledge Infrastructure (CNKI), VIP Database for Chinese Technical Periodicals (VIP), WAN FANG Database (WF), Chinese biomedical literature service system (SinoMed), PubMed, Web of Science (WOS), Embase, and Cochrane Library. The clinical trial registries consisted of the International Standard Randomized Controlled Trial Number Register (ISRCTN) and the Chinese Clinical Trial Registry (ChiCTR). The MeSH terms used in this study included: Hemiplegia, Paralysis, Clinical trials as topic, Stroke, Electric Stimulation et al. We set four categories of free words, including (1) Lower limbs, leg, foot; (2) Motor function, Hemiplegia, Dysfunction; (3) Randomized controlled trial, controlled clinical trial, clinical trials; and (4) Stroke, Cerebrovascular Accident, Brain Vascular Accident, etc. For an example, the PubMed search strategies is shown in Table 1, and the search iterms were appropriately adjusted to meet the requirements of each database in order to ensure the basic logical integrity of the search.

Results

Literature study

In this study, we identified and screened titles and abstracts of 3915 studies from 8 databases and 2 clinical trial registries. After the duplication check and preliminary screening by two reviewers, a total of 225 studies meeting the basic requirements were reviewed in full text. Through further screening, 33 RCTs [29, 32–63] meeting all the inclusion criteria were final included in this study. The screening process is illustrated in Fig 1.

In the 33 RCTs included for further analysis, a total of 2246 subjects participated in the trials, of which 51 subjects withdrew for various reasons. Most studies clearly described the type of stroke (Cerebral Infarction or Cerebral Hemorrhage) in the baseline data [29, 32, 33, 35–42, 44–52, 54, 56–61] and the course of stroke [29, 33–44, 46–48, 50, 51–62]. Only 10 trials described the specific stroke stages [29, 36, 42, 50, 52] and Brunnstrom stage [32, 35, 46, 47, 59]. Most of trials provided an accurate description of the age of the subjects (mean age range: 45.10–75.64 years) as well as the gender ratio at the baseline period. Of all 33 trials, a total of 5 trials [29, 32, 37, 48, 61] had three intervention groups with a sample size ratio of 1:1:1, and the remaining studies had two intervention groups with a sample size ratio of 1:1. The details of interventions in included studies can be found in S2 Table.

Discussion

Main findings

In this study, we comprehensively searched studies from 8 databases and 2 clinical trial registries. Then, we performed a Pairwise Meta-Analysis and NMA on the 33 RCTs included in this study. Five frequently-used electrical stimulation methods for patients with limb dysfunction after stroke were selected in the analysis, including FES, TENS, TEAS, NMES, and tDCS. This is the first systematic review and NMA on different electrical stimulation methods in the treatment of lower limb dysfunction after stroke.
The NMA results demonstrated that the electrical stimulation methods combined with RT were more effective than RT. It can be indicated that electrical stimulation methods were capable of improving motor function of the lower limbs. Nevertheless, the treatment effect varied with different electrical stimulation methods

Conclusions

Compared with the method only using RT, the comprehensive treatment schemes combined with electrical stimulation methods presented remarkable superiority in the treatment of lower limb dysfunction after stroke. Meanwhile, the relatively high comprehensive ranking of TDCS or FES could provide new ideas for clinical treatment. Moreover, TEAS combined with acupuncture points exhibited greater treatment potential than conventional TENS. The results of this study provided a basis for further application of electrical stimulation methods. Owing to the limitation of quality and quantity of the included studies, high-quality RCTs are extremely need to offer powerful evidence to further support the results.

Citation: Fang Y, Li J, Liu S, Wang Y, Li J, Yang D, et al. (2023) Optimization of electrical stimulation for the treatment of lower limb dysfunction after stroke: A 
systematic review and Bayesian network meta-analysis of randomized controlled trials. PLoS ONE 18(5): e0285523. https://doi.org/10.1371/journal.pone.0285523

Editor: Victor Afamefuna Egwuonwu, Nnamdi Azikiwe University, NIGERIA

Received: February 15, 2023; Accepted: April 25, 2023; Published: May 11, 2023

Copyright: © 2023 Fang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting information files.

Funding: Supported by “Science and Technology Development Fund of Hospital of Chengdu University of TCM[No.19MZ18]” and “Science and Technology Development Fund of Hospital of Chengdu University of TCM[No.21YS02]”. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0285523#sec029

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