Efficacy of repetitive transcranial magnetic stimulation combined with balloon dilatation and routine swallowing training in the treatment of dysphagia caused by cricopharyngeal dysfunction after stroke_West China Medical Journal

Authors：

WANG Juan ¹ , ZHENG Chanjuan ¹ , XU Ting ¹ , HUA Qiang ¹ , CUI Xiaoyang ¹ , LU Rong ¹ ,  XIA Wenguang ^1,2

1. Department of Rehabilitation Medicine, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Wuhan, Hubei 430015, P. R. China;
2. Hospitals Directly Under the Government of Hubei Province (Rehabilitation Hospital of Hubei Province), Wuhan, Hubei 430061, P. R. China;

Corresponding?author：

XIA Wenguang, Email: docxwg@163.com

Keywords：

Repetitive transcranial magnetic stimulation; balloon dilatation; stroke; cricopharyngeal dysfunction; dysphagia

DOI：

10.7507/1002-0179.202304094

Video：

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Objective To observe the clinical effect of repetitive transcranial magnetic stimulation (rTMS) combined with balloon dilatation and routine swallowing training on dysphagia caused by cricopharyngeal dysfunction (CPD) after stroke. Methods Patients with dysphagia after stroke who were hospitalized at Hubei Provincial Hospital of Integrated Chinese and Western Medicine between January 2022 and February 2023 were selected. The patients were divided into the trial group and the control group by random number table method. The control group received balloon dilatation and routine swallowing training, and the trial group received rTMS based on the treatment plan of the control group. All patients were treated for 3 weeks. The videofluoroscopic swallowing study (VFSS), Penetration Aspiration Scale (PAS), and Functional Oral Intake Scale (FOIS) were used at pre-therapy and 3 weeks after treatment to assess the improvement of swallowing function. Results A total of 49 patients were included, including 25 in the trial group and 24 in the control group. There was no statistically significant difference in age, gender, course of disease, stroke type, and swallowing function before treatment between the two groups of patients (P>0.05). After 3 weeks of treatment, the VFSS dysphagia scores (Z=?4.465, ?4.327, P<0.001) of the trial group and the control group were higher than those before treatment, and the trial group was better than that in the control group (t=2.099, P=0.041). The PAS scores (Z=?4.179, ?3.729, P<0.001) and FOIS scores (Z=?4.476, ?4.419, P<0.001) of the trial and control groups were improved after treatment, and the improvement of the PAS score (t=?2.088, P=0.042) and FOIS score (Z=?2.134, P=0.033) in the trial group were more significant (P<0.05). No serious adverse reactions were observed in patients during the study process. Conclusion The rTMS combined with balloon dilatation and routine swallowing training can significantly improve the swallowing function of patients with dysphagia caused by CPD after stroke, and further improve its clinical efficacy, worthy of clinical application.

Citation： WANG Juan, ZHENG Chanjuan, XU Ting, HUA Qiang, CUI Xiaoyang, LU Rong, XIA Wenguang. Efficacy of repetitive transcranial magnetic stimulation combined with balloon dilatation and routine swallowing training in the treatment of dysphagia caused by cricopharyngeal dysfunction after stroke. West China Medical Journal, 2023, 38(6): 843-849. doi: 10.7507/1002-0179.202304094 Copy

