Efficacy of brain-computer interface with functional electrical stimulation, transcranial direct current stimulation, and conventional therapy on upper limb recovery after stroke: a systematic review and network meta-analysis.

Objective: To systematically evaluate and rank the efficacy of brain-computer interface-based functional electrical stimulation (BCI-FES), transcranial direct current stimulation (tDCS), functional electrical stimulation (FES), conventional therapy (CT), and their combination (BCI-FES + tDCS) on upper limb functional recovery after stroke, and to compare the advantages of different intervention combinations through network meta-analysis, providing evidence-based medicine for clinical practice. Methods: A network meta-analysis method was used to comprehensively compare the efficacy of BCI-FES, tDCS and conventional motor rehabilitation in upper limb rehabilitation of stroke survivors. Statistical analysis was performed using R and Stata software, including direct meta-analysis and network meta-analysis. The direct meta-analysis used mean difference (MD) and its 95% confidence interval (CI) as effect size indicators. The network meta-analysis was performed within a Bayesian framework using the gemtc package in R. Results: A total of 13 relevant studies were finally included, comprising 11 two-arm studies and 2 three-arm studies, with a total of 777 subjects. Direct comparison meta-analysis showed: BCI-FES vs. CT MD = 6.01 (95%CI: 2.19, 9.83); BCI-FES vs. FES MD = 3.85 (95%CI: 2.17, 5.53); BCI-FES vs. tDCS MD = 6.53 (95%CI: 5.57, 7.48); BCI-FES + tDCS vs. BCI-FES MD = 3.25 (95%CI: -1.05, 7.55); BCI-FES + tDCS vs. tDCS MD = 6.05 (95%CI: -2.72, 14.82). BCI-FES showed significantly better effects than CT, FES and tDCS in improving FMA. Network meta-analysis: The inconsistency model was not significant (p = 0.060), so the consistency model was adopted. The efficacy ranking was BCI-FES + tDCS (98.9), BCI-FES (73.4), tDCS (33.3), FES (32.4), CT (12.0). BCI-FES and BCI-FES + tDCS were significantly better than CT, but there was no statistically significant difference compared with FES and tDCS. Conclusion: The combined application of BCI-FES and tDCS appears promising for upper limb rehabilitation after stroke, with potential therapeutic advantages arising from multimodal promotion of neuroplasticity. However, given the small number of trials, methodological variability, and risk of bias, this conclusion should be considered exploratory and hypothesis-generating rather than definitive guidance. Future studies should further verify its clinical benefits through standardized stimulation protocols, individualized parameter optimization and multicenter long-term follow-up studies, to promote the translational application of brain-computer interface technology in the field of neurorehabilitation. Systematic review registration: INPLASY202550066.