Effectiveness of Non-Pharmacological Interventions for Lower Limb Motor Impairment in Post-Stroke Hemiplegia: A Systematic Review and Bayesian Network Meta-Analysis

Background Hemiplegia resulting from a stroke often causes significant dysfunction in lower limb movement, greatly impacting an individual's ability to walk and maintain balance. While non-pharmacological interventions show therapeutic potential, the optimal rehabilitation approach remains unclear. This study employs a network meta-analysis (NMA) to assess these treatments and offer evidence-based recommendations for clinical application. Objective To evaluate the efficacy and comparative ranking of non-pharmacological interventions in improving lower limb motor function, balance, walking ability, and activities of daily living in individuals with post-stroke hemiplegia. Methods We conducted a search of PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) published from January 2010 to August 2025. The Cochrane Risk of Bias Tool and Review Manager 5.4 were used to assess study quality, and evidence was graded with GRADEPro. Using R Studio software, a NMA was carried out to evaluate the clinical efficacy of various treatments in improving lower limb motor function in patients with post-stroke hemiplegia, ranked by the surface under the cumulative ranking curve (SUCRA). The study was officially registered in PROSPERO under the number CRD420251169037. Results This study employed a NMA incorporating 82 randomized controlled trials involving 3,514 patients and covering 16 non-pharmacological interventions. Results indicated that repetitive transcranial magnetic stimulation (rTMS) (SMD = − 3.68; 95% CI: −5.93 to − 0.93) demonstrated the most significant effect in improving lower limb motor function (FMA-LE score) in patients with post-stroke hemiplegia. Additionally, rTMS (SMD = − 12.32; 95% CI: −15.07 to − 9.57) (SMD = − 13.51; 95% CI: −16.32 to − 10.73) showed optimal efficacy in enhancing patients' balance ability and activities of daily living. Transcranial direct current stimulation (tDCS) (SMD = − 1.47; 95% CI: −2.54 to − 0.42) demonstrated the best efficacy in improving Functional Ambulation Classification. The combination intervention of virtual reality and robotic rehabilitation (SMD = 6.39; 95% CI: 4.56 to 7.99) yielded the most favorable results in reducing the Timed Up and Go test time. Conclusion This NMA suggests that rTMS might be the preferred non-pharmacological approach for enhancing lower limb motor function in patients with post-stroke hemiplegia. For individuals experiencing difficulties with walking and balance, a combined approach using virtual reality and robot-assisted rehabilitation is recommended. However, due to the limited number of studies and small sample sizes, the evidence remains preliminary. Therefore, future large-scale, multicenter, double-blind randomized controlled trials are needed to confirm and extend these results.