Parkwood Institute Research (M.S., G.P., H.S., J.R.S., J.I., R.T.), Parkwood Institute, London, ON.
St. Joseph's Health Care (R.T.), Parkwood Institute, London, ON.
Stroke. 2022 Dec;53(12):3717-3727. doi: 10.1161/STROKEAHA.122.040687. Epub 2022 Oct 14.
Network meta-analysis is a method that can estimate relative efficacy between treatments that may not have been compared directly within the literature. The purpose of this study is to present a network meta-analysis of non-conventional interventions to improve upper extremity motor impairment after stroke.
A literature search was conducted in 5 databases from their inception until April 1, 2021. Terms were used to narrow down articles related to stroke, the upper extremity, and interventional therapies. Randomized controlled trials written in English were eligible if; 50% poststroke patients; ≥18 years old; applied an intervention for the upper extremity, and/or used the Fugl-Meyer upper extremity scale as an outcome measure; the intervention had ≥3 randomized controlled trials with comparisons against a conventional care group; conventional care groups were dose matched for therapy time. A Bayesian network meta-analysis approach was taken to estimate mean difference (MD) and 95% CI.
One hundred seventy-six randomized controlled trials containing 6781 participants examining 20 non-conventional interventions were identified for inclusion within the final model. Eight of the identified interventions proved significantly better than conventional care, with modified constraint induced movement therapy (MD, 6.7 [95% CI, 4.3-8.9]), high frequency repetitive transcranial magnetic stimulation (MD, 5.4 [95% CI, 1.9-8.9]), mental imagery (MD, 5.4 [95% CI, 1.8-8.9]), bilateral arm training (MD, 5.2 [95% CI, 2.2-8.1]), and intermittent theta-burst stimulation (MD, 5.1 [95% CI, 0.62-9.5]) occupying the top 5 spots according to the surface under the cumulative ranking curve.
Overall, it would seem that modified constraint induced movement therapy has the greatest probability of being the most effective intervention, with high-frequency repetitive transcranial magnetic stimulation, mental imagery, and bilateral arm training all having similar probabilities of occupying the next spot in the rankings. We think this analysis can provide a guide for where future resources and clinical trials should be directed, and where a clinician may begin when considering alternative therapeutic interventions.
网络荟萃分析是一种可以估计治疗效果的方法，这些治疗效果可能在文献中没有直接比较过。本研究的目的是对改善脑卒中后上肢运动功能障碍的非传统干预措施进行网络荟萃分析。
在 5 个数据库中进行文献检索，检索时间从建库开始至 2021 年 4 月 1 日。使用特定的检索词对与脑卒中、上肢和干预疗法相关的文章进行了限定。若文章为英语、为脑卒中患者、研究对象年龄≥18 岁、干预措施针对上肢、采用 Fugl-Meyer 上肢量表作为结局指标、至少有 3 项随机对照试验、常规治疗组的治疗时间相匹配，则符合纳入标准。采用贝叶斯网络荟萃分析方法来估计均数差值（MD）和 95%置信区间。
最终模型中纳入了 176 项随机对照试验，共 6781 名参与者，涉及 20 种非传统干预措施。其中 8 种干预措施明显优于常规治疗，改良强制性运动疗法（MD，6.7[95%CI，4.3-8.9]）、高频重复经颅磁刺激（MD，5.4[95%CI，1.9-8.9]）、心理意象（MD，5.4[95%CI，1.8-8.9]）、双侧上肢训练（MD，5.2[95%CI，2.2-8.1]）和间歇性经颅磁刺激（MD，5.1[95%CI，0.62-9.5]）排名前五。
总体而言，改良强制性运动疗法似乎最有可能成为最有效的干预措施，高频重复经颅磁刺激、心理意象和双侧上肢训练都有可能占据排名中的下一个位置。我们认为，这种分析可以为未来的资源和临床试验指明方向，也可以为临床医生在考虑替代治疗干预措施时提供参考。
