Repetitive peripheral magnetic stimulation for impairment and disability in people after stroke

Tomohiko Kamo; Yoshitaka Wada; Masatsugu Okamura; Kotomi Sakai; Ryo Momosaki; Shunsuke Taito

doi:10.1002/14651858.CD011968.pub4

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1: rPMS versus sham, Outcome 1: Muscle strength at the end of treatment

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Analysis 2.1

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 1: Activities of daily living at the end of treatment

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Analysis 2.2

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 2: Activities of daily living at the end of follow‐up

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Analysis 2.3

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 3: Upper limb function at the end of treatment

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Analysis 2.4

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 4: Upper limb function at the end of follow‐up

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Analysis 2.5

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 5: Spasticity of the elbow at the end of treatment

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Analysis 2.6

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 6: Spasticity of the elbow at the end of follow‐up

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Analysis 2.7

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 7: Spasticity of the wrist at the end of treatment

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Analysis 2.8

Comparison 2: rPMS plus rehabilitation versus sham plus rehabilitation, Outcome 8: Spasticity of the wrist at the end of follow‐up

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Summary of findings 1. Active rPMS only compared with sham rPMS in stroke

Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Active rPMS only compared with sham rPMS in stroke
Patient or population: people with stroke Setting: not reported Intervention: active rPMS Comparison: sham rPMS
Outcomes	Risk with sham rPMS	Risk with rPMS	Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Activities of daily living (ADLs) assessed with Barthel Index Scale, from 0 to 100	‐	‐	See comment	‐	‐	No trials measured this outcome.
Upper limb function assessed with Fugl‐Meyer Assessment Scale, from 0 to 66	‐	‐	See comment	‐	‐	No trials measured this outcome.
Lower limb function	‐	‐	See comment	‐	‐	No trials measured this outcome.
Spasticity (elbow) assessed with Modified Tardieu Scale, from 0 to 5	‐	‐	See comment	‐	‐	No trials measured this outcome.
Spasticity (wrist) assessed with Modified Tardieu Scale, from 0 to 5	‐	‐	See comment	‐	‐	No trials measured this outcome.
Muscle strength assessed with dorsiflexion strength	Mean muscle strength 10.44 kg	MD 3 kg higher (2.44 lower to 8.44 higher)	‐	18 (1 RCT)	⊕⊕⊝⊝ Low^a
Death	‐	‐	See comment	‐	‐	No trials reported this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; RCT: randomised controlled trial; rPMS: repetitive peripheral magnetic stimulation.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to the estimate of effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of effect but may be substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aOne study with small sample size; 95% CI overlaps zero.

Summary of findings 1. Active rPMS only compared with sham rPMS in stroke

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Summary of findings 2. Active rPMS only compared with no intervention in stroke

Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Active rPMS only compared with no intervention in stroke
Patient or population: people with stroke Setting: not available Intervention: active rPMS Comparison: no intervention
Outcomes	Risk with no intervention	Risk with rPMS	Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Activities of daily living (ADLs) assessed with Barthel Index Scale, from 0 to 100	‐	‐	See comment	‐	‐	No trials measured this outcome.
Upper limb function assessed with Fugl‐Meyer Assessment Scale, from 0 to 66	‐	‐	See comment	‐	‐	No trials measured this outcome.
Lower limb function	‐	‐	See comment	‐	‐	No trials measured this outcome.
Spasticity (elbow) assessed with Modified Tardieu Scale, from 0 to 5	‐	‐	See comment	‐	‐	No trials measured this outcome.
Spasticity (wrist) assessed with Modified Tardieu Scale, from 0 to 5	‐	‐	See comment	‐	‐	No trials measured this outcome.
Muscle strength assessed with dorsiflexion strength	‐	‐	See comment	‐	‐	No trials measured this outcome.
Death	‐	‐	See comment	‐	‐	No trials measured this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI). CI: confidence interval; rPMS: repetitive peripheral magnetic stimulation.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to the estimate of effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of effect but may be substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Summary of findings 2. Active rPMS only compared with no intervention in stroke

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Summary of findings 3. Active rPMS plus rehabilitation compared with sham rPMS plus rehabilitation in stroke

Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Active rPMS plus rehabilitation compared with sham rPMS plus rehabilitation in stroke
Patient or population: people with stroke Setting: neurological rehabilitation hospital Intervention: active rPMS plus rehabilitation Comparison: sham rPMS plus rehabilitation
Outcomes	Risk with sham rPMS plus rehabilitation	Risk with active rPMS plus rehabilitation	Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Activities of daily living (ADLs) assessed with Barthel Index Scale, from 0 to 100	Mean ADL score 50	MD 3 lower (16.35 lower to 10.35 higher)	‐	63 (1 RCT)	⊕⊕⊝⊝ Low^a
Upper limb function assessed with Fugl‐Meyer Assessment Scale, from 0 to 66	Mean upper limb function score 13	MD 2 higher (4.91 lower to 8.91 higher)	‐	63 (1 RCT)	⊕⊕⊝⊝ Low^a
Lower limb function	‐	‐	See comment	‐	‐	No trials measured this outcome.
Spasticity (elbow) assessed with Modified Tardieu Scale, from 0 to 5	Mean spasticity (elbow) score 1.41	MD 0.41 lower (0.89 lower to 0.07 higher)	‐	63 (1 RCT)	⊕⊕⊝⊝ Low^a
Spasticity (wrist) assessed with Modified Tardieu Scale, from 0 to 5	Mean spasticity (wrist) score 2.13	MD 0.2 lower (0.76 lower to 0.36 higher)	‐	63 (1 RCT)	⊕⊕⊝⊝ Low^a
Muscle strength assessed with dorsiflexion strength	‐	‐	See comment	‐	‐	No trials measured this outcome.
Death	‐	‐	See comment	‐	‐	No trials measured this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; RCT: randomised controlled trial; rPMS: repetitive peripheral magnetic stimulation.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to the estimate of effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of effect but may be substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aOne study with small sample size; 95% CI overlaps zero.

Summary of findings 3. Active rPMS plus rehabilitation compared with sham rPMS plus rehabilitation in stroke

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Summary of findings 4. Active rPMS plus rehabilitation compared with rehabilitation only in stroke

Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Active rPMS plus rehabilitation compared with rehabilitation only in stroke
Patient or population: people with stroke Setting: not available Intervention: active rPMS plus rehabilitation Comparison: rehabilitation only
Outcomes	Risk with rehabilitation only	Risk with active rPMS plus rehabilitation	Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Activities of daily living (ADLs) assessed with Barthel Index Scale, from 0 to 100	‐	‐	See comment	‐	‐	No trials measured this outcome.
Upper limb function assessed with Fugl‐Meyer Assessment Scale, from 0 to 66	‐	‐	See comment	‐	‐	No trials measured this outcome.
Lower limb function	‐	‐	See comment	‐	‐	No trials measured this outcome.
Spasticity (elbow) assessed with Modified Tardieu Scale, from 0 to 5	‐	‐	See comment	‐	‐	No trials measured this outcome.
Spasticity (wrist) assessed with Modified Tardieu Scale, from 0 to 5	‐	‐	See comment	‐	‐	No trials measured this outcome.
Muscle strength assessed with dorsiflexion strength	‐	‐	See comment	‐	‐	No trials measured this outcome.
Death	‐	‐	See comment	‐	‐	No trials measured this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI). CI: confidence interval; rPMS: repetitive peripheral magnetic stimulation.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to the estimate of effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of effect but may be substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Summary of findings 4. Active rPMS plus rehabilitation compared with rehabilitation only in stroke

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Comparison 1. rPMS versus sham

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Muscle strength at the end of treatment Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

Comparison 1. rPMS versus sham

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Comparison 2. rPMS plus rehabilitation versus sham plus rehabilitation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Activities of daily living at the end of treatment Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.2 Activities of daily living at the end of follow‐up Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.3 Upper limb function at the end of treatment Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.4 Upper limb function at the end of follow‐up Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.5 Spasticity of the elbow at the end of treatment Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.6 Spasticity of the elbow at the end of follow‐up Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.7 Spasticity of the wrist at the end of treatment Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.8 Spasticity of the wrist at the end of follow‐up Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

Comparison 2. rPMS plus rehabilitation versus sham plus rehabilitation

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