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

To investigate the effectiveness of noninvasive neurostimulation therapies in patients with poststroke dysphagia.Electronic databases, including Embase, PubMed, Scopus, and the Cochrane Library, were searched up to May 31, 2018.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.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.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.