Approaches to the Rehabilitation of Dysphagia in Acute Poststroke Patients

Abstract

Dysphagia occurs frequently following stroke and may result in serious health consequences including pneumonia, malnutrition, dehydration, and mortality. Prevention of these negative health outcomes requires early identification and treatment of dysphagia. The speech-language pathologist, as part of a multidisciplinary team, holds the primary responsibility for selection of an effective dysphagia rehabilitation program for these patients. Because much research has focused on patients with chronic dysphagia, this review will focus on treatment of patients within the acute phase of recovery poststroke. Although some acute patients may experience transient dysphagia that resolves spontaneously, many will go on to develop chronic dysphagia that may be prevented with provision of early and intensive treatment. An overview of dysphagia following stroke will be provided with information regarding incidence, complications, evaluation, and causes of dysphagia. A thorough discussion of evidence supporting varying approaches to dysphagia rehabilitation will follow with inclusion of several current, novel, and experimental techniques. The importance of the multidisciplinary team and regular reevaluation will be emphasized as well.

Keywords

Dysphagia - stroke - acute - rehabilitation - evidence

• References

• 1 Go AS, Mozaffarian D, Roger VL , et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 2013; 127 (1) e6-e245
• 2 Blackwell Z, Littlejohns P. A review of the management of dysphagia: a South African perspective. J Neurosci Nurs 2010; 42 (2) 61-70
• 3 Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005; 36 (12) 2756-2763
• 4 Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis 2000; 10 (5) 380-386
• 5 Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. Br Med J (Clin Res Ed) 1987; 295 (6595) 411-414
• 6 Teasell RW, Bach D, McRae M. Prevalence and recovery of aspiration poststroke: a retrospective analysis. Dysphagia 1994; 9 (1) 35-39
• 7 Smithard DG, O'Neill PA, Parks C, Morris J. Complications and outcome after acute stroke. Does dysphagia matter?. Stroke 1996; 27 (7) 1200-1204
• 8 Smithard DG, O'Neill PA, England RE , et al. The natural history of dysphagia following a stroke. Dysphagia 1997; 12 (4) 188-193
• 9 Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg 2010; 136 (8) 784-789
• 10 Hamidon BB, Nabil I, Raymond AA. Risk factors and outcome of dysphagia after an acute ischaemic stroke. Med J Malaysia 2006; 61 (5) 553-557
• 11 Smithard DG, Smeeton NC, Wolfe CDA. Long-term outcome after stroke: does dysphagia matter?. Age Ageing 2007; 36 (1) 90-94
• 12 Sharma JC, Fletcher S, Vassallo M, Ross I. What influences outcome of stroke—pyrexia or dysphagia?. Int J Clin Pract 2001; 55 (1) 17-20
• 13 Crary MA, Carnaby-Mann GD, Miller L, Antonios N, Silliman S. Dysphagia and nutritional status at the time of hospital admission for ischemic stroke. J Stroke Cerebrovasc Dis 2006; 15 (4) 164-171
• 14 Crary MA, Humphrey JL, Carnaby-Mann G, Sambandam R, Miller L, Silliman S. Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care. Dysphagia 2013; 28 (1) 69-76
• 15 Geeganage C, Beavan J, Ellender S, Bath PMW. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev 2012; 10: CD000323
• 16 Finestone HM. Safe feeding methods in stroke patients. Lancet 2000; 355 (9216) 1662-1663
• 17 Perry L, McLaren S. Implementing evidence-based guidelines for nutrition support in acute stroke. Evid Based Nurs 2003; 6 (3) 68-71
• 18 Daniels SK, Brailey K, Priestly DH, Herrington LR, Weisberg LA, Foundas AL. Aspiration in patients with acute stroke. Arch Phys Med Rehabil 1998; 79 (1) 14-19
