Review article (meta-analysis)| Volume 100, ISSUE 4, P739-750.e4, April 2019

Comparative Efficacy of Noninvasive Neurostimulation Therapies for Acute and Subacute Poststroke Dysphagia: A Systematic Review and Network Meta-analysis

Published:October 20, 2018DOI:



      To investigate the effectiveness of noninvasive neurostimulation therapies in patients with poststroke dysphagia.

      Data Sources

      Electronic databases, including Embase, PubMed, Scopus, and the Cochrane Library, were searched up to May 31, 2018.

      Study Selection

      All published randomized controlled trials (RCTs) comparing neurostimulation therapies, including repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), surface neuromuscular electrical stimulation (sNMES), and pharyngeal electrical stimulation (PES), in patients with acute and subacute poststroke dysphagia were included. Nineteen RCTs were enrolled in the meta-analysis.

      Data Extraction

      Full texts were independently reviewed. Two independent raters assessed the risk of bias of RCTs with the Cochrane risk-of-bias tool. The primary outcome measure was swallowing function evaluated before and after neurostimulation therapy.

      Data Synthesis

      Both pairwise and network meta-analysis revealed that rTMS, tDCS, and sNMES significantly improved poststroke dysphagia compared with placebo. Differences in functional improvement between PES and placebo were not significant. Based on probability ranking, rTMS seemed the best treatment among the 4 neurostimulation therapies. In the network meta-analysis, rTMS showed the best efficacy compared with placebo (standardized mean difference=1.02, 95% confidence interval, 0.61-1.43).


      Among the 4 noninvasive neurostimulation therapies, rTMS, tDCS, and sNMES were effective for treating poststroke dysphagia; furthermore, rTMS may be the most effective therapy according to probability ranking.


      List of abbreviations:

