重复经颅磁刺激治疗中枢神经源性吞咽障碍疗效及安全性的meta分析

Efficacy and safety of repetitive transcranial magnetic stimulation treatment on central neurogenic dysphagia:A meta-analysis

目的系统评价重复经颅磁刺激治疗中枢神经源性吞咽障碍的临床疗效及安全性。方法搜索国内外数据库中关于重复经颅磁刺激治疗吞咽障碍的随机对照试验,检索的时间范围自建库至2022年1月15日。根据纳入和排除标准筛选文献、提取数据并分析,同时进行文献质量评价。最终入选文献17篇,包括英文11篇,中文6篇,共857例患者。采用Cochrane风险偏倚评估工具及物理治疗证据数据库评价表进行质量评价,RevMan和R语言进行数据分析。该系统评价在PROSPERO(CRD42022304209)上登记注册。结果Meta分析结果显示:与对照组比较,重复经颅磁刺激治疗可减轻吞咽功能障碍严重程度(SMD=-0.83,95%CI:-1.03~-0.63,Z=8.14,P<0.01),改善标准吞咽功能评定量表(Standardized Swallowing Assessment,SSA)评分(MD=-3.14,95%CI:-3.70~-2.57,Z=10.84,P<0.01)、洼田饮水试验(Water Swallow Test,WST)评分(MD=0.95,95%CI:0.82~1.07,Z=15.05,P<0.01)、渗透-误吸分级量表(Penetration-Aspiration Scale,PAS)评分(MD=-0.41,95%CI:-0.63~-0.19,Z=3.68,P<0.01)、表面肌电信号(surface Electromyography,sEMG)参数(SMD=-0.47,95%CI:-0.77~-0.16,Z=2.99,P<0.01)和Barthel指数(Barthel index,BI)评分(MD=22.50,95%CI:13.67~31.32,Z=4.99,P<0.01),在咽传递时间(Pharyngeal Transit Time,PTT)(MD=-0.07,95%CI:-0.16~0.02,Z=1.45,P=0.15)和不良事件(RR=2.63,95%CI:0.85~8.14,Z=1.68,P=0.09)方面无明显差异。结论重复经颅磁刺激治疗中枢神经源性吞咽障碍有一定的临床疗效,可减轻吞咽功能障碍严重程度,提高吞咽安全、效率及日常生活能力,且未发生明显的不良事件,但在食物通过咽部的时间方面改善不明显。上述结论仍需更多高质量的研究验证。

Objective To systematically analyze the clinical efficacy and safety of repetitive transcranial magnetic stimulation in the treatment of central neurogenic dysphagia.Methods Randomized controlled trials on the treatment of dysphagia by repetitive transcranial magnetic stimulation in domestic and foreign databases were thoroughly searched.The retrieval time ranged from database inception to January 15,2022.According to the inclusion and exclusion criteria,data were extracted from eligible literatures and analyzed.Literature quality was assessed.Finally,17 articles(11 English language-published articles and 6 Chinese language-published articles)were included with a total of 857 patients.The Cochrane Collaboration tool and the Physiotherapy Evidence Database were used to evaluate the risk of bias.RevMan software and R language programming were used for statistical analysis.This systematic review was registered on International Prospective Register of Systematic Reviews(PROSPERO;CRD42022304209).Results The results of meta-analysis showed that repetitive transcranial magnetic stimulation significantly reduced the severity of dysphagia(SMD=-0.83,95%CI:-1.03,-0.63,Z=8.14,P<0.01),improved the Standardized Swallowing Assessment(SSA)score(MD=-3.14,95%CI:-3.70,-2.57,Z=10.84,P<0.01),the Water Swallow Test(WST)score(MD=0.95,95%CI:0.82,1.07,Z=15.05,P<0.01),the Penetration-Aspiration Scale(PAS)score(MD=-0.41,95%CI:-0.63,-0.19,Z=3.68,P<0.01),surface electromyography(sEMG)parameters(SMD=-0.47,95%CI:-0.77,-0.16,Z=2.99,P<0.01)and the Barthel Index(BI)(MD=22.50,95%CI:13.67,31.32,Z=4.99,P<0.01).There were no significant differences in the pharyngeal transit time(PTT)(MD=-0.07,95%CI:-0.16,0.02,Z=1.45,P=0.15)and the incidence of adverse events(RR=2.63,95%CI:0.85,8.14,Z=1.68,P=0.09).Conclusion Repetitive transcranial magnetic stimulation has a certain clinical effect in the treatment of central neurogenic dysphagia,which can reduce the severity of dysphagia,improve swallowing safety,efficiency,and daily living ability,without obvious adverse events.However,it does not significantly improve the PTT.More high-quality studies are still needed to verify the above conclusions.