Effects of Low-Frequency Repetitive Transcranial Magnetic Stimulation on Swallowing Function and Quality of Life of Post-stroke Patients

The caregiver burden of informal caregivers for stroke patients with and without dysphagia: A multi-center, cross-sectional study in Türkiye

Objectives

The aim of this study was to investigate the caregiver burden (CB) of informal caregivers for stroke survivors with and without dysphagia and to assess the relationship between the CB levels of informal caregivers for stroke survivors with dysphagia, patients' swallowing-related quality of life (QoL), and patients' stroke-specific QoL.

Patients and methods

This multi-center, prospective, cross-sectional study included a total of 120 stroke patients (76 males, 44 females; mean age: 61.1±12.3 years; range, 19 to 86 years) between October 2019 and 2020. Of the patients, 57 had dysphagia and 63 had no dysphagia. The Functional Oral Intake Scale (FOIS) was used to classify the degree of functional dietary limitation caused by each patient's swallowing impairment. Patients and caregivers completed the Eating Assessment Tool (EAT-10), Swallowing Quality of Life (SWQoL) questionnaire, Stroke Impact Scale (SIS), and the Zarit Caregiver Burden Interview (ZBI).

Results

The CB levels were higher in those caring for stroke patients with dysphagia than in those caring for stroke patients without dysphagia. Caregiver burden was found to be associated with patients' swallowing-related QoL and stroke-related QoL. Significant predictors of high CB scores (F=2.55, R2=0.59; p=0.007) were being an employed caregiver (B=17.48, p=0.003), being a caregiver with high school (B=-19.6, p=0.03), and secondary school (B=-16.28, p=0.02) educational status, being son, daughter (B=30.63, p=0.007) or other relative of the patient (B=20.06, p=0.01), lower FOIS stage (B=-3.14, p=0.011), lower SWQoL (B=0.52, p=0.009) and lower SIS (B=-0.37, p=0.04) scores.

Conclusion

Caregivers of stroke patients with dysphagia suffer from a higher CB than those without dysphagia. In stroke patients with dysphagia, swallowing-related QoL is associated with the QoL levels of stroke patients and the CB levels of their caregivers. Employment status, educational status of caregiver, caregiver's relativity to the patient, FOIS stage, swallowing and stroke related QoL of the patients are factors related to burden levels of caregivers of stroke patients with dysphagia. These results may help health professionals to understand dysphagia as an essential source of CB and consider it, while planning treatments.

Research hotspots and trends in post-stroke dysphagia: a bibliometric analysis

Background

Dysphagia represents one of the common complications following a stroke, and post-stroke dysphagia (PSD) can lead to aspiration, pneumonia, and malnutrition, thus prolonging hospital stay, escalating medical expenditures, and imposing a substantial economic strain on both patients and society. The utilization of bibliometric analysis offers a quantitative approach for investigating the existing literature and recognizes the current status of the research. However, bibliometric analysis on the subject of PSD remains absent. Consequently, we carried out this study to provide researchers with insights, facilitating their further exploration of PSD.

Methods

Conducting a bibliometric analysis of articles pertaining to PSD retrieved over the past two decades enables us to acquire the research hotspots and trends in this area. The publications concerning PSD were searched from the Core Collection of Web of Science, spanning the period ranging from 2003 to 2023. Articles or reviews published in English were included in this study. Subsequently, we employed CiteSpace and VOSviewer software to visualize the retrieved articles, thereby identifying the cooperative relationships of authors, institutions, and countries, as well as relevant information about journals and references.

Results

This study comprised 866 papers in total, and the number of articles published each year shows an overall growth trend. As for the analysis of the authors, Dziewas R. was the most prolific author with 21 articles. The most frequently published institutions, countries, and journals were the University of Manchester, China, and Dysphagia, with 28, 254, and 75 publications, respectively. And the co-cited authors and journals with the highest counts were Martino R and Stroke. According to the analysis of keywords and references, dysphagia screening and assessment, prevention of pneumonia, rehabilitation approaches, and nutritional management of PSD are considered research hotpots. Additionally, future research may focus on the topics of systematic review and meta-analysis, noninvasive brain stimulation, and lesion location.

Conclusion

Through the bibliometrics analysis of PSD, we can capture the research hotspots and frontiers of PSD, thereby providing inspiration and reference for subsequent studies in this field.

Evaluating the Therapeutic Application of Neuromodulation in the Human Swallowing System

In the last two decades, the focus of neurogenic dysphagia management has moved from passive compensatory strategies to evidence-based rehabilitative approaches. Advances in technology have enabled the development of novel treatment approaches such as neuromodulation techniques, which target the promotion of neurological reorganization for functional recovery of swallowing. Given the rapid pace of development in the field, this review aims to summarize the current findings on the effects of neuromodulation techniques on the human swallowing system and evaluate their therapeutic potential for neurogenic dysphagia. Implications for future clinical research and practical considerations for using neuromodulation in clinical practice will also be discussed.

Current evidence, clinical applications, and future directions of transcranial magnetic stimulation as a treatment for ischemic stroke

Transcranial magnetic stimulation (TMS) is a non-invasive brain neurostimulation technique that can be used as one of the adjunctive treatment techniques for neurological recovery after stroke. Animal studies have shown that TMS treatment of rats with middle cerebral artery occlusion (MCAO) model reduced cerebral infarct volume and improved neurological dysfunction in model rats. In addition, clinical case reports have also shown that TMS treatment has positive neuroprotective effects in stroke patients, improving a variety of post-stroke neurological deficits such as motor function, swallowing, cognitive function, speech function, central post-stroke pain, spasticity, and other post-stroke sequelae. However, even though numerous studies have shown a neuroprotective effect of TMS in stroke patients, its possible neuroprotective mechanism is not clear. Therefore, in this review, we describe the potential mechanisms of TMS to improve neurological function in terms of neurogenesis, angiogenesis, anti-inflammation, antioxidant, and anti-apoptosis, and provide insight into the current clinical application of TMS in multiple neurological dysfunctions in stroke. Finally, some of the current challenges faced by TMS are summarized and some suggestions for its future research directions are made.

