Estimulación magnética transcraneal y Rehabilitación Cognitiva sobre deficits de atención en el Ictus

Recientemente se han publicado varias revisiones de la Cochrane sobre el ictus, os las dejo a continuación:

Estimulación magnética transcraneal Ictus

1) En la primera de ellas se concluye que la evidencia actual no soporta el uso rutinario de la estimulación magnética transcraneal en el ictus.

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Cochrane Database Syst Rev. 2013 May 31;5:CD008862. doi: 10.1002/14651858.CD008862.pub2.
Repetitive transcranial magnetic stimulation for improving function after stroke.
Hao Z, Wang D, Zeng Y, Liu M.
Source
Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041.
Abstract
BACKGROUND:
It had been assumed that suppressing the undamaged contralesional motor cortex by repetitive low-frequency transcranial magnetic stimulation (rTMS) or increasing the excitability of the damaged hemisphere cortex by high-frequency rTMS will promote function recovery after stroke.
OBJECTIVES:
To assess the efficacy and safety of rTMS for improving function in people with stroke.
SEARCH METHODS:
We searched the Cochrane Stroke Group Trials Register (April 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), the Chinese Stroke Trials Register (April 2012), MEDLINE (1950 to May 2012), EMBASE (1980 to May 2012), Science Citation Index (1981 to April 2012), Conference Proceedings Citation Index-Science (1990 to April 2012), CINAHL (1982 to May 2012), AMED (1985 to May 2012), PEDro (April 2012), REHABDATA (April 2012) and CIRRIE Database of International Rehabilitation Research (April 2012). In addition, we searched five Chinese databases, ongoing trials registers and relevant reference lists.
SELECTION CRITERIA:
We included randomised controlled trials comparing rTMS therapy with sham therapy or no therapy. We excluded trials that reported only laboratory parameters.
DATA COLLECTION AND ANALYSIS:
Two review authors independently selected trials, assessed trial quality and extracted the data. We resolved disagreements by discussion.
MAIN RESULTS:
We included 19 trials involving a total of 588 participants in this review. Two heterogenous trials with a total of 183 participants showed that rTMS treatment was not associated with a significant increase in the Barthel Index score (mean difference (MD) 15.92, 95% CI -2.11 to 33.95). Four trials with a total of 73 participants were not found to have a statistically significant effect on motor function (standardised mean difference (SMD) 0.51, 95% CI -0.99 to 2.01). Subgroup analyses of different stimulation frequencies or duration of illness also showed no significant difference. Few mild adverse events were observed in the rTMS groups, with the most common events being transient or mild headaches (2.4%, 8/327) and local discomfort at the site of the stimulation.
AUTHORS’ CONCLUSIONS:
Current evidence does not support the routine use of rTMS for the treatment of stroke. Further trials with larger sample sizes are needed to determine a suitable rTMS protocol and the long-term functional outcome.

 

 

2) En la siguiente revisión sobre Rehabilitación Cognitiva sobre déficits de atención en el ictus, los resultados sugieren que puede haber un efecto a corto plazo sobre la capacidad de atención, pero no hay estudios de calidad sobre la persistencia de los efectos y sobre la relación con las AVDs.

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Cochrane Database Syst Rev. 2013 May 31;5:CD002842. doi: 10.1002/14651858.CD002842.pub2.
Cognitive rehabilitation for attention deficits following stroke.
Loetscher T, Lincoln NB.
Source
School of Psychology, Flinders University, Adelaide, Australia.
Abstract
BACKGROUND:
Many survivors of stroke complain about attentional impairments, such as diminished concentration and mental slowness. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.
OBJECTIVES:
To determine whether (1) people receiving attentional treatment show better outcomes in their attentional functions than those given no treatment or treatment as usual, and (2) people receiving attentional treatment techniques have a better functional recovery, in terms of independence in activities of daily living, mood and quality of life, than those given no treatment or treatment as usual.
SEARCH METHODS:
We searched the Cochrane Stroke Group Trials Register (October 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library October 2012), MEDLINE (1948 to October 2012), EMBASE (1947 to October 2012), CINAHL (1981 to October 2012), PsycINFO (1806 to October 2012), PsycBITE and REHABDATA (searched October 2012) and ongoing trials registers. We screened reference lists and tracked citations using Scopus.
SELECTION CRITERIA:
We included randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. The primary outcome was measures of global attentional functions, and secondary outcomes were measures of attention domains, functional abilities, mood and quality of life.
DATA COLLECTION AND ANALYSIS:
Two review authors independently selected trials, extracted data and assessed trial quality.
MAIN RESULTS:
We included six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no statistically significant effect of cognitive rehabilitation for persisting effects on global measures of attention (two studies, 99 participants; standardised mean difference (SMD) 0.16, 95% confidence interval (CI) -0.23 to 0.56; P value = 0.41), standardised attention assessments (two studies, 99 participants; P value ≥ 0.08) or functional outcomes (two studies, 99 participants; P value ≥ 0.15). In contrast, a statistically significant effect was found in favour of cognitive rehabilitation when compared with control for immediate effects on measures of divided attention (four studies, 165 participants; SMD 0.67, 95% CI 0.35 to 0.98; P value < 0.0001) but no significant effects on global attention (two studies, 53 participants; P value = 0.06), other attentional domains (six studies, 223 participants; P value ≥ 0.16) or functional outcomes (three studies, 109 participants; P value ≥ 0.21).Thus there was limited evidence that cognitive rehabilitation may improve some aspects of attention in the short term, but there was insufficient evidence to support or refute the persisting effects of cognitive rehabilitation on attention, or on functional outcomes in either the short or long term.
AUTHORS’ CONCLUSIONS:
The effectiveness of cognitive rehabilitation remains unconfirmed. The results suggest there may be a short-term effect on attentional abilities, but future studies need to assess the persisting effects and measure attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

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