title: Transcranial magnetic stimulation combined with upper-limb training for improving function after stroke: A systematic review and meta-analysis.
abstract: BACKGROUND
  Several neuromodulation treatments have been developed, and their effects have been studied in recent years in order to improve neurological rehabilitation after a stroke. The association between upper-limb training and repetitive transcranial magnetic stimulation (rTMS) has provoked controversies and produced inconclusive results.
  
  
  OBJECTIVE
  The purpose of this study was to investigate the effects of rTMS combined with upper-limb training versus sham rTMS combined with upper-limb training on the upper-limb recovery after a stroke.
  
  
  METHODS
  A systematic review with meta-analysis was performed. The eligible studies were randomized controlled trials with stroke subjects, and the outcomes were related to upper-limb motor/functional status and spasticity.
  
  
  RESULTS
  A total of 3234 citations were identified, and 11 studies were included. The meta-analysis included eight studies with 199 participants and did not show any difference between groups, neither for upper-limb function nor for spasticity (upper-limb function [0.03 (95% CI: -0.25 to 0.32; I(2) 0%)] and Modified Ashworth Scale [-0.31 (95% CI: -0.78 to 0.17; I(2) 43%)]).
  
  
  CONCLUSIONS
  The current state of the literature is not enough to support the hypothesis that a combination of rTMS and upper-limb training has a stronger effect on upper-limb function than upper-limb training alone.
authors.affiliation: Health Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil; Centro Universitário Ritter dos Reis (UniRitter) - Laureate International Universities, Porto Alegre, Brazil.
authors.forename: Patricia
authors.initials: P
authors.lastname: Graef
authors.affiliation: Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil.
authors.forename: Maria Luísa Rocha
authors.initials: MLR
authors.lastname: Dadalt
authors.affiliation: Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil.
authors.forename: Daiana Amaral Medeiros da Silva
authors.initials: DAMDS
authors.lastname: Rodrigués
authors.affiliation: Health Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil.
authors.forename: Cinara
authors.initials: C
authors.lastname: Stein
authors.affiliation: Health Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil; Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil; Movement Analysis and Neurological Rehabilitation Laboratory, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: alinespagnussat@gmail.com.
authors.forename: Aline de Souza
authors.initials: AS
authors.lastname: Pagnussat
mesh_terms: D015444:Exercise; D006801:Humans; D020521:Stroke / Q000503:physiopathology / Q000628:therapy*; D000071939:Stroke Rehabilitation; D050781:Transcranial Magnetic Stimulation / Q000379:methods*; D034941:Upper Extremity / Q000502:physiology*
keywords: Exercise; Meta-analysis; Stroke; Systematic review; Transcranial magnetic stimulation; Upper-limb