Review Article

Noninvasive Brain Stimulations for Unilateral Spatial Neglect after Stroke: A Systematic Review and Meta-Analysis of Randomized and Nonrandomized Controlled Trials

Table 3

Study characteristics related to intervention and control groups, assessed outcomes, and follow-up.

Author, yearDescription of interventionsDescription of control groupsMeasured outcomesFollow-up

Randomized controlled trials
Cao et al., 2016 [50]iTBS 80% RMT in the rTMS group: stimulation was applied using an 87 mm butterfly coil connected to a Magstim Rapid2 (Magstim Co., Whitland, UK), with peak intensity of 2.0 T and a maximum pulse length of 250 μs. Pulses (theta burst type) were delivered to the left dorsal lateral prefrontal cortex, the F5 label of the left hemisphere, which is between the F3 and F7, at 80% of resting motor threshold. Two sessions were applied with a 15 min interval on each day. Each session included 20 stimulation trains consisting of three pulses delivered at a frequency of 50 Hz in every 200 ms for 2 s (total 10 bursts, 30 pulses) with an interval of 8 s.Same as intervention group; however, pulses were delivered at 40% of RMTLine bisection and star cancellation testsAfter intervention
Cha and Kim, 2016 [51]Repetitive rTMS + conventional rehabilitation therapy (neurodevelopmental facilitation techniques) for a total of 40 minutes (rTMS: 10 min; rehabilitation: 30 min) per day, with a 10-minute rest period halfway through the session, for 4 weeks, 5 days per week: stimulation was delivered using figure-of-eight coil with a diameter of 80 mm connected to Magstim Rapid2 (Magstim Co. Ltd., Wales, UK). Stimulation was applied in the right posterior parietal (P3 and P4 areas) based on the electroencephalogram 10/20 system at a frequency of 1 Hz for 5 minutes with 90% of the motor threshold during rest.Sham rTMS and conventional rehabilitation therapy using the same protocol than the experimental groupMotor-Free Visual Perception Test; line bisection test; Albert test; star cancellation test4 weeks
Fu et al., 2015 [52]Left posterior parietal cortex cTBS + conventional rehabilitation training: cTBS was set over P5, three-pulse burst was delivered at 30 Hz and repeated every 200 ms for 40 s with intensity was 80% of the resting motor threshold. cTBS was delivered using a Super Rapid 2 magnetic stimulator (Magstim, Whitland, UK) with 2.0-Tesla maximum field strength, connected with a figure-of-eight coil (diameter of outside loop, 87 mm). Patients received 4 trains daily, with an interval of 15 min, for 14 consecutive days.Sham cTBS + conventional rehabilitation trainingStar cancellation test; line bisection test4 weeks
Fu et al., 2017 [60]The cTBS group received continuous TBS with the coil placed tangentially to the scalp at P3 over the left posterior parietal cortex (according to the 10–20 electrode position system of the American Electroencephalographic Association28). The magnitude of the pulses was maintained at 80% resting motor threshold. On each day for 10 consecutive days, 4 sessions of stimulation were delivered, with an interval of 15 min between every 2 sessions. Each session lasted 40 s and contained 600 pulses delivered in 200 bursts at 5 Hz (theta rhythm). Each burst included 3 pulses delivered at 30 Hz.The active control group received stimulations with the same features at the same position as the cTBS group, but with the coil placed perpendicular to the scalp surface and the amplitude of the stimulation pulses reduced to 40% resting motor thresholdStar cancellation test; line bisection test10 days
Smit et al., 2015 [56]tDCS was applied for 20 minutes over the left (cathodal) and right (anodal) posterior parietal cortex on five consecutive days with a battery-driven direct current stimulator (NeuroConnDC-Stimulator; serialnumber 0096). Stimulation parameters were set at a current of 2000 mA, and a resistance of <10 kOhm, applied for 1200s with ramping up in 30 s and ramping down in 30 s. Electrodes were located over the posterior parietal lobe, corresponding with P3 (cathodal electrode) and P4 (anodal electrode). Treatment conditions were separated by a four-week washout period.Placebo was applied for 20 minutes over the left (cathodal) and right (anodal) posterior parietal cortex at an intensity of 2 mA on five consecutive days; treatment conditions were separated by a four-week washout periodCancellation tests; line bisection tests; drawing tests1 month
Yang et al., 2015 [55]Group I: 1 Hz rTMS two times a day for 2 weeks + routine rehabilitation: stimulation was administered using a rapid magnetic stimulator (Magstim Company) with a figure-of-eight coil, peak intensity of stimulation at 2 T, and pulse duration of 250 s, at the contralateral hemisphere (P3), intensity 80% of RMT, and frequency of 1 Hz, and stimulus duration for each sequence was 8 s, repeated 82 sequences with a total of 656 pulse numbers.
Group I2: 10 Hz rTMS two times a day for 2 weeks + routine rehabilitation: stimulation was administered using a rapid magnetic stimulator (Magstim Company) with a figure-of-eight coil, peak intensity of stimulation at 2 T, and pulse duration of 250 s, at the contralateral hemisphere (P3), intensity 80% of RMT, frequency 10 Hz, with a total pulse number of 1000 and stimulation interval of 55 s.
Group I3: cTBS two times a day for 2 weeks + routine rehabilitation: stimulation was administered using a rapid magnetic stimulator (Magstim Company) with a figure-of-eight coil, peak intensity of stimulation at 2 T, and pulse duration of 250 s, at the contralateral hemisphere (P3), intensity 80% of RMT, 801 pulses, in bursts of 3 pulses at 30 Hz, repeated every 100 ms.
Sham rTMS two times a day for 2 weeks + routine rehabilitationStar cancellation test; line bisection test1 month