Comparative efficacy of different noninvasive brain stimulation therapies for recovery of global cognitive function, attention, memory, and executive function after stroke: a network meta-analysis of randomized controlled trials

Background

Which noninvasive brain stimulation (NIBS) treatment - transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS) - is more beneficial for stroke patients' cognitive rehabilitation is still up for debate.

Objectives

Our goal is to provide an overview of the research on the effectiveness and safety of various NIBS protocols.

Design

Systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs).

Methods

This NMA compared any active NIBS versus sham stimulation in adult stroke survivors to enhance cognitive function, with a focus on global cognitive function (GCF), attention, memory, and executive function (EF) using the databases MEDLINE, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov. The NMA statistical approach was built on a frequency framework. The effect size was estimated by the standardized mean difference (SMD) and a 95% confidence interval (CI). We compiled a relative ranking of the competing interventions based on their surface under the cumulative ranking curve (SUCRA).

Results

NMA showed that high-frequency repeated TMS (HF-rTMS) improved GCF compared with sham stimulation (SMD = 1.95; 95% CI: 0.47-3.43), while dual-tDCS improved memory performance versus sham stimulation significantly (SMD = 6.38; 95% CI: 3.51-9.25). However, various NIBS stimulation protocols revealed no significant impact on enhancing attention, executive function, or activities of daily living. There was no significant difference between the active stimulation protocols for TMS and tDCS and sham stimulation in terms of safety. Subgroup analysis demonstrated an effect favoring activation site of the left dorsolateral prefrontal cortex (DLPFC) (SUCRA = 89.1) for enhancing GCF and bilateral DLPFC (SUCRA = 99.9) stimulation for enhancing memory performance.

Conclusion

The HF-rTMS over the left DLPFC appears to be the most promising NIBS therapeutic option for improving global cognitive performance after stroke, according to a comparison of numerous NIBS protocols. Furthermore, for patients with post-stroke memory impairment, dual-tDCS over bilateral DLPFC may be more advantageous than other NIBS protocols. Both tDCS and TMS are reasonably safe.

Registration

PROSPERO ID: CRD42022304865.

Effect of Repetitive Transcranial Magnetic Stimulation on Post-stroke Dysphagia: A Meta-analysis of Stimulation Frequency, Stimulation Site, and Timing of Outcome Measurement

Dysphagia is one of the most frequent sequelae of stroke. It can result in various complications such as malnutrition, dehydration, aspiration pneumonia, and poor rehabilitation outcomes. Repetitive transcranial magnetic stimulation (rTMS) has been reported to improve dysphagia after a stroke; however, effective treatment protocols have not been established yet. We evaluated the effect of the following rTMS parameters on post-stroke dysphagia: stimulation frequency [high frequency (≥ 3 Hz) or low frequency (1 Hz)] and stimulation site (ipsilesional or contralesional mylohyoid cortex). Outcomes were measured immediately, at 3 weeks, and at 4 weeks after the rTMS session. The PubMed, SCOPUS, Embase, and Cochrane Library databases were systematically searched for relevant studies published between January 01, 1980, and December 13, 2021. Randomized controlled trials on the effects of rTMS on post-stroke dysphagia were included. Six studies were finally included in the analysis. The selected studies included 158 patients (rTMS group: 81 patients; sham group: 77 patients). Regarding the effect of high-frequency rTMS on the ipsilesional cortex, the standardized swallowing assessment (SSA) scores showed significant improvement after rTMS sessions immediately and at 4 weeks [immediate: P = 0.02, standard mean difference (SMD) =  - 0.61, 95% confidence interval (CI) =  - 1.14 to - 0.08; 4 weeks: P = 0.006, SMD =  - 0.74, 95% CI =  - 1.27 to - 0.21]; however, there was no significant reduction in the Penetration-Aspiration Scale (PAS) scores between the rTMS and sham groups (immediate: P = 0.43, SMD = 0.25, 95% CI =  - 0.36, 0.86; 3 weeks: P = 0.39, SMD = 0.37, 95% CI =  - 0.47 to 1.22). After low-frequency rTMS on the ipsilesional cortex, a significantly greater improvement in the SSA scores was found in the rTMS group than in the sham group, both immediately and at 4 weeks after rTMS sessions (immediate: P = 0.03, SMD =  - 0.59, 95% CI =  - 1.12 to - 0.06; 4 weeks: P = 0.001, SMD =  - 0.92, 95% CI =  - 1.48 to - 0.37). In addition, immediately after the rTMS sessions, the PAS scores were significantly reduced in the rTMS group than in the sham group (P = 0.047, SMD =  - 0.60, 95% CI =  - 1.19 to - 0.01). However, at 4 weeks after rTMS sessions, there was no significant reduction in the PAS scores in the rTMS group compared to the sham group (P = 0.48, SMD =  - 0.19, 95% CI =  - 0.71 to 0.33). Both high-frequency rTMS of the ipsilesional cortex and low-frequency rTMS of the contralesional cortex improved some measurements of the swallowing function in stroke patients immediately and at 4 weeks after treatment.

Effects of bilateral cerebellar repetitive transcranial magnetic stimulation in poststroke dysphagia: A randomized sham-controlled trial

BACKGROUND

Although increasing evidence indicates that cerebellar repetitive transcranial magnetic stimulation (rTMS) may be beneficial in the treatment of dysphagia, its clinical efficacy is still uncertain.

OBJECTIVE

To evaluate the effect of high-frequency cerebellar rTMS on poststroke dysphagia.

METHODS

This was a randomized, sham-controlled, double-blind trial. A total of eighty-four study participants were randomly assigned into the cerebellum and control groups. The cerebellum group received bilateral 10 Hz rTMS treatment of the pharyngeal motor area of the cerebellum. The control group was administered with sham rTMS of the pharyngeal motor area of the cerebellum. All patients underwent the same conventional swallowing rehabilitation training after the intervention 5 days a week for a total of 10 days. Assessment of swallowing function was done before treatment (baseline), after treatment (2 weeks), and during follow-up (2 weeks after treatment) using the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and the Penetration-Aspiration Scale (PAS).

RESULTS

The interaction between time and intervention had a significant effect on PAS (P < 0.001) and FEDSS (P < 0.001). Compared to the control group, the cerebellum group exhibited significantly improved clinical swallowing function scores (PAS: P = 0.007, FEDSS: P = 0.002).

