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Cortical and peripheral neurostimulation to improve swallowing function, aspiration, and dysphagia severity in
Kondwani J Banda1, Hsin Chu2, Chien-Mei Sung3
1School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Endoscopy Unit, Department of Surgery, Kamuzu Cortical Hospital, Ministry of Health, Lilongwe, Malawi.
Background:
Dysphagia compromises swallowing safety and efficiency, leading to malnutrition, dehydration, aspiration pneumonia, and frequent hospitalizations. Cortical neurostimulation therapies including transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and theta burst stimulation (TBS), peripheral neurostimulation therapies including, neuromuscular electrical stimulation (NMES) and pharyngeal electrical stimulation (PES), and paired associative stimulation (PAS) complement swallowing rehabilitative therapy (SRT) in dysphagia management. Despite growing evidence of their therapeutic potential, comparative evaluation of cortical and peripheral neurostimulation therapies in dysphagia management remains unexplored. Therefore, we conducted the first network meta-analysis (NMA) to explore comparative evidence of cortical and peripheral neurostimulation therapies on swallowing function, aspiration, and dysphagia severity for individuals with dysphagia.
Methods:
Cochrane Library, EBSCOHost, Embase, PubMed, CINAHL, and Web of Science were searched until June, 2025. MetaInsight, an interactive web-based application for conducting NMA, employing Frequentist and Bayesian approaches was used for data analysis presenting standardized mean difference with corresponding 95 % confidence intervals. Surface Under the Cumulative Ranking (SUCRA) was used for ranking of neurostimulation therapies.
Results:
A total of 72 randomized controlled trials with 3589 individuals with dysphagia were included. PAS + SRT 3.47 [1.43-5.50], TBS + SRT 2.56 [0.31-4.82], NMES + SRT 2.34 [0.60-4.07], tDCS + SRT 2.28 [0.51-4.06], and rTMS + SRT 2.12 [0.38-3.85] significantly improved global swallowing function with very-large effect. NMES + SRT -0.50 [-0.76-(-0.24)], rTMS + SRT -0.45 [-0.74-(-0.17)], and SRT -0.28 [-0.54-(-0.02)] significantly reduced pharyngeal transit time (PTT) with moderate to small effect. TBS + SRT -1.81 [-3.47-(-0.16)] and rTMS -1.58 [-3.04-(-0.12)] significantly reduced aspiration with very-large effect. PAS + SRT -5.43 [-8.81-(-2.04)], NMES + SRT -5.22 [-8.46-(-1.99)], NMES -4.90 [-8.50-(-1.30)], TBS + SRT -4.79 [-8.13-(-1.46)], tDCS + SRT -4.79 [-8.05-(-1.54)], PES + SRT -4.59 [-8.05-(-1.13)], and rTMS + SRT -4.58 [-7.74-(-1.43)], SRT -3.99 [-7.14-(-0.84)], rTMS -3.94 [-7.02-(-0.87)], and PAS -0.80 [-1.37-(-0.22)] significantly reduced dysphagia severity with very-large effect. SUCRA ranking revealed PAS + SRT for global swallowing function (94.6 %) and dysphagia severity (87.3 %), NMES + SRT for PTT (86.9 %), tDCS + SRT for OTT (87.2 %), and TBS + SRT for aspiration (91.0 %) as first ranked neurostimulation therapies.
Conclusion:
The findings suggest that the integration of PAS, followed by either cortical (tDCS, rTMS, TBS) or peripheral (NMES) neurostimulation therapies in combination with SRT, promote superior therapeutic benefits for improving swallowing recovery and safeguarding nutritional status of individuals with dysphagia.
Registration:
PROSPERO CRD420251031629.
