Different electromagnetic stimulation programs improve post-stroke dysphagia: a network Meta-analysis

doi:10.12307/2025.683

Abstract

Abstract: OBJECTIVE: To conduct a network Meta-analysis to assess the efficacy of various electromagnetic stimulation programs in managing post-stroke dysphagia and identify the optimal stimulation program.
METHODS: A comprehensive search was conducted across multiple databases, including CNKI, VIP, WanFang, the Chinese Biomedical Literature Database, PubMed, Web of Science, Embase, and The Cochrane Library. The search terms included “electric stimulation,” “magnetic stimulation,” “stroke,” and “deglutition disorders” in Chinese and English. The aim was to collect clinical randomized controlled trials evaluating various electromagnetic stimulation programs for the treatment of post-stroke dysphagia. The control group underwent conventional swallowing training, whereas the experimental group received electromagnetic stimulation in addition to the control treatment. The search was limited to publications from the inception of the databases until May 11, 2024. EndNote X9 software was utilized for literature management, and the Cochrane risk of bias assessment tool along with the revised Jadad scale was used to assess the risk of bias and the quality of the included studies. Direct Meta-analysis and network Meta-analysis were performed on the functional oral intake scale score, leakage-aspiration grade score, and swallowing muscle group electromyographic activity score index using RevMan 5.4 software and Stata 17 software. The strength of evidence for the outcome indicators was evaluated in accordance with the GRADE evidence level and recommendation strength grading standards.
RESULTS: A total of 59 studies were included in this analysis, comprising 50 high-quality documents and 9 low-quality documents, with a collective sample size of 3 801 patients and encompassing 15 different electromagnetic stimulation programs. (1) In the evaluation of feeding ability, the top five electromagnetic stimulation programs, ranked by the area under the cumulative ranking probability chart (SUCRA), were repetitive transcranial magnetic stimulation combined with repetitive peripheral magnetic stimulation and neuromuscular electrical stimulation (99.4%) > repetitive peripheral magnetic stimulation and neuromuscular electrical stimulation (80.8%) > repetitive transcranial magnetic stimulation and neuromuscular electrical stimulation (74.2%) > repetitive transcranial magnetic stimulation and myoelectric biofeedback electrical stimulation (68.4%) > transcranial direct current stimulation combined with neuromuscular electrical stimulation (63.2%). (2) In the assessment of anti-aspiration ability, the top five electromagnetic stimulation programs, ranked by the area under the cumulative ranking probability chart (SUCRA), were repetitive transcranial magnetic stimulation combined with repetitive peripheral magnetic stimulation and neuromuscular electrical stimulation (99.25%) > repetitive transcranial magnetic stimulation combined with myoelectric biofeedback electrical stimulation (87.5%) > repetitive transcranial magnetic stimulation combined with neuromuscular electrical stimulation (80.6%) > repetitive pheriphal magnetic stimulation combined with neuromuscular electrical stimulation (66.7%) > transcranial direct current stimulation combined with neuromuscular electrical stimulation (57.8%). (3) In the assessment of surface electromyographic activity levels in the swallowing muscles, the top five electromagnetic stimulation programs ranked by the area under the cumulative ranking probability chart (SUCRA) were repetitive transcranial magnetic stimulation combined with neuromuscular electrical stimulation (87.1%) > repetitive transcranial magnetic stimulation combined with transcranial direct current stimulation (86.3%) > transcranial direct current stimulation combined with neuromuscular electrical stimulation (83.9%) > myoelectric biofeedback electrical stimulation combined with neuromuscular electrical stimulation (77.8%) > transcranial direct current stimulation combined with myoelectric biofeedback electrical stimulation (74.4%).
CONCLUSION: Electromagnetic stimulation significantly improves swallowing function in patients with post-stroke dysphagia. Combined central and peripheral magnetic stimulation has the best effect on improving oral intale ability and anti-aspiration ability in stroke patients (medium-level evidence), followed by central magnetic stimulation combined with peripheral electrical stimulation (medium-level evidence).