1.	李超, 張夢清, 竇祖林, 等. 中國特定人群吞咽功能障礙的流行病學調查報告. 中華物理醫學與康復雜志, 2017, 39(12): 937-943.
2.	胡佑紅, 衛小梅, 竇祖林. 導管球囊擴張治療環咽肌功能障礙的機制. 中華腦科疾病與康復雜志 (電子版), 2011, 1(1): 82-87.
3.	萬桂芳, 竇祖林, 蘭月, 等. 球囊擴張術中球囊容積與吞咽功能恢復的相關性分析. 中華物理醫學與康復雜志, 2009, 31(12): 820-822.
4.	Kocdor P, Siegel ER, Tulunay-Ugur OE. Cricopharyngeal dysfunction: a systematic review comparing outcomesof dilatation, botulinum toxin injection, and myotomy. Laryngoscope, 2016, 126(1): 135-141.
5.	Ashman A, Dale OT, Baldwin DL. Management of isolated cricopharyngeal dysfunction: systematic review. J Laryngol Otol, 2016, 130(7): 611-615.
6.	朱榕, 張莉, 楊平, 等. 導尿管球囊擴張術對神經源性環咽肌失遲緩癥治療效果的 Meta 分析. 中國康復醫學雜志, 2018, 33(5): 573-577.
7.	蘭月, 竇祖林, 萬桂芳, 等. 球囊擴張術治療腦干病變后環咽肌失弛緩癥的療效研究. 中華物理醫學與康復雜志, 2009, 31(12): 835-838.
8.	閆瑩瑩, 郭鋼花, 郭君, 等. 不同頻率高頻重復經顱磁刺激治療單側腦卒中患者吞咽障礙的療效觀察. 中國康復, 2022, 37(8): 486-488.
9.	Du J, Yang F, Liu L, et al. Repetitive transcrannial magnetic stimulation for rehabilatition of paststroke dysphagia: a randomized, double-blind clinical trial. Clin Neurophysiol, 2016, 127(3): 1907-1913.
10.	中華醫學會神經病學分會, 中華醫學會神經病學分會腦血管病學組. 中國各類主要腦血管病診斷要點 2019. 中華神經科雜志, 2019, 52(9): 710-715.
11.	趙瀛, 晏正梅, 陸巧妙, 等. 肉毒毒素注射聯合球囊擴張治療慢性腦卒中后環咽肌功能障礙的療效研究. 中國實用醫藥, 2020, 15(36): 1-3.
12.	中國醫師協會神經調控專業委員會電休克與神經刺激學組. 重復經顱磁刺激治療專家共識. 轉化醫學雜志, 2018, 7(1): 4-9.
13.	Song W, Du B, Xu Q, et al. Low-frequency transcranial magnetic stimulation for visual spatial neglect: a pilot study. J Rehabil Med, 2009, 41(3): 162-165.
14.	中國吞咽障礙康復評估與治療專家共識組. 中國吞咽障礙評估與治療專家共識(2017 年版)第一部分: 評估篇. 中華物理醫學與康復雜志, 2017, 39(12): 881-892.
15.	Costa MM. Videofluoroscopy: the gold standard exam for studying swallowing and its dysfunction. Arq Gastroenterol, 2010, 47(4): 327-328.
16.	張百祥, 華何柳, 王秀玲, 等. 導尿管球囊擴張術在腦卒中后環咽肌失弛緩所致吞咽障礙患者中的應用研究. 中華物理醫學與康復雜志, 2018, 40(7): 512-514.
17.	戴萌, 竇祖林, 衛小梅, 等. 吞咽造影的分析及應用進展. 中國康復醫學雜志, 2016, 31(11): 1269-1272.
18.	Rosenbek JC, Robbins JA, Roecker EB, et al. A penetration-aspiration scale. Dysphagia, 1996, 11(2): 93-98.
19.	Robbins J, Coyle J, Rosenbek J, et al. Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 1999, 14(4): 228-232.
20.	Crary MA, Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil, 2005, 86(8): 1516-1520.
21.	Zhou H, Zhu Y, Zhang X. Validation of the Chinese version of the Functional Oral Intake Scale (FOIS) score in the assessment of acute stroke patients with dysphagia. Stud Health Technol Inform, 2017, 245: 1195-1199.
22.	王修敏, 夏清. 環咽肌失弛緩癥與環咽肌功能障礙辨析. 中華物理醫學與康復雜志, 2016, 38(12): 958-960.
23.	Arenaz Búa B, Olsson R, Westin U, et al. Treatment of cricopharyngeal dysfunction: a comparative pilot study. BMC Res Notes, 2015, 8: 301.
24.	Allen JE. Cricopharyngeal function or dysfunction: what’s the deal?. Curr Opin Otolaryngol Head Neck Surg, 2016, 24(6): 494-499.
25.	金琳娜, 廖志平, 鄒朝君. 導管球囊擴張術治療腦卒中患者環咽肌功能障礙的研究進展. 中華物理醫學與康復雜志, 2018, 40(12): 957-960.