CONCLUSION

Bilateral cerebellar rTMS is a potential new neurorehabilitation technique for post-stroke dysphagia. Studies should aim at investigating the therapeutic mechanism of cerebellar rTMS and improve this technique.

Statistical Power and Swallowing Rehabilitation Research: Current Landscape and Next Steps

Despite rapid growth in the number of treatments to rehabilitate dysphagia, studies often demonstrate mixed results with non-significant changes to functional outcomes. Given that power analyses are infrequently reported in dysphagia research, it remains unclear whether studies are adequately powered to detect a range of treatment effects. Therefore, this review sought to examine the current landscape of statistical power in swallowing rehabilitation research. Databases were searched for swallowing treatments using instrumental evaluations of swallowing and the penetration-aspiration scale as an outcome. Sensitivity power analyses based on each study's statistical test and sample size were performed to determine the minimum effect size detectable with 80% power. Eighty-nine studies with 94 treatment comparisons were included. Sixty-seven percent of treatment comparisons were unable to detect effects smaller than d = 0.80. The smallest detectable effect size was d = 0.29 for electrical stimulation, d = 0.49 for postural maneuvers, d = 0.52 for non-invasive brain stimulation, d = 0.61 for combined treatments, d = 0.63 for respiratory-based interventions, d = 0.70 for lingual strengthening, and d = 0.79 for oral sensory stimulation. Dysphagia treatments examining changes in penetration-aspiration scale scores were generally powered to reliably detect larger effect sizes and not smaller (but potentially clinically meaningful) effects. These findings suggest that non-significant results may be related to low statistical power, highlighting the need for collaborative, well-powered intervention studies that can detect smaller, clinically meaningful changes in swallowing function. To facilitate implementation, a tutorial on simulation-based power analyses for ordinal outcomes is provided ( https://osf.io/e6usd/ ).

The Effectiveness of Transcranial Stimulation in Improving Swallowing Outcomes in Adults with Poststroke Dysphagia: A Systematic Review and Meta-analysis

Transcranial stimulation has been proposed as an alternative rehabilitation therapy for adults with post-stroke dysphagia (PSD). This systematic review sought to determine the effectiveness of transcranial stimulation in patients with post-stroke dysphagia to improve swallowing function. From inception to January 3, 2021, an extensive search was conducted in PubMed, EMBASE, Cochrane, CINAHL, and Scopus, Web of Science. The randomized controlled trials (RCTs) included studies in adults aged 18 years and older who suffered from post-stroke dysphagia. Using Hedges' g as effect size, meta-analyses were conducted using random-effects models. To investigate potential sources of heterogeneity, subgroup analyses, and multivariable meta-regression analyses were conducted. Sixteen RCTs were included in this review, and 13 RCTs were used for meta-analysis. The meta-analysis showed that a large effect size in improving swallowing function after repetitive Transcranial Magnetic Stimulation (g = - 0.86, 95% CI - 1.57, - 0.16) and medium effect size in Transcranial Direct Current Stimulation (g = - 0.61, 95% CI - 1.04, - 0.17) at post-intervention, respectively. Subgroup and meta-regression analysis indicated that stimulation of the esophagus cortical area and middle-aged adults had a greater effect on swallowing function. The overall certainty of evidence assessed using the GRADE approach was low. Despite the positive results, transcranial stimulation requires additional research to reach definitive conclusions about the optimal stimulation protocol and to achieve the greatest benefit. Future trials should be more rigorous and include a larger sample size to demonstrate the efficacy of transcranial stimulation. Transcranial stimulation enables a more efficacious approach to dysphagia mitigation in PSD rehabilitation.

Expanding Rehabilitation Options for Dysphagia: Skill-Based Swallowing Training

Over the past four decades, our understanding of swallowing neural control has expanded dramatically. However, until recently, advances in rehabilitation approaches for dysphagia have not kept pace, with a persistent focussing on strengthening peripheral muscle. This approach is no doubt very appropriate for some if not many of our patients. But what if the dysphagia is not due to muscles weakness? The purpose of this clinical manuscript is to reflect on where we have been, where we are now and perhaps where we need to go in terms of our understanding of swallowing motor control and rehabilitation of motor control impairments. This compilation is presented to clinicians in the hope that suggesting approaches "outside the box" will inspire clinicians to focus their attention "inside the box" to ultimately improve rehabilitation and long-term outcomes for patients with dysphagia.

Research progress on transcranial magnetic stimulation for post-stroke dysphagia

Dysphagia is one of the most common manifestations of stroke, which can affect as many as 50–81% of acute stroke patients. Despite the development of diverse treatment approaches, the precise mechanisms underlying therapeutic efficacy remain controversial. Earlier studies have revealed that the onset of dysphagia is associated with neurological damage. Neuroplasticity-based transcranial magnetic stimulation (TMS), a recently introduced technique, is widely used in the treatment of post-stroke dysphagia (PSD) by increasing changes in neurological pathways through synaptogenesis, reorganization, network strengthening, and inhibition. The main objective of this review is to discuss the effectiveness, mechanisms, potential limitations, and prospects of TMS for clinical application in PSD rehabilitation, with a view to provide a reference for future research and clinical practice.

High-Frequency Cerebellar rTMS Improves the Swallowing Function of Patients with Dysphagia after Brainstem Stroke

Objective

To explore the efficacy of high-frequency repetitive transcranial magnetic stimulation (rTMS) of the swallowing motor area of the cerebellum in patients with dysphagia after brainstem stroke.

Methods

A total of 36 patients with dysphagia after brainstem stroke were recruited and divided into 3 groups. Before stimulation, single-pulse transcranial magnetic stimulation (TMS) was used to determine the swallowing dominant cerebellar hemisphere and the representation of the mylohyoid muscle. The three groups of patients received bilateral cerebellar sham stimulation, dominant cerebellar rTMS + contralateral sham stimulation, or bilateral cerebellar rTMS. The stimulus plan for each side was 10 Hz, 80% resting movement threshold (rMT), 250 pulses, 1 s per stimulus, and 9 s intervals. Sham rTMS was performed with the coil held at 90° to the scalp. The changes in the motor evoked potential (MEP) amplitude and the clinical swallowing function scales of the patients after stimulation were compared among the three groups.

