Transcranial magnetic stimulation combined with upper-limb training for improving function after stroke: A systematic review and meta-analysis

Background: Several neuromodulation treatments have been developed, and their effects have been studied in recent years in order to improve neurological rehabilitation after a stroke. The association between upper-limb training and repetitive transcranial magnetic stimulation (rTMS) has provoked controversies and produced inconclusive results. Objective: The purpose of this study was to investigate the effects of rTMS combined with upper-limb training versus sham rTMS combined with upper-limb training on the upper-limb recovery after a stroke. Methods: A systematic review with meta-analysis was performed. The eligible studies were randomized controlled trials with stroke subjects, and the outcomes were related to upper-limb motor/functional status and spasticity. Results: A total of 3234 citations were identified, and 11 studies were included. The meta-analysis included eight studies with 199 participants and did not show any difference between groups, neither for upper-limb function nor for spasticity (upper-limb function [0.03 (95% CI: -025 to 032;I-2 0%)] and Modified Ashworth Scale [-0.31 (95% CI: 0.78 to 0.17; I-2 43%)]). Conclusion: The current state of the literature is not enough to support the hypothesis that a combination of rTMS and upper-limb training has a stronger effect on upper-limb function than upper-limb training alone. (C) 2016 Elsevier B.V. All rights reserved.