Bilateral Cerebellar Intermittent Theta Burst Stimulation Combined With Swallowing Speech Therapy for Dysphagia After Stroke: A Randomized, Double-Blind, Sham-Controlled, Clinical Trial

Abstract

Background: Previous studies have found that high-frequency repetitive transcranial magnetic stimulation (rTMS) of the cerebellar hemisphere could improve swallowing function, but whether intermittent theta burst stimulation (iTBS), which has similar excitatory effect and higher efficiency, can also improve swallowing function for dysphagia after stroke remains unclear. Objective: This trial aimed to explore the efficacy and safety of bilateral cerebellar transcranial magnetic stimulation with iTBS for dysphagia after stroke. Methods: Seventy patients with dysphagia after stroke were divided into 2 treatment groups: true bilateral cerebellar iTBS and sham bilateral cerebellar iTBS. The true iTBS group underwent ten 100% resting motor threshold (RMT) iTBS sessions for 2 weeks. In the sham iTBS group, the parameters were the same except that the figure-eight coil was perpendicular to the skull. Both groups received traditional swallowing rehabilitation treatment 5 times a week for 2 weeks. Swallowing function was assessed with the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), Penetration/Aspiration Scale (PAS), Standardized Swallowing Assessment (SSA), and Functional Oral Intake Scale (FOIS) at baseline, 2 weeks after the intervention, and at 4 weeks of follow-up. Results: There were significant time and group interaction effects in both multi-factorial adjusted and unadjusted FEDSS, PAS, SSA, and FOIS score ( P < .001). In the pairwise comparison of the swallowing parameters among the 2 groups, the FEDSS, PAS, SSA, and FOIS scores at 2 weeks and 4 weeks showed a significantly higher improvement in the iTBS simulation group than sham group ( P < .05). In both the true iTBS and sham iTBS stimulation groups, all FEDSS, PAS, SSA, and FOIS scores were significantly improved over time ( P < .001). Conclusions: The present study suggested that as a more efficient TMS stimulation mode, iTBS could efficiently improve swallowing function by stimulating the bilateral cerebellar hemisphere. In addition, 100% resting motor threshold bilateral cerebellar iTBS is a relatively safe treatment. Clinical Trial Registration: Effect analysis of repeated transcranial magnetic stimulation of cerebellar on dysphagia after stroke. www.chictr.org.cn . Identifier: ChiCTR2100042092.

Intermittent theta-burst stimulation with physical exercise improves poststroke motor function: A systemic review and meta-analysis

“…However, 1200-pulse iTBS could attenuate the increase in excitability caused by 600-pulse iTBS ( 24 ). For clinical research, several RCTs have been used to evaluate the effects of iTBS on language function, cognitive function, and swallowing function after stroke ( 25 – 27 ). Previous studies have shown that iTBS can reduce aphasia and improve motor function in stroke patients ( 28 , 29 ).…”

The effects of intermittent theta burst stimulation of the unilateral cerebellar hemisphere on swallowing-related brain regions in healthy subjects

“…During iTBS, a 2 s train was followed by an 8 s intermission; this pattern was repeated 20 times for approximately 190 s (600 pulses). The iTBS was delivered at 100% resting motor threshold (rMT) ( Rao et al, 2022 ).…”

“…This method has led to some achievements in the research of neural mechanisms in the field of swallowing ( Ruan et al, 2017 ). Cerebellar iTBS has been shown to improve swallowing function in poststroke patients with dysphagia ( Rao et al, 2022 ). Furthermore, the fractional amplitude of low-frequency fluctuation (fALFF) approach has high sensitivity and specificity in detecting spontaneous brain activities.…”

Targeting Cerebellum with Non-Invasive Transcranial Magnetic or Current Stimulation after Cerebral Hemispheric Stroke—Insights for Corticocerebellar Network Reorganization: A Comprehensive Review

“…Applications regarding cerebellar TMS in cerebral stroke rehabilitation according to current literature concern dysphagia, gait-balance, and limb spasticity as outcomes of interest. Both rTMS and TBS have been studied but there is a prominent application of TBS, the main reason being that it can induce long-lasting cortical excitability with both lower stimulation intensity and training duration [ 33 ].…”

“…The study by Rao et al (2022) investigated an iTBS protocol [ 39 ] in 70 patients with endoscopically confirmed dysphagia. A clinically significant difference in improvement was recorded in favor of the real-iTBS group, with the degree of improvement approaching clinically the difference between nasogastric tube and oral feeding, or parenteral fluid supplementation vs. oral fluid intake [ 33 ].…”