Results

34 patients were finally included for statistical analysis. The scores of penetration aspiration scale (PAS) and functional dysphagia scale (FDS) of the patients after 2 weeks of rTMS in the unilateral stimulation group and bilateral stimulation group were better than that in the sham stimulation group, and there was no significant difference between the two groups. The increase in the MEP amplitude of the cerebral hemisphere in the bilateral stimulation group was higher than that in the other two groups, and the increase in the MEP amplitude in the unilateral stimulation group was higher than that in sham stimulation group. There was no correlation between the improvement in patients' clinical swallowing function (PAS scores and FDS scores) and the increase in MEP amplitude in either the unilateral stimulation group or the bilateral stimulation group.

Conclusion

High-frequency rTMS in the cerebellum can improve swallowing function in PSD patients and increase the excitability of the representation of swallowing in the bilateral cerebral hemispheres. Compared with unilateral cerebellar rTMS, bilateral stimulation increased the excitability of the cerebral swallowing cortex more significantly, but there was no significant difference in clinical swallowing function.

Transcranial magnetic stimulation versus transcutaneous neuromuscular electrical stimulation in post stroke dysphagia: A clinical randomized controlled trial

OBJECTIVES

To evaluate the efficacy of high-frequency repeated transcranial magnetic stimulation (rTMS) applied contralesionally versus transcutaneous neuromuscular electrical stimulation (TNES) in acute post-stroke dysphagic patients.

MATERIALS AND METHODS

A randomized, parallel, comparative, controlled trial was conducted on patients with acute ischemic stroke who were admitted to our department. Fifteen patients received rTMS, 15 patients received TNES, and 15 patients were recruited as a control group. Between the second and tenth days after a stroke, patients were enrolled. The study and follow-up periods were completed by all patients.

RESULTS

Among the screened patients, 45 (31.47%) right-handed patients were diagnosed with post-stroke dysphagia with a mean age of 60.53 ± 8.23 years. Immediately after intervention both rTMS and TNES groups significantly improve the swallowing disturbance questionnaire (SDQ) and penetration aspiration scale (PAS), compared to the control (p < 0.001 and p = 0.027), respectively. rTMS was more effective than TNES in reducing SDQ and PAS (p < 0.05). rTMS and TNES improved the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS) significantly (p = 0.002); however, their efficacy was comparable (p > 0.05). A significant (p < 0.001) strong negative correlation was observed between the grade of weakness and all scores.

CONCLUSION

Our findings showed that high-frequency rTMS and TNES effectively improved the clinical condition of acute post-stroke dysphagic patients in terms of swallowing disturbance assessed by SDQ, pharyngeal residue assessed by YPRSRS, and the severity of penetration and aspiration events evaluated by PAS, compared to the controls. The outcomes of high-frequency rTMS were more favorable than those of TNES in terms of SDQ and PAS.

Effectiveness of repetitive transcranial magnetic stimulation on poststroke dysphagia: a meta-analysis of randomized-controlled trials

Dysphagia is a common functional impairment after stroke, resulting in aspiration of liquids, ingested foods, or oral secretions and influencing the quality of life. Noninvasive repetitive transcranial magnetic stimulation has been widely used for rehabilitation of dysphagia. The purpose of this meta-analysis was to investigate the efficacy of repetitive transcranial magnetic stimulation on poststroke swallowing impairment. Four databases were systematically searched for eligible studies from their inception to 31 September 2021. Review Manager 5.4 software was used for this meta-analysis. The bias of included randomized controlled trials was assessed using the version 2 of the Cochrane risk-of-bias tool for randomized trials. Nine randomized controlled trials involving 393 patients were included according to the selection criteria. The results revealed significant benefit of repetitive transcranial magnetic stimulation as a treatment of dysphagia following the onset of stroke, when compared with intervention without repetitive transcranial magnetic stimulation. Applying repetitive transcranial magnetic stimulation on different stimulation sites effectively improved the dysphagia of poststroke patients, and no significant difference was observed among the different stimulation sites subgroups. Our findings support repetitive transcranial magnetic stimulation as an effectively treatment of the poststroke dysphagia, especially in unilateral hemispheric stroke patients.

The Effect and Optimal Parameters of Repetitive Transcranial Magnetic Stimulation on Poststroke Dysphagia: A Meta-Analysis of Randomized Controlled Trials

Objective

The objectives of the study were to evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) treatment for poststroke dysphagia (PSD) and explore the optimal stimulation parameters.

Method

The databases of Medline, Embase, Web of Science, and Cochrane Library were searched from the establishment to June 2021. All randomized controlled trials about rTMS treatment for PSD were enrolled. Dysphagia Grade (DG) and Penetration Aspiration Scale (PAS) were applied as the major dysphagia severity rating scales to evaluate the outcomes.

Results

A total of 12 clinical randomized controlled studies were included in our study. The summary effect size indicated that rTMS had a positive effect on PSD (SMD = −0.67, p < 0.001). The subgroup analysis for treatment duration and different stroke stages showed significant differences (treatment duration >5 days: SMD = −0.80, p < 0.001; subacute phase after stroke: SMD = −0.60, p < 0.001). Furthermore, no significant differences were observed among the other stimulation parameter subgroups (including stimulation frequency, location, and a single stimulation time) (p > 0.05).

Conclusion

rTMS is beneficial to the recovery of PSD patients, while an intervention of more than 5 days and in the subacute phase after stroke might bring new strategies and rational therapeutics to the treatment of PSD.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022299469.

Transcranial Magnetic Stimulation for Improving Dysphagia After Stroke: A Meta-Analysis of Randomized Controlled Trials

Background

Rehabilitation of post-stroke dysphagia is an urgent clinical problem, and repetitive transcranial magnetic stimulation (rTMS) has been widely used in the study of post-stroke function. However, there is no reliable evidence-based medicine to support the effect of rTMS on post-stroke dysphagia. This review aims to evaluate the effectiveness and safety of rTMS on post-stroke dysphagia.

Methods

English-language literature published before December 20, 2021, were searched in six electronic databases. Identified articles were screened, data were extracted, and the methodological quality of included trials was assessed. Meta-analysis was performed using RevMan 5.3 software. The GRADE method was used to assess the quality of the evidence.