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

Key words: dysphagia, neuromuscular electrical stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, electromyographic biofeedback therapy, peripheral magnetic stimulation, physical therapy, stroke, functional restoration, network meta-analysis

CLC Number:

Hu Tong, Li Xuan, Yuan Jing, Wang Wei. Different electromagnetic stimulation programs improve post-stroke dysphagia: a network Meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2025, 29(24): 5224-5236.

Figures/Tables 13

2.2 纳入文献基本特征文章共纳入59篇文献，发表年限为2013-2024年，包含NMES、PES、rTMS、重复外周磁刺激(repetitive peripheral magnetic stimulation，rPMS)、间歇性爆发性θ刺激(intermittent theta-burst stimulation，iTBS)、肌电生物反馈电刺激(electromyographic biofeedback therapy，EMGBF)、tDCS及其联合电磁刺激，共15种电磁刺激方案。纳入文献的基本特征见表1。 2.3 纳入文献的方法学质量评估 59篇文献提及随机化，其中11篇文献未明确报道随机化方法[19，21-22，24，29，33-34，41，46，48，59]，1篇文献没有严格执行随机分组[31]，11篇文献采用分配隐藏的方法[20，27-28，30，32，36-38，49，56，64]，10篇文献严格执行盲法[24，27-29，34，38，56，60，64-65]，25篇文献采取评估者盲法[18-19，23-25，27-31，33，35-37，49，52，55-56，64-65，68，71-73，76]。所纳入的研究均不存在选择性报告和结果缺失，文中均未提及其他偏倚风险。详细结果见图3。根据修订版Jadad量表进行质量评价结果，1-3分为低质量，4-7分为高质量，结果显示高质量文献50篇[18，20，23-30，32，34-40，42-45，47，49-58，60-76]，低质量文献9篇[19，21-22，31，33，41，46，48，59]，平均4.35分，纳入文献总体质量较高，见表2。 2.4 传统Meta分析结果在改善经口摄食能力方面，涉及22篇文献[18-19，22，26-28，30-31，35-36，39，42，47，52-53，57，59，61，65，68-69，72]，包含9种电磁刺激方案，整体异质性检验I2=75%，P < 0.05，提示各研究间差异较大。剔除高异质性文献后整体异质性I2=57%，P < 0.05，异质性仍较高，因此仅对结果做描述性分析，与对照组相比，电磁刺激组(MD=1.00，95%CI：0.82-1.18)能显著提高患者经口摄食能力。根据干预方式的不同进行亚组分析，与常规训练相比，各电磁刺激方案均能显著提高患者经口摄食能力，见图4。在防误吸能力方面，涉及25篇文献[18，21，23-25，27，29，32-34，36-38，41，44，49-50，52，55，68，71-74，76]，包含8种电磁刺激方案，整体异质性检验I2=15%，P=0.22，各研究间差异较小，采用固定效应模型进行分析，结果表明，与对照组相比，电磁刺激组 (MD=-0.86，95%CI：-0.96至-0.76)能显著提高患者防误吸能力(P < 0.05)。根据干预方式的不同进行亚组分析，与常规训练相比，各电磁刺激方案均能显著提高患者防误吸能力，差异有显著性意义 (P < 0.05)，见图5。在提高吞咽肌群肌电活动水平方面，涉及13篇[24，41，45，50-51，54-55，58，60，62，66，74-75]文献，包含8种电磁刺激方案，整体异质性检验I2=89%，P < 0.05，提示各研究间差异较大。逐一剔除文献后异质性没有显著降低，采用随机效应模型进行分析，因此仅对结果做描述性分析，结果表明与对照组相比，电磁刺激组 (SMD=1.38，95%CI：1.21-1.25)能够较好地提高患者吞咽肌群肌电活动水平。按干预方式进行亚组分析后组内异质性显著降低，采用固定效应模型进行分析，结果表明，与常规训练相比，各电磁刺激方案均能显著提高患者咽肌群肌电活动水平(P < 0.05)，见图6。 2.5 网状Meta分析结果 2.5.1 网络证据图各指标的网络证据图，见图7。各圆点分别代表不同干预措施，圆点大小代表参与患者的数量，圆点之间的连线是两种干预措施之间直接比较研究的数量，实线越粗，表明直接比较的研究越多。 2.5.2 不一致性检验结果在功能性经口摄食量表评分结局指标方面，整体不一致检验P=0.87，节点分裂法对局部进行不一致性检验，结果显示各组比较P > 0.05。在渗透-误吸分级评分结局指标方面，整体不一致检验P=0.25，节点分裂法对局部进行不一致性检验，结果显示各组比较P > 0.05。在吞咽肌群表面肌电活动评分结局指标方面，整体不一致检验P=0.128，节点分裂法对局部进行不一致性检验，结果显示NMES与EMGBF两两对比存在局部不一致性，其他各组P > 0.05。通过Inconsistency图检验结局指标的环不一致性。3个结局指标的环不一致性因子(IF)的95%CI均包含0，表明直接比较和间接比较之间具有较好的一致性，见图8。 2.5.3 纳入研究的累积概率排序比较结果在功能性经口摄食量表评"

