Protocol-specific Efficacy of Non-invasive Brain Stimulation and Peripheral Electrical Stimulation for Walking Speed in Cerebral Palsy: A Network Meta-analysis of Randomized Controlled Trials
Muneeb Ahmad Muneer1, Amatul Aala2, Rania Naqrashi3, Zainab Aslam Saeed Memon4, Aima Muzaffar2, Mohammad Burhanuddin5, Abdur Rehman2, Zainab Awan6, Affan Tasleem2, Ashan Fareed7, Muhammad Asad Asif8, Zonaira Mushahid9, Dabbara Venkata Ramana10, Apeksha Pokalkar11
1Allama Iqbal Medical College, 2Nishtar Medical University, 3Frontier Medical and Dental College, 4Aga Khan University Hospital, 5Bhaskar Medical College, 6Liaquat National Hospital and Medical College, 7Al Nafees Medical College, 8Healing House Psychiatric Clinic, 9Dow University of Health Sciences, 10Osmania Medical college, 11University of Kentucky
Objective:
To assess the protocol-specific and overall comparative efficacy of non-invasive brain stimulation (NIBS) and peripheral electrical stimulation (PES) on walking speed in patients with cerebral palsy (CP) using network meta-analysis (NMA).
Background:
Cerebral palsy, the leading childhood physical disability, often impairs walking speed; while transcranial direct current stimulation (tDCS), neuromuscular electrical stimulation (NMES), and functional electrical stimulation (FES) show promise for gait improvement, their comparative efficacy and parameter-specific effects remain unclear.
Design/Methods:
We systematically searched PubMed, Embase, Scopus, and ClinicalTrials.gov to July 2025 for randomized controlled trials (RCTs) reporting walking speed or equivalent gait outcomes in CP. Twenty RCTs (591 patients) were included. A frequentist random-effects NMA estimated mean differences (MDs) versus sham, with ranking assessed by P-scores. Subanalyses were conducted by stimulation modality and protocol parameters.
Results:
The overall NMA demonstrated that all active interventions significantly outperformed sham. tDCS showed the largest effect (MD = 0.22, 95% CI 0.14–0.29, p < 0.0001), followed by FES (MD = 0.16, 95% CI 0.06–0.26, p = 0.0015) and NMES (MD = 0.11, 95% CI 0.05–0.18, p = 0.0010). Protocol-specific analyses revealed that tDCS over the primary motor cortex (M1) at 1 mA for 20 minutes combined with treadmill training yielded the greatest improvement (MD = 0.29, 95% CI 0.22–0.36). Quadriceps-targeted NMES for one hour also showed robust benefits (MD = 0.27, 95% CI 0.16–0.37). FES of the common peroneal nerve for 4–8 hours produced significant gains (MD range 0.19–0.27). Other NMES protocols, including gluteus maximus or gastrocnemius stimulation, did not differ from sham. Heterogeneity was minimal (I² = 0.4%), and no inconsistency was detected.
Conclusions:
Both overall and protocol-specific analyses confirm that NIBS and PES enhance walking speed in CP, with tDCS over M1 and quadriceps-targeted NMES demonstrating the strongest effects. Tailoring stimulation parameters may optimize motor rehabilitation strategies for this population.
Disclaimer: Abstracts were not reviewed by Neurology® and do not reflect the views of Neurology® editors or staff.