Results

A total of 10 studies with 246 patients were included. Meta-analysis showed that rTMS significantly improved overall swallowing function (standardized mean difference [SMD]−0.76, 95% confidence interval (CI)−1.07 to−0.46, p < 0.0001, n = 206; moderate-quality evidence), Penetration Aspiration Scale (PAS) (mean difference [MD]−1.03, 95% CI−1.51 to−0.55, p < 0.0001, n = 161; low-quality evidence) and Barthel index scale (BI) (MD 23.86, 95% CI 12.73 to 34.99, p < 0.0001, n = 136; moderate-quality evidence). Subgroup analyses revealed that (1) rTMS targeting the affected hemisphere and targeting both hemispheres significantly enhanced overall swallowing function and reduced aspiration. (2) Low-frequency rTMS significantly enhanced overall swallowing function and reduced aspiration, and there was no significant difference between high-frequency rTMS and control group in reducing aspiration (p = 0.09). (3) There was no statistical difference in the dropout rate (low-quality evidence) and adverse effects (moderate-quality evidence) between the rTMS group and the control group.

Conclusion

rTMS improved overall swallowing function and activity of daily living ability and reduced aspiration in post-stroke patients with good acceptability and mild adverse effects.

The Effectiveness of Repetitive Transcranial Magnetic Stimulation for Post-stroke Dysphagia: A Systematic Review and Meta-Analysis

Background

Repetitive transcranial magnetic stimulation (rTMS) applied to the mylohyoid cortical region has positive clinical effects on post-stroke. Therefore, we conducted a meta-analysis to investigate the efficacy of rTMS for patients with post-stroke dysphagia.

Methods

According to PRISMA guidelines, we searched the databases of MEDLINE (PubMed), Cochrane Library, Embase, Web of Science, CNKI, Wangfang. We searched for studies of randomized controlled trials (RCTs) of rTMS to treat dysphagia after stroke and screened by inclusion and exclusion criteria. Features of RCTs were extracted. The heterogeneity of the trials was measured by I 2 statistic.

Results

In total, 11 RCTs with 463 dysphagia patients fulfilled our inclusion criteria. In our analysis, rTMS demonstrated a great beneficial effect for post-stroke dysphagia when combined with traditional swallowing exercises. Moreover, a greatly significant difference (P = 0.008) was noted based on stimulation frequency (high frequency vs. low frequency). Additionally, no significant difference (P = 0.53) was observed based on stimulation site (affected vs. unaffected hemisphere).

Conclusions

Overall, rTMS can effectively accelerate the improvement of swallowing function in patients with post-stroke swallowing disorders.

Neurostimulation in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analysis of Randomised Controlled Trials-Part II: Brain Neurostimulation

Objective. To assess the effects of brain neurostimulation (i.e., repetitive transcranial magnetic stimulation [rTMS] and transcranial direct current stimulation [tDCS]) in people with oropharyngeal dysphagia (OD). Methods. Systematic literature searches were conducted in four electronic databases (CINAHL, Embase, PsycINFO, and PubMed) to retrieve randomised controlled trials (RCTs) only. Using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2), the methodological quality of included studies was evaluated, after which meta-analysis was conducted using a random-effects model. Results. In total, 24 studies reporting on brain neurostimulation were included: 11 studies on rTMS, 9 studies on tDCS, and 4 studies on combined neurostimulation interventions. Overall, within-group meta-analysis and between-group analysis for rTMS identified significant large and small effects in favour of stimulation, respectively. For tDCS, overall within-group analysis and between-group analysis identified significant large and moderate effects in favour of stimulation, respectively. Conclusion. Both rTMS and tDCS show promising effects in people with oropharyngeal dysphagia. However, comparisons between studies were challenging due to high heterogeneity in stimulation protocols and experimental parameters, potential moderators, and inconsistent methodological reporting. Generalisations of meta-analyses need to be interpreted with care. Future research should include large RCTs using standard protocols and reporting guidelines as achieved by international consensus.

The Effect of Repetitive Transcranial Magnetic Stimulation on Dysphagia After Stroke: A Systematic Review and Meta-Analysis

Objective: The primary purpose of our study is to systemically evaluate the effect of repetitive transcranial magnetic stimulation (rTMS) on recovery of dysphagia after stroke.

Search Methods: We searched randomized controlled trials (RCTs) and non-RCTs published by PubMed, the Cochrane Library, ScienceDirect, MEDLINE, and Web of Science from inception until April 24, 2021. Language is limited to English. After screening and extracting the data, and evaluating the quality of the selected literature, we carried out the meta-analysis with software RevMan 5.3 and summarized available evidence from non-RCTs.

Results: Among 205 potentially relevant articles, 189 participants (from 10 RCTs) were recruited in the meta-analysis, and six non-RCTs were qualitatively described. The random-effects model analysis revealed a pooled effect size of SMD = 0.65 (95% CI = 0.04–1.26, p = 0.04), which indicated that rTMS therapy has a better effect than conventional therapy. However, the subgroup analysis showed that there was no significant difference between low-frequency and high-frequency groups. Even more surprisingly, there were no statistically significant differences between the two groups and the conventional training group in the subgroup analysis, but the combined effect was positive.

Conclusion: Our study suggests that rTMS might be effective in treating patients with dysphagia after stroke.

Systematic Review and Network Meta-Analysis of Noninvasive Brain Stimulation on Dysphagia after Stroke

Background

Dysphagia is a common sequelae after stroke. Noninvasive brain stimulation (NIBS) is a tool that has been used in the rehabilitation process to modify cortical excitability and improve dysphagia.

Objective

To systematically evaluate the effect of NIBS on dysphagia after stroke and compare the effects of two different NIBS.

Methods

Randomized controlled trials about the effect of NIBS on dysphagia after stroke were retrieved from databases of PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and CBM, from inception to June 2021. The quality of the trials was assessed, and the data were extracted according to the Cochrane Handbook for Systematic Reviews of Interventions. A statistical analysis was carried out using RevMan 5.3 and ADDIS 1.16.8. The effect size was evaluated by using the standardized mean difference (SMD) and a 95% confidence interval (CI).

