Noninvasive neuromodulation for unilateral neglect after stroke: a systematic review and network meta-analysis

Objective To systematically evaluate the effect of noninvasive neuromodulation (NINM) on unilateral neglect (UN) after stroke and compare the effects of different NINMs. Methods Randomized controlled trials (RCTs) on the effect of NINM on UN after stroke were retrieved from the PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and CBM databases from inception to January 2022. The risk of bias and quality of the trials were assessed following the Cochrane Handbook of Systematic Reviews and the physiotherapy evidence database PEDro Scale. Statistical analysis was conducted with Stata 16.0 and R 4.0.2. This study was registered on PROSPERO (No. CRD42021295336). Results A total of 12 RCTs involving 291 patients were included. Meta-analysis showed that NINM could reduce the line bisection test (LBT) score (SMD= -1.56, 95% CI -2.10 similar to -1.03, P < 0.05), the line cancellation test score (SMD= -1.83, 95% CI - 2.39 similar to -1.27, P < 0.05), and the star cancellation test score (SMD = -2.85, 95% CI - 4.93 similar to -0.76, P < 0.05). Network meta-analysis showed that the best probabilistic ranking of the effects of different NINMs on the LBT score was theta-burst stimulation (TBS) (P = 0.915) > repetitive transcranial magnetic stimulation (P = 0.068) > transcranial direct current stimulation (P = 0.018). Conclusion Existing evidence showed that NINM could improve UN after stroke and that TBS was best. Due to the number of included studies and sample size, more large-sample, multicenter, double-blinded, high-quality clinical RCTs are still needed in the future to further confirm the results of this research.