• 19 Holas MA, DePippo KL, Reding MJ. Aspiration and relative risk of medical complications following stroke. Arch Neurol 1994; 51 (10) 1051-1053
• 20 Johnson ER, McKenzie SW, Sievers A. Aspiration pneumonia in stroke. Arch Phys Med Rehabil 1993; 74 (9) 973-976
• 21 Martino R, Martin RE, Black S. Dysphagia after stroke and its management. CMAJ 2012; 184 (10) 1127-1128
• 22 Hughes SM. Management of dysphagia in stroke patients. Nurs Older People 2011; 23 (3) 21-24
• 23 Masrur S, Smith EE, Saver JL , et al. Dysphagia Screening and Hospital-acquired Pneumonia in Patients with Acute Ischemic Stroke: Findings from Get with the Guidelines-Stroke. J Stroke Cerebrovasc Dis 2013; ; In press
• 24 Tippett DC. Clinical challenges in the evaluation and treatment of individuals with poststroke dysphagia. Top Stroke Rehabil 2011; 18 (2) 120-133
• 25 Daniels SK, Anderson JA, Willson PC. Valid items for screening dysphagia risk in patients with stroke: a systematic review. Stroke 2012; 43 (3) 892-897
• 26 Massey R, Jedlicka D. The Massey Bedside Swallowing Screen. J Neurosci Nurs 2002; 34 (5) 252-253 , 257–260
• 27 Logemann JA, Veis S, Colangelo L. A screening procedure for oropharyngeal dysphagia. Dysphagia 1999; 14 (1) 44-51
• 28 Turner-Lawrence DE, Peebles M, Price MF, Singh SJ, Asimos AW. A feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med 2009; 54 (3) 344-348 , e1
• 29 Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A novel emergency department dysphagia screen for patients presenting with acute stroke. Acad Emerg Med 2011; 18 (6) 584-589
• 30 Barnard SL. Nursing dysphagia screening for acute stroke patients in the emergency department. J Emerg Nurs 2011; 37 (1) 64-67
• 31 Courtney BA, Flier LA. RN dysphagia screening, a stepwise approach. J Neurosci Nurs 2009; 41 (1) 28-38
• 32 Martino R, Silver F, Teasell R , et al. The Toronto Bedside Swallowing Screening Test (TOR-BSST): development and validation of a dysphagia screening tool for patients with stroke. Stroke 2009; 40 (2) 555-561
• 33 Archer SK, Wellwood I, Smith CH, Newham DJ. Dysphagia therapy in stroke: a survey of speech and language therapists. Int J Lang Commun Disord 2013; 48 (3) 283-296
• 34 Aviv JE, Sacco RL, Thomson J , et al. Silent laryngopharyngeal sensory deficits after stroke. Ann Otol Rhinol Laryngol 1997; 106 (2) 87-93
• 35 Kobayashi H, Hoshino M, Okayama K, Sekizawa K, Sasaki H. Swallowing and cough reflexes after onset of stroke. Chest 1994; 105 (5) 1623
• 36 Terré R, Mearin F. Resolution of tracheal aspiration after the acute phase of stroke-related oropharyngeal dysphagia. Am J Gastroenterol 2009; 104 (4) 923-932
• 37 Shaker R, Geenen JE. Management of dysphagia in stroke patients. Gastroenterol Hepatol (N Y) 2011; 7 (5) 308-332
• 38 Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke 1999; 30 (4) 744-748
• 39 Terré R, Mearin F. Oropharyngeal dysphagia after the acute phase of stroke: predictors of aspiration. Neurogastroenterol Motil 2006; 18 (3) 200-205
• 40 Park T, Kim Y, McCullough G. Oropharyngeal transition of the bolus in post-stroke patients. Am J Phys Med Rehabil 2013; 92 (4) 320-326
• 41 Kim Y, McCullough GH. Stage transition duration in patients poststroke. Dysphagia 2007; 22 (4) 299-305
• 42 Park T, Kim Y, Ko DH, McCullough G. Initiation and duration of laryngeal closure during the pharyngeal swallow in post-stroke patients. Dysphagia 2010; 25 (3) 177-182
• 43 Kim Y, McCullough GH. Maximal hyoid excursion in poststroke patients. Dysphagia 2010; 25 (1) 20-25
• 44 Daniels SK, Schroeder MF, DeGeorge PC, Corey DM, Foundas AL, Rosenbek JC. Defining and measuring dysphagia following stroke. Am J Speech Lang Pathol 2009; 18 (1) 74-81
• 45 Lugger KE. Dysphagia in the elderly stroke patient. J Neurosci Nurs 1994; 26 (2) 78-84
