Virtual Reality and Noninvasive Brain Stimulation in Stroke: How Effective Is Their Combination for Upper Limb Motor Improvement?—A Meta‐Analysis

Abstract

Background Efforts to augment post‐stroke upper limb (UL) motor improvement include the use of newer interventions such as noninvasive brain stimulation (NIBS) and task practice in virtual reality environments (VEs). Despite increasing interest in using a combination of these 2 interventions, the effectiveness of this combination to enhance UL motor improvement outcomes has not been examined. Objective To evaluate the effectiveness of a combination of NIBS and task practice in a VE to augment post‐stroke UL motor improvement. Methods We conducted a systematic search of the published literature using standard methodology. The Down and Black checklist and the Physiotherapy Evidence Database Research Organization Scale were used to assess study quality. We compared changes in UL impairment and activity levels between active stimulation and sham or other interventions using standardized mean differences and derived a summary effect size. Results We retrieved 5 studies that examined the role of a combination of NIBS and task practice in a VE to optimize UL motor improvement. These 5 studies included 3 randomized controlled trials, 1 cross‐sectional study, and 1 crossover study. There was level 1a evidence that the combination was beneficial in subacute stroke. There was level 1b evidence that provision of real stimulation was not superior to sham stimulation in chronic stroke. Effect sizes favoring the combination were moderate for improvements in UL impairment and small for activity levels. Conclusions Preliminary evidence supports the effectiveness of this combination in subacute stroke. Emergent questions need to be addressed to derive maximum benefit of this combination to augment post‐stroke UL motor improvement. Level of Evidence I

Virtual reality and non-invasive brain stimulation for rehabilitation applications: a systematic review

“…The application of the magnetic fields is carried out by a magnetic coil that is placed near the scalp over the cortical region of interest. TMS can be used in different ways, as single-pulse, repetitive TMS pulses (rTMS) [ 15 , 16 ], or intermittent theta burst stimulation (iTBS) when magnetic pulses are intermittently applied in a specific burst [ 17 ]. NIBS with TMS have been used for the treatment of depression and schizophrenia [ 18 , 19 ], pain [ 18 ], obsessive–compulsive disorder, Parkinson’s disease, epilepsy, task-related dystonia, and tic disorders [ 19 ].…”

Transcranial Magnetic Stimulation Meets Virtual Reality: The Potential of Integrating Brain Stimulation With a Simulative Technology for Food Addiction

“…The authors supported neuromodulation potential in priming the brain prior to other therapies, enhancing clinical outcomes in neurological conditions even though information regarding its frequency and duration are needed. Subramanian and Prasanna (2018) conducted a meta-analysis on the suitability of NIBS-VR combination in post-stroke upper limb motor rehabilitation showing that effectiveness of NIBS varied depending on the stage of the stroke. Studies that employed in the sub-acute stage contralesional cathodal tDCS ( Lee and Chun, 2014 ) and inhibited TMS ( Zheng et al, 2015 ) showed greater improvements.…”

Virtual Reality Meets Non-invasive Brain Stimulation: Integrating Two Methods for Cognitive Rehabilitation of Mild Cognitive Impairment

“…For instance, it has been employed to induce embodiment for an artificial hand (82), to treat spider phobia (83) and in interventions in different populations, such as children with cerebral palsy, post-stroke patients, and healthy people (84). In rehabilitation settings, different studies have investigated the potential of joining VR and transcranial direct current stimulation (tDCS)/TMS for the rehabilitation of the upper limb, one of the most common deficits following a stroke (84)(85)(86)(87)(88)(89). Kim and colleagues (90) found that VR wrist exercise after tDCS had greater immediate and sustained corticospinal facilitation effects than exercise without tDCS and tDCS without exercise.…”