Estimulação cerebral não-invasiva para negligência espacial unilateral após acidente vascular cerebral: uma revisão sistemática de ensaios clínicos randomizados e não-randomizados.
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Data
2017-12-08
Autores
Kashiwagi, Flávio Taira
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Universidade Estadual Paulista (Unesp)
Resumo
Objetivo: Uma revisão sistemática para investigar o impacto da estimulação cerebral não-invasivas (i.e., estimulação transcraniana de corrente direta (ETCC), estimulação magnética transcraniana repetitiva (EMTr) e Theta-Burst (TBS)) em comparação com placebo para negligência espacial unilateral após acidente vascular encefálico (NEU). Bases de dados: Pesquisas na MEDLINE, EMBASE, CENTRAL, CINAHL e LILACS até julho de 2017. Seleção de estudos: Ensaios controlados randomizados (ECRs) e não-ECRs. Extração de dados: Dois pares de revisores examinaram de forma independente artigos potencialmente elegíveis, extraíram dados dos estudos incluídos sobre populações, intervenções e resultados e avaliaram seu risco de viés. Utilizamos a abordagem GRADE para avaliar a certeza geral da evidência por resultado. Síntese de dados: 12 ensaios randomizados, incluindo 273 participantes, e quatro não- ECRs, incluindo 94 participantes, mostraram ser elegíveis. Os resultados fornecidos pelos ECR sugerem um benefício no NEU geral medido pelo Teste de Bissecção de Linhas com estimulação cerebral não invasiva em comparação com placebo (SMD – 2,35, IC 95% -3,72, -0,98; p = 0,0001; I2 = 85%); particularmente a EMTr produziu resultados que foram consistentes com a meta-análise geral (SMD -2,82, IC 95% -3,66, -1,98; p = 0,09; I2 = 0%). Os resultados de dois ECRs que comparam o EMTr com placebo também sugeriram um benefício no NEU geral medido pelo Motor Free Perception Test com EMTr 1Hz(SMD 1,46, IC 95% 0,73, 2,20; p <0,0001; I2 = 0%). Houve também um benefício no NEU global medido pelo Teste de Albert e Teste de Cancelamento de Linha com rTMS de 1 Hz em comparação com placebo (SMD 2,04, IC 95% 1,14, 2,95; p <0,0001; I2 = não aplicável). Os resultados também sugerem um possível melhora nas atividades da vida diária com EMTr de 10 Hz em comparação com placebo (SMD 1,83, IC 95% 0,68, 2,97; p = 0,002; I2 = não aplicável). Conclusões: Evidências de qualidade moderada mostram que o EMTr, com 1 Hz é mais eficaz que o placebo para negligência espacial unilateral após o AVC medido pelo Motor Free Perception Test. Além disso, evidências de baixa qualidade também sugerem um benefício da estimulação cerebral não-invasiva, particularmente com o uso de EMTr, para o NEU medido pelo Teste de Bissecção de Linha, Teste de Albert e Teste de Cancelamento de Linha. Esses achados devem ser explorados ainda mais no contexto da prática clínica entre neurologistas e fisioterapeutas.
Objective: A systematic review to investigate the impact of non-invasive brain stimulations (i.e., transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and theta-burst (TBS)) compared to sham for unilateral spatial neglect after stroke. Data sources: Searches of MEDLINE, EMBASE, CENTRAL, CINAHL, and LILACS up to July 2017. Study selection: Randomized controlled trials (RCTs) and non-RCTs. Data extraction: Two pairs of reviewers independently screened potentially eligible articles, extracted data from included studies on populations, interventions and outcomes, and assessed their risk of bias. We used the GRADE approach to rate overall certainty of the evidence by outcome. Data synthesis: 12 randomized trials including 273 participants, and four non-RCTs including 94 participants proved eligible. Results provided by RCTs suggest a benefit in overall USN measured by Line Bisection Test with non-invasive brain stimulations in comparison to sham (SMD -2.35, 95% CI -3.72, -0.98; p = 0.0001; I2=85%); particularly the rTMS yielded results that were consistent with the overall meta-analysis (SMD -2.82, 95% CI -3.66, -1.98; p = 0.09; I2=0%). Results from two RCTs comparing rTMS with sham also suggested a benefit in overall USN measured by Motor Free Visual Perception Test with 1 Hz (SMD 1.46, 95% CI 0.73, 2.20; p < 0.0001; I2=0%). There was also a benefit in overall USN measured by Albert test and Line crossing test with 1 Hz rTMS compared to sham (SMD 2.04, 95% CI 1.14, 2.95; p <0.0001; I2=not applicable). Results also suggest a possible increase in daily life functions with 10 Hz rTMS compared to sham (SMD 1.83, 95% CI 0.68, 2.97; p =0.002; I2=not applicable). Conclusions: Moderate-quality evidence shows that rTMS, with 1 Hz, is more efficacious compared to sham for unilateral spatial neglect after stroke measured by Motor Free Visual Perception Test. Furthermore, low-quality evidence also suggests a benefit of non-invasive brain stimulation, particularly with the use of rTMS, for overall USN measured by Line Bisection Test, Albert test and Line crossing test. These findings should be explored further in the context of the clinical practice among neurologists and physiotherapists.
Objective: A systematic review to investigate the impact of non-invasive brain stimulations (i.e., transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and theta-burst (TBS)) compared to sham for unilateral spatial neglect after stroke. Data sources: Searches of MEDLINE, EMBASE, CENTRAL, CINAHL, and LILACS up to July 2017. Study selection: Randomized controlled trials (RCTs) and non-RCTs. Data extraction: Two pairs of reviewers independently screened potentially eligible articles, extracted data from included studies on populations, interventions and outcomes, and assessed their risk of bias. We used the GRADE approach to rate overall certainty of the evidence by outcome. Data synthesis: 12 randomized trials including 273 participants, and four non-RCTs including 94 participants proved eligible. Results provided by RCTs suggest a benefit in overall USN measured by Line Bisection Test with non-invasive brain stimulations in comparison to sham (SMD -2.35, 95% CI -3.72, -0.98; p = 0.0001; I2=85%); particularly the rTMS yielded results that were consistent with the overall meta-analysis (SMD -2.82, 95% CI -3.66, -1.98; p = 0.09; I2=0%). Results from two RCTs comparing rTMS with sham also suggested a benefit in overall USN measured by Motor Free Visual Perception Test with 1 Hz (SMD 1.46, 95% CI 0.73, 2.20; p < 0.0001; I2=0%). There was also a benefit in overall USN measured by Albert test and Line crossing test with 1 Hz rTMS compared to sham (SMD 2.04, 95% CI 1.14, 2.95; p <0.0001; I2=not applicable). Results also suggest a possible increase in daily life functions with 10 Hz rTMS compared to sham (SMD 1.83, 95% CI 0.68, 2.97; p =0.002; I2=not applicable). Conclusions: Moderate-quality evidence shows that rTMS, with 1 Hz, is more efficacious compared to sham for unilateral spatial neglect after stroke measured by Motor Free Visual Perception Test. Furthermore, low-quality evidence also suggests a benefit of non-invasive brain stimulation, particularly with the use of rTMS, for overall USN measured by Line Bisection Test, Albert test and Line crossing test. These findings should be explored further in the context of the clinical practice among neurologists and physiotherapists.
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Palavras-chave
Estimulação, Cerebral, Não-invasiva, Acidente vascular cerebral, Negligência