• 46 Sellars C, Bowie L, Bagg J , et al. Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke 2007; 38 (8) 2284-2291
• 47 Lieu PK, Chong MS, Seshadri R. The impact of swallowing disorders in the elderly. Ann Acad Med Singapore 2001; 30 (2) 148-154
• 48 Leder SB, Suiter DM, Lisitano Warner H. Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia 2009; 24 (3) 290-295
• 49 Nakajima M, Takada T, Terasaki Y, Nagano K, Naritomi H, Minematsu K. Clinical significance of oral intake in patients with acute stroke. Dysphagia 2010; 25 (3) 192-197
• 50 Flowers HL, Skoretz SA, Streiner DL, Silver FL, Martino R. MRI-based neuroanatomical predictors of dysphagia after acute ischemic stroke: a systematic review and meta-analysis. Cerebrovasc Dis 2011; 32 (1) 1-10
• 51 Gonzalez-Fernandez M, Kleinman JT, Ky PKS, Palmer JB, Hillis AE. Supratentorial regions of acute ischemia associated with clinically important swallowing disorders: a pilot study. Stroke 2008; 39 (11) 3022-3028
• 52 Kumar S, Langmore S, Goddeau Jr RP , et al. Predictors of percutaneous endoscopic gastrostomy tube placement in patients with severe dysphagia from an acute-subacute hemispheric infarction. J Stroke Cerebrovasc Dis 2012; 21 (2) 114-120
• 53 Remesso GC, Fukujima MM, Chiappetta AL , et al. Swallowing disorders after ischemic stroke. Arq Neuropsiquiatr 2011; 69 (5) 785-789
• 54 Robbins J, Levine R. Swallowing after lateral medullary syndrome plus. Clin Commun Disord 1993; 3 (4) 45-55
• 55 Robbins J, Levine RL, Maser A, Rosenbek JC, Kempster GB. Swallowing after unilateral stroke of the cerebral cortex. Arch Phys Med Rehabil 1993; 74 (12) 1295-1300
• 56 Flowers HL, Silver FL, Fang J, Rochon E, Martino R. The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke. J Commun Disord 2013; 46 (3) 238-248
• 57 Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S ; Stroke Practice Improvement Network Investigators. Formal dysphagia screening protocols prevent pneumonia. Stroke 2005; 36 (9) 1972-1976
• 58 Odderson IR, Keaton JC, McKenna BS. Swallow management in patients on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil 1995; 76 (12) 1130-1133
• 59 Robbins J, Butler SG, Daniels SK , et al. Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence. J Speech Lang Hear Res 2008; 51 (1) S276-S300
• 60 Martin RE. Neuroplasticity and swallowing. Dysphagia 2009; 24 (2) 218-229
• 61 Linden P, Tippett D, Johnston J, Siebens A, French J. Bolus position at swallow onset in normal adults: preliminary observations. Dysphagia 1989; 4 (3) 146-150
• 62 Dennis M, Warlow C. Safe feeding after stroke. Lancet 2000; 356 (9229) 594
• 63 Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996; 348 (9039) 1421-1424
• 64 Holloway R. Timing and route of enteral tube-feeding did not reduce death or poor outcome in stroke and dysphagia. ACP J Club 2005; 143 (2) 37
• 65 Hamidon BB, Abdullah SA, Zawawi MF, Sukumar N, Aminuddin A, Raymond AA. A prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with acute dysphagic stroke. Med J Malaysia 2006; 61 (1) 59-66
• 66 Williams LS. Feeding patients after stroke: who, when, and how. Ann Intern Med 2006; 144 (1) 59-60
• 67 Sandman L, Agren Bolmsjö I, Westergren A. Ethical considerations of refusing nutrition after stroke. Nurs Ethics 2008; 15 (2) 147-159
• 68 Terré R, Mearin F. Effectiveness of chin-down posture to prevent tracheal aspiration in dysphagia secondary to acquired brain injury. A videofluoroscopy study. Neurogastroenterol Motil 2012; 24 (5) 414-419 , e206
• 69 Robbins J, Kays SA, Gangnon RE , et al. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil 2007; 88 (2) 150-158
• 70 Diniz PB, Vanin G, Xavier R, Parente MA. Reduced incidence of aspiration with spoon-thick consistency in stroke patients. Nutr Clin Pract 2009; 24 (3) 414-418