26.	舒璇, 劉淑芬, 陳麗霞. 非侵入性腦刺激技術在神經系統疾病康復中的應用進展. 華西醫學, 2021, 36(5): 566-571.
27.	王曈, 董凌輝, 孟萍萍, 等. 重復經顱磁刺激治療卒中后吞咽困難的相關臨床研究進展. 中華物理醫學與康復雜志, 2022, 44(10): 931-934.
28.	Hamdy S, Aziz Q, Rothwell JC, et al. Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Gastroenterology, 1998, 1l5(5): l104-1112.
29.	Murase N, Duque J, Mazzocchio R, et al. Influence of interhemispheric interactions on motor function in chronic stroke. Ann Neurol, 2004, 55(3): 400-409.
30.	柳華, 韓肖華, 黃曉琳. 重復經顱磁刺激調控皮質興奮性的影響因素及機制. 中國康復醫學雜志, 2017, 32(3): 354-358.
31.	王京利, 張志強, 張立新, 等. 重復經顱磁刺激治療卒中后吞咽障礙的研究進展. 中國康復醫學雜志, 2019, 34(12): 1493-1496.
32.	Roque C, Pinto N, Vaz Patto M, et al. Astrocytes contribute to the neuronal recovery promoted by high-frequency repetitive magnetic stimulation in in vitro models of ischemia. J Neurosci Res, 2021, 99(5): 1414-1432.
33.	Baek A, Kim JH, Pyo S, et al. The differential effects of repetitive magnetic stimulation in an in vitro neuronal model of ischemia/reperfusion injury. Front Neurol, 2018, 9: 50.
34.	Wen X, Liu Z, Zhong L, et al. The effectiveness of repetitive transcranial magnetic stimulation for post-stroke dysphagia: a systematic review and Meta-analysis. Front Hum Neurosci, 2022, 16: 841781.
35.	Xie YL, Wang S, Jia JM, et al. Transcranial magnetic stimulation for improving dysphagia after stroke: a Meta-analysis of randomized controlled trials. Front Neurosci. 2022, 16: 854219.
36.	Wagner T, Valero-Cabre A, Pascual-Leone A. Noninvasive human brain stimulation. Annu Rev Biomed Eng, 2007, 9: 527-565.
37.	衛小梅, 竇祖林, 蘭月, 等. 吞咽障礙干預的中樞神經通路調控機制. 中華物理醫學與康復雜志, 2013, 35(12): 934-937.
38.	Cheng IKY, Chan KMK, Wong CS, et al. Neuronavigated high-frequency repetitive transcranial magnetic stimulation for chronic post-stroke dysphagia: a randomized controlled study. J Rehabil Med, 2017, 49(6): 475-481.
39.	李曉麗, 郭鋼花, 李哲, 等. 重復經顱磁刺激對腦出血術后吞咽障礙伴顱骨缺損患者吞咽功能的影響. 中華物理醫學與康復雜志, 2021, 43(3): 243-245.
40.	Mistry S, Verin E, Singh S, et al. Unilateral suppression of pharyngeal motor cortex to repetitive transcranial magnetic stimulation reveals functional asymmetry in the hemispheric projections to human swallowing. J Physiol, 2007, 585(Pt2): 525-538.
41.	Modugno N, Nakamura Y, Mackinnon CD, et al. Motor cortex excitability following short trains of repetitive magnetic stimuli. Exp Brain Res, 2001, 140(4): 453-459.
42.	Khedr EM, 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(5): 495-499.
43.	Park E, Kim MS, Chang WH, et a1. Effects of bilateral repetitive transcranial magnetic stimulation on post-stroke dysphagia. Brain Stimul, 2017, 10(1): 75-82.
44.	劉袁穎, 竇艷仙, 李哲賢, 等. 重復經顱磁刺激聯合針刺治療腦梗死后吞咽障礙對吞咽功能及皮質興奮性的影響. 中國醫學物理學雜志, 2022, 39(5): 623-626.
45.	王偉, 劉亞群, 楊娜. 導管球囊擴張術聯合重復經顱磁刺激治療腦卒中后環咽肌失弛緩致吞咽功能障礙的臨床觀察. 中華物理醫學與康復雜志, 2021, 43(8): 717-720.