Kim et al., 2013 [53]Group A: 10 sessions of low-frequency (1 Hz) rTMS over the nonlesioned left posterior parietal cortex (P3) at a 90% motor threshold in 4 trains of 5-minute duration, each separated by 1 minute (resulting in a total stimulation period of 20 minutes). rTMS was delivered using a Magstim Super Rapid Magnetic Stimulator with a 70-millimeter, air-cooled 8-shaped coil. rTMS was performed 5 times per week for 2 weeks. Patients also received conventional rehabilitation treatment (including physical, occupational, and cognitive therapies).
Group B: 10 sessions of high-frequency (10 Hz) rTMS over the lesioned right posterior parietal cortex (P4) at a 90% motor threshold in 4 trains of 5-minute duration, each separated by 55 seconds (resulting in a total stimulation period of 20 minutes). The remaining of the protocol followed the same instructions as group A.
Sham rTMS + conventional rehabilitationMotor-Free Visual Perception Test; line bisection test; cancellation test; Catherine Bergego scale; Korean-modifiedBarthel index2 weeks
Sunwoo et al., 2013 [57]Group A: dual-mode (tDCS dual) direct current was delivered by two sets of battery-powered devices (Phoresor II Auto Mod-elPM850, IOMED, USA) using two pairs of surface saline-soaked sponge electrodes (5 cm × 5 cm). Anodal tDCS of the first circuit over the right PPC (P4) was accompanied by cathodal tDCS of the second circuit over the left PPC (P3). Therefore, in the first tDCS circuit, the anode was placed over P4 and the cathode was placed over the left supraorbital area. In the second tDCS circuit, the anode was placed over the right supraorbital area and the cathode was placed over the P3. A constant current of 1 mA was delivered for 20 min.
Group B: Single-mode (tDCS single) direct current was delivered by two sets of battery-powered devices (Phoresor II Auto Mod-elPM850, IOMED, USA) using two pairs of surface saline-soaked sponge electrodes (5 cm × 5 cm). The anode was placed over P4 and the cathode over the left supraorbital area (the first tDCS circuit), and real stimulation was provided, whereas the second tDCS circuit received sham stimulation. For the real stimulation, a constant current of 1 mA was delivered for 20 min. For the sham stimulation, the stimulator was turned on and the current intensity was gradually increased for 5 s, and was then tapered off over 5 s.
Sham mode (tDCS sham) in the first and second tDCS circuits. The stimulator was turned on and the current intensity was gradually increased for 5 s, and was then tapered off over 5 sLine bisection test; star cancelation testImmediately after treatment
Cazzoli et al., 2012 [14]cTBS for 2 days on week 1 and sham TBS for 2 days on week 2. cTBS was applied by means of a MagPro X100 stimulator (Medtronic Functional Diagnostics) connected to a round coil with 60 mm outer radius (Magnetic Coil Transducer MC-125). cTBS protocol comprised 801 pulses, delivered in a continuous train and consisting of 267 bursts, each one contained three pulses at 30 Hz, repeated at 6 Hz (total duration of one single, cTBS train was 44 s), and eight cTBS trains were applied over 2 days. cTBS was applied over P3. Besides, patients received neurorehabilitation therapy including 1 h neuropsychological training, 1 h of occupational therapy, and 1 h of physiotherapy per day.Control A: sham TBS for 2 days on week 1 and cTBS for 2 days on week 2. cTBS protocol was the same described for intervention A. Besides, patients received neurorehabilitation therapy including 1 h neuropsychological training, 1 h of occupational therapy, and 1 h of physiotherapy per day
Control B: sham TBS for 2 days on week 1 and sham TBS for 2 days on week 2. Besides, patients received neurorehabilitation therapy including 1 h neuropsychological training, 1 h of occupational therapy, and 1 h of physiotherapy per day
Catherine Bergego scale; Vienna Test System; random shape cancelation test2 weeks
Ko et al., 2008 [58]tDCS to the right posterior parietal cortex for 20 min (2 mA anodal DC brain polarization) delivery by a battery-powered device (Phoresor II Auto model PM850, IOMED, USA), using a pair of saline-soaked surface sponge electrodes (5 cm × 5 cm). The anode was placed over P4, and cathode was placed over left supraorbital area.Sham tDCS (current was delivered for 10 s and then turned off)Line bisection test; shape-unstructuredcancellation test; letter-structuredcancellation testImmediately post intervention
Koch et al., 2012 [54]cTBS was delivered using a MagStim Super Rapid magnetic stimulator (Magstim Company, Whitland, Wales, UK), connected with a figure-of-eight coil with a diameter of 70 mm. In each session, 3-pulse bursts at 50 Hz repeated every 200 ms for 40 s were delivered at 80% of the active motor threshold over the left PPC (600 pulses). Every day, 2 sessions of left PPC cTBS were applied with an interval of 15 minutes and lasted for 10 days (5 days per week, Monday to Friday). Patients also received rehabilitation program consisted of 20 sessions of 45 minutes each, held 5 days per week (based on computerized visuospatial scanning training) and motor rehabilitation when necessary.Sham cTBS was delivered with the coil angled at 90°, with only the edge of the coil resting on the scalp
Stimulus intensity, expressed as a percentage of the maximum stimulator output, was set at 80% of the active motor threshold inducing the same acoustic sensation as for real TBS
Patients also received rehabilitation program
Line crossing test; letter cancellation test; star cancellation test; figure and shape copying test; representative drawing test1 month
Bonnì et al., 2011 [59]cTBS over the left PPC, for two weeks.Sham cTBSStandardized behavioural inattention test; excitability of the parieto-frontalfunctional connectionsNR