• 71 Goulding R, Bakheit AM. Evaluation of the benefits of monitoring fluid thickness in the dietary management of dysphagic stroke patients. Clin Rehabil 2000; 14 (2) 119-124
• 72 Robbins J, Gensler G, Hind J , et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med 2008; 148 (7) 509-518
• 73 Westergren A, Ohlsson O, Rahm Hallberg I. Eating difficulties, complications and nursing interventions during a period of three months after a stroke. J Adv Nurs 2001; 35 (3) 416-426
• 74 Watando A, Ebihara S, Ebihara T , et al. Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest 2004; 126 (4) 1066-1070
• 75 Clayton B. Stroke, dysphagia and oral care: what is best practice?. Alta RN 2012; 68 (1) 26-27
• 76 Hamdy S, Jilani S, Price V, Parker C, Hall N, Power M. Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury. Neurogastroenterol Motil 2003; 15 (1) 69-77
• 77 Cola PC, Gatto AR, da Silva RG , et al. Taste and temperature in swallowing transit time after stroke. Cerebrovasc Dis Extra 2012; 2 (1) 45-51
• 78 Logemann JA, Pauloski BR, Colangelo L, Lazarus C, Fujiu M, Kahrilas PJ. Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. J Speech Hear Res 1995; 38 (3) 556-563
• 79 Bisch EM, Logemann JA, Rademaker AW, Kahrilas PJ, Lazarus CL. Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and in normal subjects. J Speech Hear Res 1994; 37 (5) 1041-1059
• 80 Rosenbek JC, Roecker EB, Wood JL, Robbins J. Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia 1996; 11 (4) 225-233
• 81 Rosenbek JC, Robbins J, Fishback B, Levine RL. Effects of thermal application on dysphagia after stroke. J Speech Hear Res 1991; 34 (6) 1257-1268
• 82 Nakamura T, Fujishima I. Usefulness of ice massage in triggering the swallow reflex. J Stroke Cerebrovasc Dis 2013; 22 (4) 378-382
• 83 Theurer JA, Johnston JL, Fisher J , et al. Proof-of-principle pilot study of oropharyngeal air-pulse application in individuals with dysphagia after hemispheric stroke. Arch Phys Med Rehabil 2013; 94 (6) 1088-1094
• 84 Konaka K, Kondo J, Hirota N , et al. Relationship between tongue pressure and dysphagia in stroke patients. Eur Neurol 2010; 64 (2) 101-107
• 85 McCullough GH, Kamarunas E, Mann GC, Schmidley JW, Robbins JA, Crary MA. Effects of Mendelsohn maneuver on measures of swallowing duration post stroke. Top Stroke Rehabil 2012; 19 (3) 234-243
• 86 Crary MA, Carnaby Mann GD, Groher ME, Helseth E. Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia 2004; 19 (3) 160-164
• 87 McCullough GH, Kim Y. Effects of the Mendelsohn maneuver on extent of hyoid movement and UES opening post-stroke. Dysphagia 2013; ; In press
• 88 Chaudhuri G, Hildner CD, Brady S, Hutchins B, Aliga N, Abadilla E. Cardiovascular effects of the supraglottic and super-supraglottic swallowing maneuvers in stroke patients with dysphagia. Dysphagia 2002; 17 (1) 19-23
• 89 Bogaardt HCA, Grolman W, Fokkens WJ. The use of biofeedback in the treatment of chronic dysphagia in stroke patients. Folia Phoniatr Logop 2009; 61 (4) 200-205
• 90 Sukthankar SM, Reddy NP, Canilang EP, Stephenson L, Thomas R. Design and development of portable biofeedback systems for use in oral dysphagia rehabilitation. Med Eng Phys 1994; 16 (5) 430-435
• 91 Crary MA. A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia 1995; 10 (1) 6-18
• 92 Huckabee ML, Cannito MP. Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: a retrospective evaluation. Dysphagia 1999; 14 (2) 93-109
• 93 Stepp C, Britton D, Chang C, Merati A, Matsuoka Y. Feasibility of game-based electromyographic biofeedback for dysphagia rehabilitation. Paper presented at: Proc 5th Int IEEE EMBS Conf Neural Eng; Cancun, Mexico; April 27-May 1, 2011
