# Efficacy and safety of neuromodulation and multimodal therapies for traumatic brain injury-induced disorders of consciousness: an updated umbrella review

## TL;DR

This paper reviews the best available evidence on therapies for disorders of consciousness after traumatic brain injury, identifying effective treatments like brain stimulation and acupuncture.

## Contribution

The study provides an updated umbrella review synthesizing high-quality evidence on neuromodulation and multimodal therapies for TBI-induced disorders of consciousness.

## Key findings

- Neuromodulation techniques like rTMS and tDCS significantly improved consciousness measures in TBI patients.
- Acupuncture and multisensory stimulation also showed robust improvements in clinical outcomes.
- The study emphasizes the need for standardized protocols and personalized therapy selection tools.

## Abstract

Post-traumatic disorders of consciousness (DoC) remain a major barrier to recovery after traumatic brain injury (TBI), yet therapeutic guidance is fragmented across modalities.

To synthesize the highest-level evidence on efficacy and safety of interventions for TBI-related DoC and derive practice-oriented recommendations.

Following PRISMA and a prospectively registered protocol (INPLASY202480015), we systematically screened PubMed, Embase, Web of Science, and CNKI through June 2024 for peer-reviewed systematic reviews and meta-analyses focused on TBI-induced DoC. Methodological quality was appraised using AMSTAR-2. Primary outcomes were CRS-R, GCS, GOS, and overall efficacy rate; random- or fixed-effects models were applied per heterogeneity.

Seven high-quality evidence syntheses encompassing 121 trials and eight interventions were included. Neuromodulation showed consistent benefits: repetitive transcranial magnetic stimulation (rTMS) improved CRS-R (MD 3.00, 95% CI 2.47–3.52) and GCS (MD 2.92, 1.65–4.19); transcranial direct current stimulation (tDCS) improved CRS-R (MD 2.08, 0.63–3.25). Peripheral and sensory approaches were robust: acupuncture improved GCS (MD 2.03, 1.54–2.52), GOS (RR 1.22, 1.16–1.29), and Efficacy Rate (RR 1.48, 1.40–1.56); multisensory stimulation improved GCS (MD 2.28, 2.02–2.54) and GOS (MD 1.11, 0.77–1.45). Right median nerve stimulation (RMNS) and family-centered sensory-affective stimulation also yielded significant gains, while single-study Trigeminal nerve stimulation (TNS) effects were mixed.

tDCS, rTMS, median nerve stimulation, multisensory stimulation, and acupuncture emerge as leading strategies for TBI-related DoC. We highlight priorities for the field: adequately powered multicenter RCTs with standardized protocols, mechanistic studies to refine dosing and targets, and predictive tools for personalized therapy selection. This umbrella synthesis provides a pragmatic evidence map to accelerate recovery and improve long-term outcomes in this vulnerable population.