非药物疗法治疗脑卒中后认知障碍有效性和安全性的网状meta分析

Network meta-analysis of the efficacy and safety of non-pharmacological therapies for post-stroke cognitive impairment

目的采用网状meta分析的方法评价基于非药物疗法的多种干预措施治疗脑卒中后认知障碍的有效性和安全性。方法系统检索PubMed、Web of Science、Cochrane Library、MEDLINE,中国知网、维普网、万方数据知识服务平台、中国生物医学文献数据库中有关不同治疗措施对于脑卒中后认知障碍患者治疗效果的随机对照试验,检索时间建库至2023年10月。按照文献纳入、排除标准进行筛选、质量评估和信息提取,采用Stata 17.0和RevMan 5.4进行数据分析及制图。结果本研究纳入了42项随机对照试验,共涉及2965例卒中后认知障碍患者和5种非药物疗法。网状meta分析结果显示,在简易智能状态检查量表评分方面:针灸[标准化均数差(SMD)=1.02,95%CI:0.52~1.53]、经颅磁刺激(SMD=1.03,95%CI:0.43~1.63)、经颅直流电刺激(SMD=0.79,95%CI:0.18~1.39)、计算机辅助认知训练(SMD=0.69,95%CI:0.23~1.16)与常规护理措施比较,差异有统计学意义(P<0.05)。根据累积排序概率曲线下面积(SUCRA)值排序结果显示,针灸成为最佳非药物治疗措施的可能性最大(SUCRA=76.9)。在蒙特利尔认知评分方面:经颅磁刺激(SMD=2.10,95%CI:1.15~3.05)、经颅直流电刺激(SMD=1.30,95%CI:0.01~2.59)与常规护理措施比较,差异有统计学意义(P<0.05)。根据SUCRA值由高到低排序为:重复经颅磁刺激、经颅直流电刺激、针灸、计算机辅助认知训练、虚拟现实技术、常规护理。在日常生活能力评分方面:针灸(SMD=1.44,95%CI:0.86~2.03)、经颅直流电刺激(SMD=1.32,95%CI:0.58~2.06)、经颅磁刺激(SMD=0.86,95%CI:0.32~1.40)与常规护理措施比较,差异有统计学意义(P<0.05)。针灸(SMD=1.46,95%CI:0.41~2.52)、经颅直流电刺激(SMD=1.34,95%CI:0.11~2.57)与虚拟现实技术比较,差异有统计学意义(P<0.05)。SUCRA排序结果显示,针灸(SUCRA=83.3)成为最佳治疗措施的可能性最大。结论目前研究表明,针灸和经颅磁刺激在改善卒中后认知障碍患者认知功能及日常生活能力方面效果更好。在未来的研究中,应重视非药物治疗对脑卒中后认知功能的改善,并根据患者病情特点选择合适的干预措施。

Objective To evaluate the efficacy and safety of a variety of interventions based on non-pharmacological therapies in the treatment of post-stroke cognitive impairment by network meta-analysis.Methods Systematic retrieval of different treatment measures in PubMed,Web of Science,Cochrane Library,MEDLINE,CNKI,VIP,Wanfang Data,and China Biomedical Literature Database for randomised controlled trials on the therapeutic effect of patients with post-stroke cognitive impairment.The search was from inception to October 2023.Screening,quality assessment,and information extraction were carried out according to the literature inclusion exclusion criteria,and data were analysed and mapped using Stata 17.0 and RevMan 5.4.Results This study included 42 randomized controlled trials,involving a total of 2965 patients with post-stroke cognitive impairment and five non-pharmacological therapies.The results of network meta-analysis showed that in terms of simple intelligence status check scale scores:acupuncture(standardised mean difference[SMD]=1.02,95%CI:0.52-1.53),transcranial magnetic stimulation(SMD=1.03,95%CI:0.43-1.63),transcranial direct current stimulation(SMD=0.79,95%CI:0.18-1.39),and computer-assisted cognitive training(SMD=0.69,95%CI:0.23-1.16)were significantly different from conventional nursing measures(P<0.05).Ranking results according to the surface under the cumulative ranking(SUCRA)value showed that acupuncture was most likely to be the best non-pharmacological treatment(SUCRA=76.9).In terms of Montreal cognitive scores:transcranial magnetic stimulation(SMD=2.10,95%CI:1.15-3.05)and transcranial direct current stimulation(SMD=1.30,95%CI:0.01-2.59)were significantly different from conventional nursing measures(P<0.05).In descending order according to SUCRA values were:repetitive transcranial magnetic stimulation,transcranial direct current stimulation,acupuncture,computer-assisted cognitive training,virtual reality technology,and conventional nurse.In terms of the ability to perform daily life scores:acupuncture(SMD=1.44,95%CI:0.86-2.03),transcranial direct current stimulation(SMD=1.32,95%CI:0.58-2.06),and transcranial magnetic stimulation(SMD=0.86,95%CI:0.32-1.40)were significantly different from conventional nursing measures(P<0.05).Acupuncture(SMD=1.46,95%CI:0.41-2.52)and transcranial direct current stimulation(SMD=1.34,95%CI:0.11-2.57)were significantly different from virtual reality(P<0.05).The SUCRA ranking results showed that acupuncture(SUCRA=83.3)had the highest likelihood of being the best treatment measure.Conclusion Current studies have shown that acupuncture and transcranial magnetic stimulation are more effective in improving the cognitive function and daily life ability of patients with post-stroke cognitive impairment.In future research,attention should be paid to the improvement of non-pharmacological therapies for the post-stroke cognitive function,and appropriate intervention measures should be selected according to the characteristics of the patient’s condition.