      CI (confidence interval), NIBS (noninvasive brain stimulation), PES (pharyngeal electrical stimulation), RCT (randomized controlled trial), rTMS (repetitive transcranial magnetic stimulation), SMD (standardized mean difference), sNMES (surface neuromuscular electrical stimulation), tDCS (transcranial direct current stimulation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mann G.
        • Hankey G.J.
        • Cameron D.
        Swallowing function after stroke: prognosis and prognostic factors at 6 months.
        Stroke. 1999; 30: 744-748
        • Roth E.J.
        • Lovell L.
        • Harvey R.L.
        • Heinemann A.W.
        • Semik P.
        • Diaz S.
        Incidence of and risk factors for medical complications during stroke rehabilitation.
        Stroke. 2001; 32: 523-529
        • Cohen D.L.
        • Roffe C.
        • Beavan J.
        • et al.
        Post-stroke dysphagia: a review and design considerations for future trials.
        Int J Stroke. 2016; 11: 399-411
        • Langhorne P.
        • Bernhardt J.
        • Kwakkel G.
        Stroke rehabilitation.
        Lancet. 2011; 377: 1693-1702
        • Jorgensen H.S.
        • Nakayama H.
        • Raaschou H.O.
        • Vive-Larsen J.
        • Stoier M.
        • Olsen T.S.
        Outcome and time course of recovery in stroke. Part II: time course of recovery. The Copenhagen Stroke Study.
        Arch Phys Med Rehabil. 1995; 76: 406-412
        • Mistry S.
        • Michou E.
        • Vasant D.H.
        • Hamdy S.
        Direct and indirect therapy: neurostimulation for the treatment of dysphagia after stroke.
        in: Ekberg O. Dysphagia: diagnosis and treatment. Springer-Verlag Berlin Heidelberg, New York2012: 519-538
        • Yang S.N.
        • Pyun S.B.
        • Kim H.J.
        • Ahn H.S.
        • Rhyu B.J.
        Effectiveness of non-invasive brain stimulation in dysphagia subsequent to stroke: a systemic review and meta-analysis.
        Dysphagia. 2015; 30: 383-391
        • Liao X.
        • Xing G.
        • Guo Z.
        • et al.
        Repetitive transcranial magnetic stimulation as an alternative therapy for dysphagia after stroke: a systematic review and meta-analysis.
        Clin Rehabil. 2017; 31: 289-298
        • Pisegna J.M.
        • Kaneoka A.
        • Pearson Jr., W.G.
        • Kumar S.
        • Langmore S.E.
        Effects of non-invasive brain stimulation on post-stroke dysphagia: a systematic review and meta-analysis of randomized controlled trials.
        Clin Neurophysiol. 2016; 127: 956-968
        • Chen Y.W.
        • Chang K.H.
        • Chen H.C.
        • Liang W.M.
        • Wang Y.H.
        • Lin Y.N.
        The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: a systemic review and meta-analysis.
        Clin Rehabil. 2016; 30: 24-35
        • Scutt P.
        • Lee H.S.
        • Hamdy S.
        • Bath P.M.
        Pharyngeal electrical stimulation for treatment of poststroke dysphagia: individual patient data meta-analysis of randomised controlled trials.
        Stroke Res Treat. 2015; 2015: 429053
        • Park E.
        • Kim M.S.
        • Chang W.H.
        • et al.
        Effects of bilateral repetitive transcranial magnetic stimulation on post-stroke dysphagia.
        Brain Stimul. 2017; 10: 75-82
        • Khedr E.M.
        • Abo-Elfetoh N.
        Therapeutic role of rTMS on recovery of dysphagia in patients with lateral medullary syndrome and brainstem infarction.
        J Neurol Neurosurg Psychiatry. 2010; 81: 495-499
        • Du J.
        • Yang F.
        • Liu L.
        • et al.
        Repetitive transcranial magnetic stimulation for rehabilitation of poststroke dysphagia: a randomized, double-blind clinical trial.
        Clin Neurophysiol. 2016; 127: 1907-1913
        • Zhang M.
        • Tao T.
        • Zhang Z.B.
        • et al.
        Effectiveness of neuromuscular electrical stimulation on patients with dysphagia with medullary infarction.
        Arch Phys Med Rehabil. 2016; 97: 355-362
        • Xia W.
        • Zheng C.
        • Lei Q.
        • et al.
        Treatment of post-stroke dysphagia by vitalstim therapy coupled with conventional swallowing training.
        J Huazhong Univ Sci Technolog Med Sci. 2011; 31: 73-76
        • Huang K.L.
        • Liu T.Y.
        • Huang Y.C.
        • Leong C.P.
        • Lin W.C.
        • Pong Y.P.
        Functional outcome in acute stroke patients with oropharyngeal dysphagia after swallowing therapy.
        J Stroke Cerebrovasc Dis. 2014; 23: 2547-2553
        • Bath P.M.
        • Scutt P.
        • Love J.
        • et al.
        Pharyngeal electrical stimulation for treatment of dysphagia in subacute stroke: a randomized controlled trial.
        Stroke. 2016; 47: 1562-1570
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151 (W64): 264-269
        • Higgins J.P.
        • Green S.
        Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.
