不同模式经颅磁刺激对脑卒中后吞咽障碍患者的干预效果:贝叶斯网状Meta分析

Intervention Effect of Different Modes of Transcranial Magnetic Stimulation on Patients with Post-Stroke Dysphagia:a Bayesian Network Meta-analysis

目的通过贝叶斯网状Meta分析探讨不同模式经颅磁刺激(TMS)对脑卒中后吞咽障碍(PSD)患者的干预效果。方法计算机检索中国知网、维普网、万方数据知识服务平台、中国生物医学文献数据库、PubMed、Cochrane Library、Embase、Web of Science、CINAHL和Medline中关于不同模式TMS干预PSD患者的随机对照试验,检索时限为建库至2023-11-01。由两名研究人员独立筛选文献、提取资料并评价文献偏倚风险。试验组采用不同模式TMS治疗,对照组采用常规吞咽障碍治疗(CTD)或假刺激,结局指标包括吞咽功能指标〔标准吞咽功能评估量表(SSA)、纤维鼻咽内镜吞咽障碍严重程度量表(FEDSS)、功能性经口摄食量表(FOIS)评分〕、误吸风险指标〔渗透-误吸量表(PAS)评分〕及不良反应。采用R 4.3.0软件进行Meta分析、贝叶斯网状Meta分析。结果最终纳入26篇文献,样本量为1185例,其中对照组634例、试验组551例。Meta分析结果显示,接受3 Hz-重复经颅磁刺激(rTMS)治疗的PSD患者SSA评分低于接受CTD者,接受1 Hz-rTMS、3 Hz-rTMS、5 Hz-rTMS、10 Hz-rTMS、间歇性Theta爆发式磁刺激(iTBS)治疗的PSD患者SSA评分低于接受假刺激治疗者(P<0.05);接受5 Hz-rTMS、10 Hz-rTMS、iTBS治疗的PSD患者FEDSS评分低于接受假刺激治疗者(P<0.05);接受3 Hz-rTMS、5 Hz-rTMS治疗的PSD患者FOIS评分高于接受CTD者,接受1 Hz-rTMS、iTBS治疗的PSD患者FOIS评分高于接受假刺激治疗者(P<0.05);接受3 Hz-rTMS、5 Hz-rTMS、10 Hz-rTMS、iTBS治疗的PSD患者PAS评分低于接受CTD者,接受1 Hz-rTMS、5 Hz-rTMS、10 Hz-rTMS、iTBS治疗的PSD患者PAS评分低于接受假刺激治疗者(P<0.05)。贝叶斯网状Meta分析结果显示,接受3 Hz-rTMS治疗的PSD患者SSA评分低于接受CTD者,接受3 Hz-rTMS、5 Hz-rTMS、iTBS治疗的PSD患者SSA评分低于接受假刺激治疗者(P<0.05);接受10 Hz-rTMS、iTBS治疗的PSD患者FEDSS评分低于接受假刺激治疗者(P<0.05);接受3 Hz-rTMS、5 Hz-rTMS、10 Hz-rTMS、iTBS治疗的PSD患者PAS评分低于接受CTD者,接受1 Hz-rTMS、3 Hz-rTMS、5 Hz-rTMS、10 Hz-rTMS、iTBS治疗的PSD患者PAS评分低于接受假刺激治疗者(P<0.05)。累积排序概率图分析结果显示,PSD患者SSA、FEDSS、FOIS评分累积排序概率图下面积(SUCRA)最大的治疗方式分别为3 Hz-rTMS、iTBS、3 Hz-rTMS,PAS评分SUCRA最大的治疗方式为iTBS。26篇文献中8篇文献报告治疗过程中患者未出现任何不良反应、5篇文献报告的不良反应轻微。结论3 Hz-rTMS、iTBS在改善PSD患者吞咽功能方面可能更有效,iTBS在降低PSD患者吞咽风险方面可能更有效;不同模式TMS干预PSD患者的不良反应较少,且症状多轻微。

