Centre for Gastrointestinal Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
Neuromodulation. 2021 Dec;24(8):1388-1401. doi: 10.1111/ner.13327. Epub 2020 Dec 10.
To evaluate the effects of neurostimulation, including repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and pharyngeal electrical stimulation (PES), for poststroke dysphagia based on evidence from randomized controlled trials (RCTs).
Electronic databases were systematically searched between January 1985 and June 2020 and studies were included based on prespecified selection criteria. The quality of studies was evaluated and data were extracted and synthesized by two independent reviewers. The primary outcome measure was change in (any) relevant clinical swallowing-related characteristic. Subgroup analysis were conducted based on follow-up period and stimulation parameters.
Data from 852 stroke patients were collected from 26 RCTs studies. Active neurostimulation treatments demonstrated a significant and moderate effect size compared to control treatment (0.69 [95% CI = 0.50, 0.89]; p < 0.001). The effect size of rTMS was the largest (0.73 [95% CI = 0.49, 0.98]; p < 0.001), followed by PES (0.68 [95% CI = 0.22, 1.14]; p = 0.004) and tDCS (0.65 [95% CI = 0.25, 1.04]; p = 0.001). All treatments showed comparable effect sizes within the first two weeks. Between three weeks and two months, tDCS demonstrated the largest effects (1.02 [95% CI = 0.45, 1.59]; p < 0.001) among the three treatments. No significant treatment effects were reported beyond three months. The combined effect size was large when applied in acute (<14 days) stroke (0.8 [95% CI = 0.34, 1.26]; p < 0.001). For noninvasive brain stimulation (NIBS), bihemispheric stimulation demonstrated the strongest effect size (0.93 [95% CI = 0.53, 1.33]; p < 0.001). In contrast, unilateral rTMS using ipsilesional high-frequency stimulation had a combined effect size of 0.83 (95% CI = 0.14, 1.52; p = 0.02). For tDCS, a significant effect size was found only with anodal stimulation applied over the contralesional hemisphere (1.04 [95% CI = 0.54, 1.53]; p < 0.001).
The results show that neurostimulation can benefit patients with poststroke dysphagia. The treatment effects were the strongest in acute stroke patients and within the first two months of application. For NIBS, bihemispheric stimulation appeared to be most effective. The most beneficial hemisphere for unilateral stimulation differed between rTMS and tDCS. These findings provide a platform for future studies and clinical practice.
基于随机对照试验（RCT）的证据，评估神经刺激（包括重复经颅磁刺激（rTMS）、经颅直流电刺激（tDCS）和咽电刺激（PES））对卒中后吞咽困难的疗效。
系统检索了 1985 年 1 月至 2020 年 6 月的电子数据库，并根据预设的选择标准纳入研究。由两名独立评审员评估研究质量并提取和综合数据。主要观察指标为（任何）相关临床吞咽特征的变化。根据随访时间和刺激参数进行亚组分析。
从 26 项 RCT 研究中收集了 852 例卒中患者的数据。与对照组相比，活性神经刺激治疗显示出显著且中等的治疗效果（0.69 [95% CI = 0.50, 0.89]；p<0.001）。rTMS 的治疗效果最大（0.73 [95% CI = 0.49, 0.98]；p<0.001），其次是 PES（0.68 [95% CI = 0.22, 1.14]；p=0.004）和 tDCS（0.65 [95% CI = 0.25, 1.04]；p=0.001）。所有治疗方法在最初的两周内均显示出相当的治疗效果。在 3 周到 2 个月之间，tDCS 的治疗效果最大（1.02 [95% CI = 0.45, 1.59]；p<0.001）。3 个月后，治疗效果无显著差异。在急性（<14 天）卒中中应用时，联合治疗效果较大（0.8 [95% CI = 0.34, 1.26]；p<0.001）。对于非侵入性脑刺激（NIBS），双半球刺激显示出最强的治疗效果（0.93 [95% CI = 0.53, 1.33]；p<0.001）。相反，使用同侧高频刺激的单侧 rTMS 的联合治疗效果为 0.83（95% CI = 0.14, 1.52；p=0.02）。对于 tDCS，仅在对侧半球应用阳极刺激时才发现显著的治疗效果（1.04 [95% CI = 0.54, 1.53]；p<0.001）。
结果表明神经刺激可以使卒中后吞咽困难的患者受益。在急性卒中患者和治疗开始后的 2 个月内，治疗效果最强。对于 NIBS，双半球刺激似乎最有效。单侧刺激最有益的半球在 rTMS 和 tDCS 之间有所不同。这些发现为未来的研究和临床实践提供了平台。