分评分结局指标方面，包括27篇文献[18-19，22，26-28，30-31，35-36，39，42-43，46-47，52-53，57，59，61，63-65，68-70，72]，共1 968例患者，涉及13种电磁刺激方案，与常规吞咽训练组相比，电磁刺激组在提高脑卒中后吞咽障碍患者经口摄食能力上效果更优，评分差异均具有显著性意义。在不同电磁刺激方案之间，rTMS+rPMS+NMES明显优于除rTMS+NMES外的其他电磁刺激方案，差异有显著性意义，见图9。各电磁刺激方案的最佳概率排序为rTMS+rPMS+NMES > rPMS+NMES > rTMS+NMES > rTMS+EMGBF > tDCS+NMES > rPMS > EMGBF+NMES > tDCS+EMGBF > tDCS > iTBS > NMES > rTMS > EMGBF > 常规吞咽训练，累计概率比较见图10。在渗透-误吸分级评分结局指标方面，包括30篇文献[18，21，23-25，27，29，32-34，36-38，41，44，49-50，52，55-56，63-64，67-68，70-74，76]，共1 512例患者，涉及11种电磁刺激方案，与常规吞咽训练组相比，电磁刺激组在提高脑卒中后吞咽障碍患者防误吸能力上效果更优，评分差异均具有显著性意义。在不同电磁刺激方案之间，rTMS+rPMS+NMES明显优于除rTMS+EMGBF外的其他电磁刺激方案，差异有显著性意义，见图9。各电磁刺激方案的最佳概率排序为rTMS+rPMS+NMES > rTMS+EMGBF > rTMS+NMES > rPMS+NMES > tDCS+NMES > rPMS > EMGBF > tDCS > iTBS > rTMS > NMES > 常规吞咽训练，累计概率比较见图10。在吞咽肌群表面肌电活动评分结局指标方面，包括16篇文献[20，24，40-41，45，48，50-51，54-55，58，60，62，66，74-75]，共1 165例患者，涉及12种电磁刺激方案，除iTBS和PES外，其他各电磁刺激组均优于常规吞咽训练组，评分差异有显著性意义。在不同电磁刺激方案之间，rTMS+NMES和rTMS+tDCS明显优于其他电磁刺激方案，评分差异有显著性意义，但两组间评分差异无显著性意义，见图9。各电磁刺激方案的最佳概率排序为rTMS+NMES > rTMS+tDCS > tDCS+NMES > EMGBF+NNMES > tDCS+EMGBF > tDCS > EMGBF > tDCS+NMES > NMES > rTMS > iTBS > PES > 常规吞咽训练，累积概率比较见图10。"

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