Results

Ultimately, 18 studies involving 738 patients were included. Meta-analysis showed that NIBS could improve the dysphagia outcome and severity scale (DOSS) score (standard mean difference (SMD) = 1.44, 95% CI 0.80 to 2.08, P < 0.05) and the water swallow test score (SMD = 6.23, 95% CI 5.44 to 7.03, P < 0.05). NIBS could reduce the standardized swallowing assessment (SSA) score (SMD = −1.04, 95% CI -1.50 to -0.58, P < 0.05), the penetration-aspiration scale (PAS) score (SMD = −0.85, 95% CI -1.33 to -0.36, P < 0.05), and the functional dysphagia scale score (SMD = −1.05, 95% CI -1.48 to -0.62, P < 0.05). Network meta-analysis showed that the best probabilistic ranking of the effects of two different NIBS on the DOSS score is rTMS (P = 0.52) > tDCS (P = 0.48), the best probabilistic ranking of the SSA score is rTMS (P = 0.72) > tDCS (P = 0.28), and the best probabilistic ranking of the PAS score is rTMS (P = 0.68) > tDCS (P = 0.32).

Conclusion

Existing evidence showed that NIBS could improve swallowing dysfunction and reduce the occurrence of aspiration after stroke, and that rTMS is better than tDCS. Limited by the number of included studies, more large-sample, multicenter, double-blind, high-quality clinical randomized controlled trials are still needed in the future to further confirm the results of this research.

The effects of different frequencies of repetitive transcranial magnetic stimulation (rTMS) on patients with swallowing disorders after cerebral infarction

BACKGROUND

Swallowing disorders represent one of the most common complications after cerebral infarction.

OBJECTIVE

To study the effects of different frequencies of repetitive transcranial magnetic stimulation (rTMS) on swallowing disorders after cerebral infarction.

METHODS

Ninety patients with swallowing disorder after cerebral infarction were enrolled and randomly assigned to three groups: the 10 Hz frequency rTMS group (30 patients), the 5 Hz frequency rTMS group (30 patients), and the 1 Hz frequency rTMS group (30 patients); another 90 healthy persons without swallowing disorders were included as the control group. The Kubota's water-swallow test, the video fluoroscopic swallow study (VFSS), and the Electroencephalograph (EEG) were analyzed before and after treatment; the EEG of the control group was detected as the baseline.

RESULTS

The Kubota's water-swallow test scores were significantly decreased while the scores of pharynx period and the aspiration degree of VFSS significantly increased in 10 Hz frequency rTMS group than before treatment (P≤0.05); the amplitudes of C3 of the EEG significantly increased in three frequency groups than before treatment (P≤0.05).

CONCLUSIONS

10 Hz frequency of rTMS is effective for the treatment of swallowing disorder after cerebral infarction, the excitement of C3 area maybe the therapeutic target of rTMS on swallowing disorder after cerebral infarction.

Metaplasticity in the human swallowing system: clinical implications for dysphagia rehabilitation

Dysphagia is a common and devastating complication following brain damage. Over the last 2 decades, dysphagia treatments have shifted from compensatory to rehabilitative strategies that facilitate neuroplasticity, which is the reorganization of neural networks that is essential for functional recovery. Moreover, there is growing interest in the application of cortical and peripheral neurostimulation to promote such neuroplasticity. Despite some preliminary positive findings, the variability in responsiveness toward these treatments remains substantial. The purpose of this review is to summarize findings on the effects of neurostimulation in promoting neuroplasticity for dysphagia rehabilitation and highlight the need to develop more effective treatment strategies. We then discuss the role of metaplasticity, a homeostatic mechanism of the brain to regulate plasticity changes, in helping to drive neurorehabilitation. Finally, a hypothesis on how metaplasticity could be applied in dysphagia rehabilitation to enhance treatment outcomes is proposed.

Current perspectives on the benefits, risks, and limitations of noninvasive brain stimulation (NIBS) for post-stroke dysphagia

INTRODUCTION

Studies have shown that noninvasive brain stimulation (NIBS), including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), can promote neuroplasticity, which is considered important for functional recovery of swallowing after stroke. Despite extensive studies on NIBS, there remains a gap between research and clinical practice.

AREAS COVERED

In this article, we update the current knowledge on the benefits and challenges of rTMS and tDCS for post-stroke dysphagia. We identify some key limitations of these techniques that hinder the translation from clinical trials to routine practice. Finally, we discuss the future of NIBS as a treatment for post-stroke dysphagia in real-world settings.

EXPERT OPINION

Current evidence suggests that rTMS and tDCS show promise as a treatment for post-stroke dysphagia. However, these techniques are limited by the response variability, uncertainty on the safety in patients with comorbidities and difficulties in clinical study designs. Such limitations call for further work to enhance their utility through individualized approaches. Despite this, the last decade has seen a growing acceptance toward these techniques among clinical personnel. As such, we advocate caution but support optimism that NIBS will gradually be recognized as a mainstream treatment approach for post-stroke dysphagia in the future.

Comparative efficacy of non-invasive neurostimulation therapies for poststroke dysphagia: A systematic review and meta-analysis

OBJECTIVE

To explore the effect of non-invasive neurostimulation therapies on dysphagia patients after stroke.

METHODS

We searched MEDLINE (Ovid), PubMed, Embase, Web of Science, ScienceDirect, and Cochrane library databases until April 22, 2020. All published and unpublished randomized controlled trials (RCT) were included. Full texts were independently reviewed. The risk of RCT bias was evaluated by two independent assessors using the Cochrane risk of bias tool. The primary outcome measure was swallowing function before and after neurostimulation therapy. The effect sizes are calculated from the extracted data and combined into a comprehensive summary statistic.

RESULT

A total of 27 randomized controlled trials were included in this study, involving 914 stroke patients (27 intervention groups and 20 control groups). Meta-analysis showed that compared with the control group, noninvasive neurostimulation therapies (repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), surface neuromuscular electrical stimulation (sNMES) or pharyngeal electrical stimulation (PES)) had a better effect (SMD = 0.91; 95% CI: 0.54-1.27; Z = 4.84; P < 0.00001; I² = 86%). In the subgroup analysis based on type of stimulus, rTMS appeared to perform better. In the subgroup analysis based on clinical phase, stimulation applied in the acute phase may be more effective. In the subgroup analysis based on the site of injury, the brainstem injury group seemed to achieve better outcomes. In the subgroup analysis based on stroke type, the cerebral infarction group had better outcomes than the cerebral infarction/hemorrhage mixed group.