1. 李超, 張夢清, 竇祖林, 等. 中國特定人群吞咽功能障礙的流行病學調查報告. 中華物理醫學與康復雜志, 2017, 39(12): 937-943.
2. 胡佑紅, 衛小梅, 竇祖林. 導管球囊擴張治療環咽肌功能障礙的機制. 中華腦科疾病與康復雜志 (電子版), 2011, 1(1): 82-87.
3. 萬桂芳, 竇祖林, 蘭月, 等. 球囊擴張術中球囊容積與吞咽功能恢復的相關性分析. 中華物理醫學與康復雜志, 2009, 31(12): 820-822.
4. Kocdor P, Siegel ER, Tulunay-Ugur OE. Cricopharyngeal dysfunction: a systematic review comparing outcomesof dilatation, botulinum toxin injection, and myotomy. Laryngoscope, 2016, 126(1): 135-141.
5. Ashman A, Dale OT, Baldwin DL. Management of isolated cricopharyngeal dysfunction: systematic review. J Laryngol Otol, 2016, 130(7): 611-615.
6. 朱榕, 張莉, 楊平, 等. 導尿管球囊擴張術對神經源性環咽肌失遲緩癥治療效果的 Meta 分析. 中國康復醫學雜志, 2018, 33(5): 573-577.
7. 蘭月, 竇祖林, 萬桂芳, 等. 球囊擴張術治療腦干病變后環咽肌失弛緩癥的療效研究. 中華物理醫學與康復雜志, 2009, 31(12): 835-838.
8. 閆瑩瑩, 郭鋼花, 郭君, 等. 不同頻率高頻重復經顱磁刺激治療單側腦卒中患者吞咽障礙的療效觀察. 中國康復, 2022, 37(8): 486-488.
9. Du J, Yang F, Liu L, et al. Repetitive transcrannial magnetic stimulation for rehabilatition of paststroke dysphagia: a randomized, double-blind clinical trial. Clin Neurophysiol, 2016, 127(3): 1907-1913.
10. 中華醫學會神經病學分會, 中華醫學會神經病學分會腦血管病學組. 中國各類主要腦血管病診斷要點 2019. 中華神經科雜志, 2019, 52(9): 710-715.
11. 趙瀛, 晏正梅, 陸巧妙, 等. 肉毒毒素注射聯合球囊擴張治療慢性腦卒中后環咽肌功能障礙的療效研究. 中國實用醫藥, 2020, 15(36): 1-3.
12. 中國醫師協會神經調控專業委員會電休克與神經刺激學組. 重復經顱磁刺激治療專家共識. 轉化醫學雜志, 2018, 7(1): 4-9.
13. Song W, Du B, Xu Q, et al. Low-frequency transcranial magnetic stimulation for visual spatial neglect: a pilot study. J Rehabil Med, 2009, 41(3): 162-165.
14. 中國吞咽障礙康復評估與治療專家共識組. 中國吞咽障礙評估與治療專家共識(2017 年版)第一部分: 評估篇. 中華物理醫學與康復雜志, 2017, 39(12): 881-892.
15. Costa MM. Videofluoroscopy: the gold standard exam for studying swallowing and its dysfunction. Arq Gastroenterol, 2010, 47(4): 327-328.
16. 張百祥, 華何柳, 王秀玲, 等. 導尿管球囊擴張術在腦卒中后環咽肌失弛緩所致吞咽障礙患者中的應用研究. 中華物理醫學與康復雜志, 2018, 40(7): 512-514.
17. 戴萌, 竇祖林, 衛小梅, 等. 吞咽造影的分析及應用進展. 中國康復醫學雜志, 2016, 31(11): 1269-1272.
18. Rosenbek JC, Robbins JA, Roecker EB, et al. A penetration-aspiration scale. Dysphagia, 1996, 11(2): 93-98.
19. Robbins J, Coyle J, Rosenbek J, et al. Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 1999, 14(4): 228-232.
20. Crary MA, Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil, 2005, 86(8): 1516-1520.
21. Zhou H, Zhu Y, Zhang X. Validation of the Chinese version of the Functional Oral Intake Scale (FOIS) score in the assessment of acute stroke patients with dysphagia. Stud Health Technol Inform, 2017, 245: 1195-1199.
22. 王修敏, 夏清. 環咽肌失弛緩癥與環咽肌功能障礙辨析. 中華物理醫學與康復雜志, 2016, 38(12): 958-960.
23. Arenaz Búa B, Olsson R, Westin U, et al. Treatment of cricopharyngeal dysfunction: a comparative pilot study. BMC Res Notes, 2015, 8: 301.
24. Allen JE. Cricopharyngeal function or dysfunction: what’s the deal?. Curr Opin Otolaryngol Head Neck Surg, 2016, 24(6): 494-499.
25. 金琳娜, 廖志平, 鄒朝君. 導管球囊擴張術治療腦卒中患者環咽肌功能障礙的研究進展. 中華物理醫學與康復雜志, 2018, 40(12): 957-960.
26. 舒璇, 劉淑芬, 陳麗霞. 非侵入性腦刺激技術在神經系統疾病康復中的應用進展. 華西醫學, 2021, 36(5): 566-571.
27. 王曈, 董凌輝, 孟萍萍, 等. 重復經顱磁刺激治療卒中后吞咽困難的相關臨床研究進展. 中華物理醫學與康復雜志, 2022, 44(10): 931-934.