        (Available at:) (Accessed October 30, 2018)
        • Fleiss J.L.
        The statistical basis of meta-analysis.
        Stat Methods Med Res. 1993; 2: 121-145
        • Hutton B.
        • Salanti G.
        • Caldwell D.M.
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
        • White I.R.
        Network meta-analysis.
        Stata J. 2015; 15: 951-985
        • Yu-Kang T.
        Node-splitting generalized linear mixed models for evaluation of inconsistency in network meta-analysis.
        Value Health. 2016; 19: 957-963
        • Tu Y.K.
        Using generalized linear mixed models to evaluate inconsistency within a network meta-analysis.
        Value Health. 2015; 18: 1120-1125
        • Terre R.
        • Mearin F.
        A randomized controlled study of neuromuscular electrical stimulation in oropharyngeal dysphagia secondary to acquired brain injury.
        Eur J Neurol. 2015; 22 (687-e44)
        • Ko K.R.
        • Park H.J.
        • Hyun J.K.
        • Seo I.H.
        • Kim T.U.
        Effect of laryngopharyngeal neuromuscular electrical stimulation on dysphonia accompanied by dysphagia in post-stroke and traumatic brain injury patients: a pilot study.
        Ann Rehabil Med. 2016; 40: 600-610
        • Kim L.
        • Chun M.H.
        • Kim B.R.
        • Lee S.J.
        Effect of repetitive transcranial magnetic stimulation on patients with brain injury and dysphagia.
        Ann Rehabil Med. 2011; 35: 765-771
        • Suntrup S.
        • Marian T.
        • Schroder J.B.
        • et al.
        Electrical pharyngeal stimulation for dysphagia treatment in tracheotomized stroke patients: a randomized controlled trial.
        Intensive Care Med. 2015; 41: 1629-1637
        • Dziewas R.
        • Mistry S.
        • Hamdy S.
        • et al.
        Design and implementation of pharyngeal electrical stimulation for early de-cannulation in TRACheotomized (PHAST-TRAC) stroke patients with neurogenic dysphagia: a prospective randomized single-blinded interventional study.
        Int J Stroke. 2017; 12: 430-437
        • Rofes L.
        • Arreola V.
        • Lopez I.
        • et al.
        Effect of surface sensory and motor electrical stimulation on chronic poststroke oropharyngeal dysfunction.
        Neurogastroenterol Motil. 2013; 25 (888-e701)
        • Park J.S.
        • Oh D.H.
        • Hwang N.K.
        • Lee J.H.
        Effects of neuromuscular electrical stimulation combined with effortful swallowing on post-stroke oropharyngeal dysphagia: a randomised controlled trial.
        J Oral Rehabil. 2016; 43: 426-434
        • Momosaki R.
        • Abo M.
        • Watanabe S.
        • Kakuda W.
        • Yamada N.
        • Mochio K.
        Functional magnetic stimulation using a parabolic coil for dysphagia after stroke.
        Neuromodulation. 2014; 17 ([discussion: 641]): 637-641
        • Michou E.
        • Mistry S.
        • Jefferson S.
        • Tyrrell P.
        • Hamdy S.
        Characterizing the mechanisms of central and peripheral forms of neurostimulation in chronic dysphagic stroke patients.
        Brain Stimul. 2014; 7: 66-73
        • Lim K.B.
        • Lee H.J.
        • Lim S.S.
        • Choi Y.I.
        Neuromuscular electrical and thermal-tactile stimulation for dysphagia caused by stroke: a randomized controlled trial.
        J Rehabil Med. 2009; 41: 174-178
        • Cheng I.K.
        • Chan K.M.
        • Wong C.S.
        • et al.
        Neuronavigated high-frequency repetitive transcranial magnetic stimulation for chronic post-stroke dysphagia: a randomized controlled study.
        J Rehabil Med. 2017; 49: 475-481
        • Ahn Y.H.
        • Sohn H.J.
        • Park J.S.
        • et al.
        Effect of bihemispheric anodal transcranial direct current stimulation for dysphagia in chronic stroke patients: a randomized clinical trial.
        J Rehabil Med. 2017; 49: 30-35
        • Cheng I.K.
        • Chan K.M.
        • Wong C.S.
        • Cheung R.T.
        Preliminary evidence of the effects of high-frequency repetitive transcranial magnetic stimulation (rTMS) on swallowing functions in post-stroke individuals with chronic dysphagia.
        Int J Lang Commun Disord. 2015; 50: 389-396
        • Li L.
        • Li Y.
        • Huang R.
        • Yin J.
        • Shen Y.
        • Shi J.
        The value of adding transcutaneous neuromuscular electrical stimulation (VitalStim) to traditional therapy for post-stroke dysphagia: a randomized controlled trial.
        Eur J Phys Rehabil Med. 2015; 51: 71-78
        • Lin W.S.
        • Chou C.L.
        • Chang M.H.
        • Chung Y.M.
        • Lin F.G.
        • Tsai P.Y.
        Vagus nerve magnetic modulation facilitates dysphagia recovery in patients with stroke involving the brainstem—a proof of concept study.
        Brain Stimul. 2018; 11: 264-270
        • Sproson L.
        • Pownall S.
        • Enderby P.
        • Freeman J.