CONCLUSIONS

Non-invasive neurostimulation therapies can effectively promote the recovery of dysphagia after stroke.

Repetitive Transcranial Magnetic Stimulation at Different Sites for Dysphagia After Stroke: A Randomized, Observer-Blind Clinical Trial

Background: The clinical efficacy of repetitive transcranial magnetic stimulation (rTMS) protocols on patients with poststroke dysphagia is still unclear.

Objective: This trial aimed to explore and analyze the effectiveness of 5 Hz rTMS on the unaffected hemisphere, affected hemisphere, and cerebellum in stroke patients with dysphagia.

Methods: This observer-blind and randomized controlled trial included a total of 147 patients with stroke. Patients were divided into four treatment groups: the unaffected hemispheric group, the affected hemispheric group, the cerebellum group and the control group. Each group received traditional dysphagia treatment 5 days a week for 2 weeks. All recruited patients except for those in the control group underwent 10 consecutive rTMS sessions for 2 weeks. For the affected hemispheric group and unaffected hemispheric group, 5 Hz rTMS was applied to the affected mylohyoid cortical region or to the unaffected mylohyoid cortical region. For the cerebellum group, 5 Hz rTMS was applied to the mylohyoid cortical representation of the cerebellum (4.3 cm lateral and 2.4 cm below the inion). The Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), Penetration/Aspiration Scale (PAS), Gugging Swallowing Screen (GUSS), and Standardized Swallowing Assessment (SSA) were used to evaluate clinical swallowing function before the intervention (baseline), immediately after the intervention and 2 weeks after the intervention.

Results: There were significant time and intervention interaction effects on the FEDSS, PAS, SSA, and GUSS scores (p < 0.05). In a direct comparison of the swallowing parameters of the four groups, the changes in FEDSS, PAS, SSA, and GUSS scores showed a significantly greater improvement in the unaffected hemispheric group, the affected hemispheric group and cerebellum group than in the control group (p < 0.05).

Conclusions: Whether stimulating the unaffected hemisphere or the affected hemisphere, 5 Hz high-frequency rTMS on mylohyoid cortical tissue might have a positive effect on poststroke patients with dysphagia. In addition, cerebellar rTMS is a safe method that represents a potential treatment for poststroke dysphagia, and more clinical trials are needed to develop this technique further.

Clinical Trial Registration:chictr.org.cn, identifier: ChiCTR2000032255.

High-Frequency rTMS Improves Cognitive Function by Regulating Synaptic Plasticity in Cerebral Ischemic Rats

Poststroke cognitive impairment (PSCI) is one of the most severe sequelae of stroke and lacks effective treatment. Previous studies have shown that high-frequency repetitive transcranial magnetic stimulation (rTMS) may be a promising PSCI therapeutic approach, but the underlying mechanism is unclear. To uncover the effect of rTMS on PSCI, a transient middle cerebral artery occlusion (tMCAO) model was established. Modified Neurological Severity Score (mNSS) test and Morris Water Maze (MWM) test were performed to assess the neurological and cognitive function of rats. Furthermore, to explore the underlying mechanism, differentially expressed genes (DEGs) in the hippocampus of rats in the rTMS group and tMCAO group were compared using RNA sequencing. Then, bioinformatics analysis, including gene ontology (GO) analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis and protein-protein interaction (PPI) network analysis, was conducted to elaborate these DEGs. Our results indicated that high-frequency rTMS could significantly improve neurological and cognitive function, according to mNSS and MWM tests. We found 85 DEGs, including 71 upregulated genes and 14 downregulated genes, between the rTMS group and tMCAO group. The major functional category was related to chemical synaptic transmission modulation and several DEGs were significantly upregulated in processes related to synaptic plasticity, such as glutamatergic synapses. Calb2, Zic1, Kcnk9, and Grin3a were notable in PPI analysis. These results demonstrate that rTMS has a beneficial effect on PSCI, and its mechanism may be related to the regulation of synaptic plasticity and functional genes such as Calb2, Zic1, Kcnk9, and Grin3a in the hippocampus.

Effects of Neurostimulation on Poststroke Dysphagia: A Synthesis of Current Evidence From Randomized Controlled Trials

Objectives

To evaluate the effects of neurostimulation, including repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and pharyngeal electrical stimulation (PES), for poststroke dysphagia based on evidence from randomized controlled trials (RCTs).

Materials and Methods

Electronic databases were systematically searched between January 1985 and June 2020 and studies were included based on prespecified selection criteria. The quality of studies was evaluated and data were extracted and synthesized by two independent reviewers. The primary outcome measure was change in (any) relevant clinical swallowing‐related characteristic. Subgroup analysis were conducted based on follow‐up period and stimulation parameters.

Results

Data from 852 stroke patients were collected from 26 RCTs studies. Active neurostimulation treatments demonstrated a significant and moderate effect size compared to control treatment (0.69 [95% CI = 0.50, 0.89]; p < 0.001). The effect size of rTMS was the largest (0.73 [95% CI = 0.49, 0.98]; p < 0.001), followed by PES (0.68 [95% CI = 0.22, 1.14]; p = 0.004) and tDCS (0.65 [95% CI = 0.25, 1.04]; p = 0.001). All treatments showed comparable effect sizes within the first two weeks. Between three weeks and two months, tDCS demonstrated the largest effects (1.02 [95% CI = 0.45, 1.59]; p < 0.001) among the three treatments. No significant treatment effects were reported beyond three months. The combined effect size was large when applied in acute (<14 days) stroke (0.8 [95% CI = 0.34, 1.26]; p < 0.001). For noninvasive brain stimulation (NIBS), bihemispheric stimulation demonstrated the strongest effect size (0.93 [95% CI = 0.53, 1.33]; p < 0.001). In contrast, unilateral rTMS using ipsilesional high‐frequency stimulation had a combined effect size of 0.83 (95% CI = 0.14, 1.52; p = 0.02). For tDCS, a significant effect size was found only with anodal stimulation applied over the contralesional hemisphere (1.04 [95% CI = 0.54, 1.53]; p < 0.001).

Conclusions

The results show that neurostimulation can benefit patients with poststroke dysphagia. The treatment effects were the strongest in acute stroke patients and within the first two months of application. For NIBS, bihemispheric stimulation appeared to be most effective. The most beneficial hemisphere for unilateral stimulation differed between rTMS and tDCS. These findings provide a platform for future studies and clinical practice.