Non-RCTs
Cazzoli et al., 2015 [61]cTBS over the left, contralesional PPC (P3), was applied using a MagPro X100 stimulator, connected to either a round coil (MC-125 Medtronic Functional Diagnostics). The cTBS protocol consisted of 801 pulses delivered in a continuous train. The train was comprised of 267 bursts, where each contained three single pulses at 30 Hz, repeated at 6 Hz, and had a total duration of 44 s. Application consisted on two trains separated by a 15 min interval.Sham cTBS over the left, contralesional PPC, was applied using a sham coil (MC-P-B70 Medtronic Functional Diagnostics)Computerised balloon test with eye movement recording; paper-pencil cancellation tasks8 hours
Hopfner et al., 2015 [62]cTBS comprised 801 pulses, delivered in a continuous train of 267 bursts (each including 3 pulses at 30 Hz, repeated at 6 Hz). The total duration of a single cTBS train was 44 s. Two cTBS trains were applied overP3, with an intertrain interval of 15 min. A MagPro X100 stimulator (Medtronic Functional Diagnostics, Farum, Denmark), connected to around coil (Magnetic Coil Transducer MC-125) was used to deliver biphasic, repetitive magnetic pulses. Besides, 12 (from 18) patients also received smooth pursuit eye movement training.Sham cTBS connected to a placebo coil (Magnetic Coil Transducer MC-P-B70)
Besides, 12 (from 18) patients also received Smooth pursuit eye movement training
Center of cancellation score; x-position of leftmost cancelled target; number of cancelled targetsRight after treatment
Làdavas et al., 2015 [64]Group A: 2-week rehabilitation program consisted of 10 sessions of cathodal tDCS lasting 30 minutes each and held 5 days per week. tDCS was applied using a battery-driven Eldith (neuroConn GmbH, Ilmenau, Germany) Programmable Direct Current Stimulator with a pair of surface saline-soaked sponge electrodes. In each session, a constant current of 2 mA intensity (current density: 0.57 mA/cm2) was delivered lasting 20 minutes of cathodal tDCS of the left, intact PPC (over P5).
Group B: 2-week rehabilitation program consisted of 10 sessions of anodal tDCS lasting 30 minutes each and held 5 days per week. The anodal tDCS was placed over the PPC of the damaged hemisphere (P6). The remaining protocol was the same used in group A.
Sham tDCS (montage used in the sham group mimicked that used in the two active groups)Behavioral Inattention TestFinal follow-up within the first week after the last session
Agosta et al., 2014 [63]A 10-minute train of repetitive low-frequency (1 Hz) rTMS over the left parietal lobe (P3 site) identified using the 10/20 EEG measurement system. The stimulus was delivered using a 70 mm figure-of-eight coil connected to a Magstim Rapid2 (Magstim Co., UK). Stimulation strength was set to 90% of the threshold to evoke motor responses at rest.Sham rTMS over the intact left parietal cortexVisual tracking task; unilateral and bilateral tasks30 minutes

C: control group; cTBS: continuous theta burst stimulation; I: intervention; iTBS: intermittent theta burst; PPC: posterior parietal cortex; RMT: resting motor threshold; rTMS: repetitive transcranial magnetic stimulation; tDCS: transcranial direct current stimulation; TBS: theta burst stimulation; USN: unilateral spatial neglect.