        Combined electrical stimulation and exercise for swallow rehabilitation post-stroke: a pilot randomized control trial.
        Int J Lang Commun Disord. 2018; 53: 405-417
        • Konecny P.
        • Elfmark M.
        Electrical stimulation of hyoid muscles in post-stroke dysphagia.
        Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2018; 162: 40-42
        • Guillen-Sola A.
        • Messagi Sartor M.
        • Bofill Soler N.
        • Duarte E.
        • Barrera M.C.
        • Marco E.
        Respiratory muscle strength training and neuromuscular electrical stimulation in subacute dysphagic stroke patients: a randomized controlled trial.
        Clin Rehabil. 2017; 31: 761-771
        • Bulow M.
        • Speyer R.
        • Baijens L.
        • Woisard V.
        • Ekberg O.
        Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction.
        Dysphagia. 2008; 23: 302-309
        • Permsirivanich W.
        • Tipchatyotin S.
        • Wongchai M.
        • et al.
        Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study.
        J Med Assoc Thai. 2009; 92: 259-265
        • Park J.W.
        • Oh J.C.
        • Lee J.W.
        • Yeo J.S.
        • Ryu K.H.
        The effect of 5Hz high-frequency rTMS over contralesional pharyngeal motor cortex in post-stroke oropharyngeal dysphagia: a randomized controlled study.
        Neurogastroenterol Motil. 2013; 25 (324-e250)
        • Khedr E.M.
        • Abo-Elfetoh N.
        • Rothwell J.C.
        Treatment of post-stroke dysphagia with repetitive transcranial magnetic stimulation.
        Acta Neurol Scand. 2009; 119: 155-161
        • Yang E.J.
        • Baek S.R.
        • Shin J.
        • et al.
        Effects of transcranial direct current stimulation (tDCS) on post-stroke dysphagia.
        Restor Neurol Neurosci. 2012; 30: 303-311
        • Shigematsu T.
        • Fujishima I.
        • Ohno K.
        Transcranial direct current stimulation improves swallowing function in stroke patients.
        Neurorehabil Neural Repair. 2013; 27: 363-369
        • Kumar S.
        • Wagner C.W.
        • Frayne C.
        • et al.
        Noninvasive brain stimulation may improve stroke-related dysphagia: a pilot study.
        Stroke. 2011; 42: 1035-1040
        • Park J.W.
        • Kim Y.
        • Oh J.C.
        • Lee H.J.
        Effortful swallowing training combined with electrical stimulation in post-stroke dysphagia: a randomized controlled study.
        Dysphagia. 2012; 27: 521-527
        • Lee K.W.
        • Kim S.B.
        • Lee J.H.
        • Lee S.J.
        • Ri J.W.
        • Park J.G.
        The effect of early neuromuscular electrical stimulation therapy in acute/subacute ischemic stroke patients with dysphagia.
        Ann Rehabil Med. 2014; 38: 153-159
        • Vasant D.H.
        • Michou E.
        • O'Leary N.
        • Vail A.
        • Mistry S.
        • Hamdy S.
        Pharyngeal electrical stimulation in dysphagia poststroke: a prospective, randomized single-blinded interventional study.
        Neurorehabil Neural Repair. 2016; 30: 866-875
        • Jayasekeran V.
        • Singh S.
        • Tyrrell P.
        • et al.
        Adjunctive functional pharyngeal electrical stimulation reverses swallowing disability after brain lesions.
        Gastroenterology. 2010; 138: 1737-1746
        • Lim K.B.
        • Lee H.J.
        • Yoo J.
        • Kwon Y.G.
        Effect of low-frequency rTMS and NMES on subacute unilateral hemispheric stroke with dysphagia.
        Ann Rehabil Med. 2014; 38: 592-602
        • Suntrup-Krueger S.
        • Ringmaier C.
        • Muhle P.
        • et al.
        Randomized trial of transcranial direct current stimulation for poststroke dysphagia.
        Ann Neurol. 2018; 83: 328-340
        • Meng P.
        • Zhang S.
        • Wang Q.
        • et al.
        The effect of surface neuromuscular electrical stimulation on patients with post-stroke dysphagia.
        J Back Musculoskelet Rehabil. 2018; 31: 363-370
        • Sparing R.
        • Mottaghy F.M.
        Noninvasive brain stimulation with transcranial magnetic or direct current stimulation (TMS/tDCS)—from insights into human memory to therapy of its dysfunction.
        Methods. 2008; 44: 329-337
        • Dobek C.E.
        • Blumberger D.M.
        • Downar J.
        • Daskalakis Z.J.
        • Vila-Rodriguez F.
        Risk of seizures in transcranial magnetic stimulation: a clinical review to inform consent process focused on bupropion.
        Neuropsychiatr Dis Treat. 2015; 11: 2975-2987
        • Gallas S.
        • Marie J.P.
        • Leroi A.M.
        • Verin E.
        Sensory transcutaneous electrical stimulation improves post-stroke dysphagic patients.
        Dysphagia. 2010; 25: 291-297
        • Fraser C.
        • Power M.
        • Hamdy S.
        • et al.
        Driving plasticity in human adult motor cortex is associated with improved motor function after brain injury.
        Neuron. 2002; 34: 831-840