28. Hamdy S, Aziz Q, Rothwell JC, et al. Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Gastroenterology, 1998, 1l5(5): l104-1112.
29. Murase N, Duque J, Mazzocchio R, et al. Influence of interhemispheric interactions on motor function in chronic stroke. Ann Neurol, 2004, 55(3): 400-409.
30. 柳華, 韓肖華, 黃曉琳. 重復經顱磁刺激調控皮質興奮性的影響因素及機制. 中國康復醫學雜志, 2017, 32(3): 354-358.
31. 王京利, 張志強, 張立新, 等. 重復經顱磁刺激治療卒中后吞咽障礙的研究進展. 中國康復醫學雜志, 2019, 34(12): 1493-1496.
32. Roque C, Pinto N, Vaz Patto M, et al. Astrocytes contribute to the neuronal recovery promoted by high-frequency repetitive magnetic stimulation in in vitro models of ischemia. J Neurosci Res, 2021, 99(5): 1414-1432.
33. Baek A, Kim JH, Pyo S, et al. The differential effects of repetitive magnetic stimulation in an in vitro neuronal model of ischemia/reperfusion injury. Front Neurol, 2018, 9: 50.
34. Wen X, Liu Z, Zhong L, et al. The effectiveness of repetitive transcranial magnetic stimulation for post-stroke dysphagia: a systematic review and Meta-analysis. Front Hum Neurosci, 2022, 16: 841781.
35. Xie YL, Wang S, Jia JM, et al. Transcranial magnetic stimulation for improving dysphagia after stroke: a Meta-analysis of randomized controlled trials. Front Neurosci. 2022, 16: 854219.
36. Wagner T, Valero-Cabre A, Pascual-Leone A. Noninvasive human brain stimulation. Annu Rev Biomed Eng, 2007, 9: 527-565.
37. 衛小梅, 竇祖林, 蘭月, 等. 吞咽障礙干預的中樞神經通路調控機制. 中華物理醫學與康復雜志, 2013, 35(12): 934-937.
38. Cheng IKY, Chan KMK, Wong CS, et al. Neuronavigated high-frequency repetitive transcranial magnetic stimulation for chronic post-stroke dysphagia: a randomized controlled study. J Rehabil Med, 2017, 49(6): 475-481.
39. 李曉麗, 郭鋼花, 李哲, 等. 重復經顱磁刺激對腦出血術后吞咽障礙伴顱骨缺損患者吞咽功能的影響. 中華物理醫學與康復雜志, 2021, 43(3): 243-245.
40. Mistry S, Verin E, Singh S, et al. Unilateral suppression of pharyngeal motor cortex to repetitive transcranial magnetic stimulation reveals functional asymmetry in the hemispheric projections to human swallowing. J Physiol, 2007, 585(Pt2): 525-538.
41. Modugno N, Nakamura Y, Mackinnon CD, et al. Motor cortex excitability following short trains of repetitive magnetic stimuli. Exp Brain Res, 2001, 140(4): 453-459.
42. Khedr EM, 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(5): 495-499.
43. Park E, Kim MS, Chang WH, et a1. Effects of bilateral repetitive transcranial magnetic stimulation on post-stroke dysphagia. Brain Stimul, 2017, 10(1): 75-82.
44. 劉袁穎, 竇艷仙, 李哲賢, 等. 重復經顱磁刺激聯合針刺治療腦梗死后吞咽障礙對吞咽功能及皮質興奮性的影響. 中國醫學物理學雜志, 2022, 39(5): 623-626.
45. 王偉, 劉亞群, 楊娜. 導管球囊擴張術聯合重復經顱磁刺激治療腦卒中后環咽肌失弛緩致吞咽功能障礙的臨床觀察. 中華物理醫學與康復雜志, 2021, 43(8): 717-720.

West China Medical Journal

Efficacy of repetitive transcranial magnetic stimulation combined with balloon dilatation and routine swallowing training in the treatment of dysphagia caused by cricopharyngeal dysfunction after stroke

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