Advances in the Use of Neuromodulation for Neurogenic Dysphagia: Mechanisms and Therapeutic Application of Pharyngeal Electrical Stimulation, Transcranial Magnetic Stimulation, and Transcranial Direct Current Stimulation

Purpose The swallowing motor system and, specifically, its cortical substrates appear to have certain unique properties that make it highly susceptible to brain plasticity, both driven and following injury. Furthermore, neurogenic dysphagia is a common complication of brain disease, associated with poor outcomes, and yet treatment options remain limited. Therefore, translating the physiology of neurostimulation into clinical populations becomes imperative. In this review, we describe therapeutic application of neuroplasticity in the human swallowing motor system by initially examining the role of pharyngeal electrical stimulation from a mechanistic perspective and then reporting on clinical studies using this approach. Thereafter, we explore the application of noninvasive brain stimulation, which has previously been used to treat nervous system disorders such as depression, pain modulation, and cognitive impairment. Transcranial brain stimulations, in particular, transcranial magnetic stimulation and transcranial direct current stimulation, have been utilized by a number of investigators for rehabilitation in early-stage clinical trials, including dysphagia after neurological disease. In this review, we assess its usefulness in neurogenic dysphagia. Conclusion Early studies indicate these emerging neurostimulatory techniques hold future therapeutic promise. However, both a greater number of and larger clinical trials are required to provide evidence delineating their efficacy and scope of application.

Role of bilateral corticobulbar tracts in dysphagia after middle cerebral artery stroke

BACKGROUND AND PURPOSE

The corticobulbar tract is a potential neural pathway involved in swallowing. The frontal operculum, insular cortex, corona radiata and internal capsule, which are frequently involved in middle cerebral artery (MCA) strokes, are locations in which lesions cause dysphagia. However, it is unclear whether the locations are linked to the corticobulbar tract or whether corticobulbar tract integrity is associated with dysphagia severity. This study aimed to assess the association between corticobulbar tract integrity and dysphagia severity after MCA stroke.

METHODS

Thirty dysphagic patients after MCA stroke and 27 healthy controls were examined. Diffusion tensor imaging (DTI)-derived parameters of the corticobulbar tract were compared between patient and control groups. Next, patients were divided into mild and moderate-to-severe dysphagia groups, and DTI-derived parameters of the corticobulbar tract were compared between the subgroups. Logistic regression analysis was used to determine the association between corticobulbar tract integrity and dysphagia severity.

RESULTS

The tract volume (TV) of the affected corticobulbar tract was lower in dysphagic patients than in healthy controls (P < 0.001). According to dysphagia severity, TV of the unaffected corticobulbar tract was higher in the mild dysphagia group than in the moderate-to-severe dysphagia group (P = 0.012). TV of the unaffected corticobulbar tract was independently associated with dysphagia severity according to the logistic regression model (adjusted odds ratio 0.817, 95% confidence interval 0.683-0.976).

CONCLUSIONS

The corticobulbar tract was affected after MCA stroke and may be associated with dysphagia. A higher corticobulbar TV in the unaffected hemisphere was indicative of better swallowing function in dysphagic patients after MCA stroke.

Research hotspots and effectiveness of repetitive transcranial magnetic stimulation in stroke rehabilitation

Repetitive transcranial magnetic stimulation, as a relatively new type of rehabilitation treatment, is a painless and non-invasive method for altering brain excitability. Repetitive transcranial magnetic stimulation has been widely used in the neurorehabilitation of stroke patients. Here, we used CiteSpace software to visually analyze 315 studies concerning repetitive transcranial magnetic stimulation for stroke rehabilitation from 1999 to 2019, indexed by Web of Science, to clarify the research hotspots in different periods and characterize the gradual process of discovery in this field. We found that four main points were generally accepted: (1) repetitive transcranial magnetic stimulation has a positive effect on motor function recovery in patients with subcortical stroke; (2) it may be more advantageous for stroke patients to receive low-frequency repetitive transcranial magnetic stimulation in the unaffected hemispheres than to receive high-frequency repetitive transcranial magnetic stimulation in affected hemisphere; (3) low-frequency repetitive transcranial magnetic stimulation has become a potential therapeutic tool for patients with non-fluent aphasia after chronic stroke for neurological rehabilitation and language recovery; and (4) there are some limitations to these classic clinical studies, such as small sample size and low test efficiency. Our assessment indicates that prospective, multi-center, large-sample, randomized controlled clinical trials are still needed to further verify the effectiveness of various repetitive transcranial magnetic stimulation programs for the rehabilitation of stroke patients.

Research on Assisting Clinicians to Operate rTMS Precisely Based on the Coil Magnetic Field Spatial Distribution With Magnetic Resonance Imaging Navigation

Objective: To assist clinicians to operate repetitive Transcranial Magnetic Stimulation (rTMS) precisely based on the coil magnetic field spatial distribution with Magnetic Resonance Imaging (MRI) Navigation.

Methods: A fast method for calculating electromagnetic fields in layered brain structures in frequency domain was proposed. By approaching Bessel function in different intervals, the integral with a highly oscillatory kernel was transformed into two parts: a definite integral and a weakened oscillatory one. The distribution of induced current density and magnetic field intensity of rTMS stimulation effect on brain was quantitatively calculated, so that clinicians could intuitively grasp the safe range of coil stimulation on the brain. Then, the crucial factor of the stimulation effect of rTMS was determined, and an accurate coil positioning of the rTMS efficiently was completed.

Result: The maximal attenuation of induced electric field and magnetic induction intensity was 72.20 and 86.867% at 3 cm away from the skin in the brain layered model. The clinical examination results of electric field intensity distribution, magnetic field intensity distribution, current density distribution, layered brain modeling, and coil location speed in the brain model teaching group were significantly higher than those in the traditional teaching group (P < 0.001).

Conclusion: It is suitable for clinicians to quickly complete the precise positioning of rTMS, master the adjustment of coil stimulation therapeutic parameters, and realize the precise positioning operation of rTMS with MRI navigation in intracranial.

Clinical Trial registration: Chinese Clinical Trial Registry (ChiCTR1800018616); Registered on 30th September 2018