'Enhances' is NOT GOOD ENOUGH! Survivors want spasticity cured! When the hell will you GET THERE? Why is failure to cure spasticity not being treated as career ending in stroke research?
Comparison of the effects of different physical stimulation therapies on reducing upper limb spastic paralysis and motor dysfunction in stroke survivors after stroke: a network meta-analysis of randomized controlled trials
Mingtong Bian1,2
Fuyan Chen1,2,3*Huizhen Su3
Zhiying Li1,2Xiaowei Sun1,2
Yang Liu1,2
Jinyuan Shi1,2Shuo Liu1,2Ru Rong1,2- 1Department of Acupuncture, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- 2National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- 3Qinghai Provincial Hospital of Traditional Chinese Medicine, Xining, Qinghai, China
Background: Upper limb spasticity is a common and disabling sequela of stroke, which significantly impairing motor function and the capacity to perform activities of daily living (ADL). The relative efficacy of different physical therapies and their combinations compared to monotherapies remains unclear.
Methods: A comprehensive database search was conducted to identify randomized controlled trials (RCTs) published from database inception to 2024 that evaluated physical therapies for post-stroke upper limb spasticity. Data were analyzed using RevMan and STATA/R software with a Bayesian framework for network meta-analysis. Evidence consistency was assessed via node-splitting approaches, and intervention efficacy was ranked using the surface under the cumulative ranking curve (SUCRA). Effect sizes were expressed as mean differences (MD) with 95% confidence intervals (CI), and study quality was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system.
Results: Forty-nine RCTs involving 3,219 patients were included. The combination of physical rehabilitation (PR) with repetitive transcranial magnetic stimulation (rTMS) and electro-acupuncture (EA) demonstrated the highest improvement in Fugl-Meyer Assessment for Upper Extremity (FMA-UE) scores (91.1%), outperforming PR alone (13.2%) or EA monotherapy (30.3%). PR combined with rTMS and body acupuncture (BA) shows the most significant improvement in the Modified Barthel Index (MBI) (83.1%), superior to PR (20.8%) or BA (23.8%) alone. Adverse events (e.g., minor bruising from EA) were infrequent and self-resolving.
Conclusion: Current evidence indicates that synergistic application of PR with rTMS and acupuncture (EA/BA) significantly enhances upper limb motor function and ADL capacity. However, GRADE evaluations rated most evidence as moderate quality, limited by implementation bias, insufficient subgroup analyses, and lack of long-term follow-up data. Future studies should adopt standardized protocols and investigate efficacy variations across stroke subtypes.
Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42025633289, identifier [CRD42025633289].
1 Introduction
Upper limb dysfunction following a stroke represents a significant cause of long-term disability in patients, frequently occurring in conjunction with a range of injuries, including upper limb weakness and spasticity. The principal manifestation of upper limb spastic paralysis is an increase in muscle tone on the affected side, which is characterized by symptoms such as shoulder adduction and internal rotation, elbow flexion and pronation, wrist flexion and ulnar deviation, and finger clenching (1). This can result in a number of adverse effects, including pain, muscle contraction, changes in soft tissue structure, weakness, associated reactions, loss of passive function, limited active function, and a decrease in quality of life. This has a significant impact on the patient’s activities of daily living (2). The pathological mechanism of upper limb spasticity is complex, involving damage to the corticospinal tract, peripheral mechanisms, extensor mechanisms, and potential spastic dystonia, among other factors (3). Furthermore, because the upper limb’s role in more refined and diverse functions, the recovery of its dysfunction is more complex and slow, posing significant challenges to the patient’s daily life and social participation.
Nevertheless, research has demonstrated that spasticity can be effectively managed in the chronic phase of stroke through appropriate intervention, thereby enhancing motor function and facilitating the restoration of limb function (4). It is therefore imperative to identify and investigate efficacious rehabilitation techniques to facilitate enhanced recovery of upper limb function in patients. At present, there is a general consensus on the rehabilitation treatment for this condition, both domestically and internationally. The aforementioned treatments are primarily comprised of physical exercise and occupational therapy. In recent years, the advancement of medical technology and the intensification of clinical research have given rise to a multitude of novel rehabilitation therapies, including acupuncture, massage, proprioceptive neuromuscular facilitation (PNF), repetitive transcranial magnetic stimulation (rTMS), and theta-burst stimulation (TBS). A number of studies (5–8) have demonstrated that these physical therapies can facilitate the improvement of post-stroke spastic paralysis to a certain extent. However, existing research has predominantly focused on monotherapies, with insufficient comparative investigations of multimodal therapeutic regimens, leaving the optimal therapeutic combinations poorly defined.
Network meta-analysis (NMA) overcomes the limitations of traditional pairwise meta-analyses, which are restricted to comparing two interventions at a time, by integrating direct and indirect evidence to systematically evaluate the synergistic effects of complex multimodal rehabilitation strategies within a unified framework (9). This study applied NMA to compare the efficacy of 21 intervention modalities for post-stroke upper limb spasticity, aiming to provide evidence-based insights for personalized, multimodal rehabilitation protocols. A total of 49 randomized controlled trials (RCTs) involving 3,219 participants, published between 2009 and 2024, were included. Outcomes were quantified using the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) for motor function and the Modified Barthel Index (MBI) for activities of daily living (ADL). A Bayesian network meta-analysis (implemented in STATA/R) was conducted to comprehensively assess efficacy differences among rehabilitation therapies, neuromodulation techniques, and integrative traditional Chinese medicine (TCM) regimens. Interventions were ranked via the surface under the cumulative ranking curve (SUCRA). The results elucidated effectiveness hierarchies through probabilistic estimates and established indirect efficacy comparison pathways for interventions lacking direct comparative data. This framework provides clinicians and patients with a scientific foundation for optimizing combined strategies of rehabilitation, neuromodulation, and TCM therapies, while bridging critical evidence gaps in the current literature on post-stroke spasticity management.
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