Noninvasive brain stimulation for dysphagia after acquired brain injury : a systematic review

The purpose of this study was to review the best available evidence of noninvasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) for dysphagia after acquired brain injury. We searched randomized controlled trials that compared noninvasive brain stimulation with control used to improve dysphagia after acquired brain injury. We assessed dysphagia severity rating scales and penetration-aspiration scale as outcomes immediately after intervention. We calculated the pooled estimate of the standardized mean difference (SMD) to combine individual results. We included 8 published studies. Two heterogenous trials of 48 patients showed that rTMS was associated with a significant improvement in the dysphagia severity rating scale score (SMD 2.95). Three homogeneous trials of 88 patients showed a significant effect of rTMS on the penetration-aspiration scale score (SMD 0.77). Two homogeneous trials of 34 patients showed that tDCS was associated with a significant improvement in the dysphagia severity rating scale score (SMD 1.20). The review provided low-quality evidence for the effectiveness of noninvasive brain stimulation in improving dysphagia after acquired brain injury. Further trials of larger sample sizes are needed to determine the most appropriate noninvasive brain stimulation protocol

A multi-center study on low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis in post-stroke patients

<p>Abstract</p> <p>Background</p> <p>Both low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) have been recently reported to be clinically beneficial for post-stroke patients with upper limb hemiparesis. Based on these reports, we developed an inpatient combination protocol of these two modalities for the treatment of such patients. The aims of this pilot study were to confirm the safety and feasibility of the protocol in a large number of patients from different institutions, and identify predictors of the clinical response to the treatment.</p> <p>Methods</p> <p>The study subjects were 204 post-stroke patients with upper limb hemiparesis (mean age at admission 58.5 ± 13.4 years, mean time after stroke 5.0 ± 4.5 years, ± SD) from five institutions in Japan. During 15-day hospitalization, each patient received 22 treatment sessions of 20-min low-frequency rTMS and 120-min intensive OT daily. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere over the primary motor area. The intensive OT, consisting of 60-min one-to-one training and 60-min self-exercise, was provided after the application of low-frequency rTMS. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were performed serially. The physiatrists and occupational therapists involved in this study received training prior to the study to standardize the therapeutic protocol.</p> <p>Results</p> <p>All patients completed the protocol without any adverse effects. The FMA score increased and WMFT log performance time decreased significantly at discharge, relative to the respective values at admission (change in FMA score: median at admission, 47 points; median at discharge, 51 points; p < 0.001. change in WMFT log performance time: median at admission, 3.23; median at discharge, 2.51; p < 0.001). These changes were persistently seen up to 4 weeks after discharge in 79 patients. Linear regression analysis found no significant relationship between baseline parameters and indexes of improvement in motor function.</p> <p>Conclusions</p> <p>The 15-day inpatient rTMS plus OT protocol is a safe, feasible, and clinically useful neurorehabilitative intervention for post-stroke patients with upper limb hemiparesis. The response to the treatment was not influenced by age or time after stroke onset. The efficacy of the intervention should be confirmed in a randomized controlled study including a control group.</p

Bilateral Repetitive Transcranial Magnetic Stimulation Combined with Intensive Swallowing Rehabilitation for Chronic Stroke Dysphagia: A Case Series Study

The purpose of this study was to clarify the safety and feasibility of a 6-day protocol of bilateral repetitive transcranial magnetic stimulation (rTMS) combined with intensive swallowing rehabilitation for chronic poststroke dysphagia. In-hospital treatment was provided to 4 poststroke patients (age at treatment: 56-80 years; interval between onset of stroke and treatment: 24-37 months) with dysphagia. Over 6 consecutive days, each patient received 10 sessions of rTMS at 3 Hz applied to the pharyngeal motor cortex bilaterally, followed by 20 min of intensive swallowing rehabilitation exercise. The swallowing function was evaluated by the Penetration Aspiration Scale (PAS), Modified Mann Assessment of Swallowing Ability (MMASA), Functional Oral Intake Scale (FOIS), laryngeal elevation delay time (LEDT) and Repetitive Saliva-Swallowing Test (RSST) on admission and at discharge. All patients completed the 6-day treatment protocol and none showed any adverse reactions throughout the treatment. The combination treatment improved laryngeal elevation delay time in all patients. Our proposed protocol of rTMS plus swallowing rehabilitation exercise seems to be safe and feasible for chronic stroke dysphagia, although its efficacy needs to be confirmed in a large number of patients

Clinical Effectiveness of Board-certificated Physiatrists on Functional Recovery in Elderly Stroke Patients During Convalescence: A Retrospective Cohort Study

Background: Rehabilitation is an important determinant of functional recovery in elderly stroke patients. The purpose of this study was to clarify the clinical effectiveness of board-certificated physiatrists as responsible physicians on functional recovery in elderly stroke patients during convalescence. Methods: In this retrospective study, we analyzed the data of post-stroke patients admitted to rehabilitation wards entered into the Japan Rehabilitation Database between 2005 and 2013. The main outcome was Functional Independence Measure efficiency. For analysis, we used propensity scores and inverse probability weighting adjustment to reduce selection bias. A generalized estimation equation was used to account for confounding by cluster. Results: A total of 2873 patients (mean age: 70) were eligible after applying exclusion criteria. The responsible physicians caring for 1214 stroke patients were board-certificated physiatrists. Using inverse propensity score weighting, patients' baseline characteristics were closely balanced between patients who were managed by board-certificated physiatrists and those without board-certificated physiatrists. After adjustment, patients who were managed by a board-certificated physiatrist as a responsible physician had significantly higher scores for Functional Independence Measure efficiency than those without a board-certificated physiatrist (mean: 0.31 vs 0.28; p = 0.035). Conclusions: Our results suggest that clinical management provided to elderly stroke patients by board-certificated physiatrists is associated with good functional improvement. Board certification should be encouraged to improve the quality of rehabilitative management of post-stroke patients