Repetitive Transcranial Magnetic Stimulation Strategies for Poststroke Dysphagia: A Systematic Review and Network Meta-analysis.

Abstract

Repetitive transcranial magnetic stimulation (rTMS) is a promising approach in improving swallowing function after stroke. However, comparative efficacy of different rTMS protocols for poststroke dysphagia (PSD) remains unclear. PubMed, Embase, and Cochrane database were systematically searched for eligible random controlled trials (RCTs) from inception to August 30, 2024. RCTs comparing rTMS with control or head-to-head comparisons of 2 rTMS protocols in patients with PSD. Data were extracted by 2 independent reviewers. A network meta-analysis combining direct and indirect evidence was conducted to assess the pooled findings of RCTs with standard mean difference (SMD) with 95% credible interval (CrI). Eighteen RCTs involving 760 participants (mean age of 62.4 [range 49.7-74.7] years; 45.7% women) were included. Pooled data showed that high frequency (HF)/ipsilesional hemisphere (ipsi-hemi) (SMD, -0.94; 95% CrI, -1.51 to -0.44), HF/bilateral hemisphere (bi-hemi) (SMD, -2.59; 95% CrI, -3.50 to -1.72), HF/ipsilesional cerebellar (ipsi-CRB) (SMD, -0.79; 95% CrI, -1.55 to -0.10), HF/bilateral cerebellar (bi-CRB) (SMD, -1.02; 95% CrI, -1.83 to -0.29), and HF/ipsi-hemi + low frequency (LF)/contralesional hemisphere (contra-hemi) (SMD, -2.72; 95% CrI, -4.12 to -1.41) rTMS all significantly improved swallowing function compared with control. For patients with acute stroke, HF/ipsi-hemi rTMS had a positive effect (SMD, -1.36; 95% CrI, -2.86 to -0.02); in subacute stage, HF/ipsi-hemi + LF/contra-hemi rTMS showed the best efficacy (SMD, -2.68; 95% CrI, -4.26 to -1.26). However, rTMS failed to improve swallowing function in chronic stage. This network meta-analysis showed that most of the rTMS protocols (HF/ipsi-hemi, HF/bi-hemi, HF/ipsi-CRB, HF/bi-CRB, and HF/ipsi-hemi + LF/contra-hemi) may improve swallowing function in patients with PSD. The HF/ipsi-hemi rTMS had a positive effect in acute stage and the HF/ipsi-hemi + LF/contra-hemi protocol seemed to have the best efficacy when applied in subacute stroke.