Objective To investigate the intervention effect of different modes of transcranial magnetic stimulation(TMS)on patients with post-stroke dysphagia(PSD)using Bayesian network meta-analysis.Methods CNKI,VIP,Wanfang Data,Chinese Biomedical Literature Database,PubMed,Cochrane Library,Embase,Web of Science,CINAHL and Medline were searched to collect randomised controlled trials on different modes of TMS of intervention for patients with PSD,with a timeframe of the search being from database construction to 2023-11-01.Two researchers independently screened the literature,extracted information and assessed the risk of literature bias.The experimental group was treated with different modes of TMS and the control group was treated with conventional treatment of dysphagia(CTD)or sham stimulation.Outcome indicators were swallowing function indicators[Standardized Swallowing Assessment(SSA),Fiberoptic Endoscopic Dysphagia Severity Scale(FEDSS)and Functional Oral Intake Scale(FOIS)scores],aspiration risk indicators[Penetration-Aspiration Scale(PAS)score]and adverse reactions.Meta-analysis and Bayesian network meta-analysis were performed using R 4.3.0 software.Results Twenty-six papers with a sample size of 1185 cases were finally included,including 634 cases in the control group and 551 cases in the experimental group.Meta-analysis results showed that SSA score of PSD patients treated with 3 Hz-repetitive transcranial magnetic stimulation(rTMS)was lower than that of patients treated with CTD,and the SSA score of PSD patients treated with 1 Hz-rTMS,3 Hz-rTMS,5 Hz-rTMS,10 Hz-rTMS and intermittent Theta burst stimulation(iTBS)was lower than that of patients treated with sham stimulation(P<0.05).The FEDSS scores of PSD patients treated with 5 Hz-rTMS,10 Hz-rTMS and iTBS were lower than those of patients treated with sham stimulation(P<0.05).The FOIS scores of PSD patients treated with 3 Hz-rTMS and 5 Hz-rTMS were higher than those of patients treated with CTD,and the FOIS scores of PSD patients treated with 1 Hz-rTMS and iTBS were higher than those of patients treated with sham stimulation(P<0.05).The PAS scores of PSD patients treated with 3 Hz-rTMS,5 Hz-rTMS,10 Hz-rTMS and iTBS were lower than those of patients treated with CTD,and the PAS scores of PSD patients treated with 1 Hz-rTMS,5 Hz-rTMS,10 Hz-rTMS and iTBS were lower than those of patients treated with sham stimulation(P<0.05).The results of Bayesian network meta-analysis showed that the SSA score of patients treated with 3 Hz-rTMS was lower than that of patients treated with CTD,and the SSA score of patients treated with 3 Hz-rTMS,5 Hz-rTMS and iTBS was lower than that of patients treated with sham stimulation(P<0.05).The FEDSS score of patients treated with 10 Hz-rTMS and iTBS was lower than that of patients treated with sham stimulation(P<0.05).The PAS scores of PSD patients treated with 3 Hz-rTMS,5 Hz-rTMS,10 Hz-rTMS and iTBS were lower than those of patients treated with CTD,and the PAS scores of PSD patients treated with 1 Hz-rTMS,3 Hz-rTMS,5 Hz-rTMS,10 Hz-rTMS and iTBS were lower than those of patients treated with sham stimulation(P<0.05).The results of cumulative ranking probability plot analysis showed that the treatment methods of maximum surface under the cumulative ranking(SUCRA)of SSA,FEDSS and FOIS scores in PSD patients were 3 Hz-rTMS,iTBS and 3 Hz-rTMS,respectively,and the treatment methods of maximum SUCRA of PAS score was iTBS.Among the 26 literature,8 literature reported no adverse reactions during the treatment,and 5 literature reported mild adverse reactions.Conclusion 3 Hz-rTMS and iTBS may be more effective in improving swallowing function in patients with PSD,and iTBS may be more effective in reducing swallowing risk in patients with PSD;the adverse reactions of different modes of TMS in the intervention of PSD patients are less,and the symptoms are mostly mild.