• 94 Kushner DS, Peters K, Eroglu ST, Perless-Carroll M, Johnson-Greene D. Neuromuscular electrical stimulation efficacy in acute stroke feeding tube-dependent dysphagia during inpatient rehabilitation. Am J Phys Med Rehabil 2013; 92 (6) 486-495
• 95 Clark H, Lazarus C, Arvedson J, Schooling T, Frymark T. Evidence-based systematic review: effects of neuromuscular electrical stimulation on swallowing and neural activation. Am J Speech Lang Pathol 2009; 18 (4) 361-375
• 96 Hamdy S. Role of neurostimulation and neuroplasticity in the rehabilitation of dysphagia after stroke. Perspectives on Swallowing and Swallowing Disorders 2010; 19 (1) 3-9
• 97 Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg 2007; 133 (6) 564-571
• 98 Huckabee ML, Doeltgen S. Emerging modalities in dysphagia rehabilitation: neuromuscular electrical stimulation. N Z Med J 2007; 120 (1263) U2744
• 99 Lim KB, Lee HJ, Lim SS, Choi YI. Neuromuscular electrical and thermal-tactile stimulation for dysphagia caused by stroke: a randomized controlled trial. J Rehabil Med 2009; 41 (3) 174-178
• 100 Permsirivanich W, Tipchatyotin S, Wongchai M , et al. Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study. J Med Assoc Thai 2009; 92 (2) 259-265
• 101 Freed ML, Freed L, Chatburn RL, Christian M. Electrical stimulation for swallowing disorders caused by stroke. Respir Care 2001; 46 (5) 466-474
• 102 Leelamanit V, Limsakul C, Geater A. Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope 2002; 112 (12) 2204-2210
• 103 Shaw GY, Sechtem PR, Searl J, Keller K, Rawi TA, Dowdy E. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality?. Ann Otol Rhinol Laryngol 2007; 116 (1) 36-44
• 104 Bülow M, Speyer R, Baijens L, Woisard V, Ekberg O. Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction. Dysphagia 2008; 23 (3) 302-309
• 105 Ryu JS, Kang JY, Park JY , et al. The effect of electrical stimulation therapy on dysphagia following treatment for head and neck cancer. Oral Oncol 2009; 45 (8) 665-668
• 106 Suiter DM, Leder SB, Ruark JL. Effects of neuromuscular electrical stimulation on submental muscle activity. Dysphagia 2006; 21 (1) 56-60
• 107 Barritt AW, Smithard DG. Role of cerebral cortex plasticity in the recovery of swallowing function following dysphagic stroke. Dysphagia 2009; 24 (1) 83-90
• 108 Hamdy S, Aziz Q, Rothwell JC , et al. Explaining oropharyngeal dysphagia after unilateral hemispheric stroke. Lancet 1997; 350 (9079) 686-692
• 109 Rofes L, Vilardell N, Clavé P. Post-stroke dysphagia: progress at last. Neurogastroenterol Motil 2013; 25 (4) 278-282
• 110 Zhao XF, Du Y, Liu PG, Wang S. Acupuncture for stroke: evidence of effectiveness, safety, and cost from systematic reviews. Top Stroke Rehabil 2012; 19 (3) 226-233
• 111 Li M, Sun J, Lu J, Liu L, Geng H. [Observation on therapeutic effect of five-needle-in-nape acupuncture for treatment of poststroke pseudobulbar paralysis dysphagia]. . Zhongguo Zhen Jiu 2009; 29 (11) 873-875
• 112 Seki T, Kurusu M, Tanji H, Arai H, Sasaki H. Acupuncture and swallowing reflex in poststroke patients. J Am Geriatr Soc 2003; 51 (5) 726-727
• 113 Seki T, Iwasaki K, Arai H , et al. Acupuncture for dysphagia in poststroke patients: a videofluoroscopic study. J Am Geriatr Soc 2005; 53 (6) 1083-1084
• 114 Xie Y, Wang L, He J, Wu T. Acupuncture for dysphagia in acute stroke. Cochrane Database Syst Rev 2008; (3) CD006076
• 115 Foley N, Teasell R, Salter K, Kruger E, Martino R. Dysphagia treatment post stroke: a systematic review of randomised controlled trials. Age Ageing 2008; 37 (3) 258-264
• 116 Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol 2006; 5 (1) 31-37
• 117 Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2007; (4) CD000197
• 118 Heckert KD, Komaroff E, Adler U, Barrett AM. Postacute reevaluation may prevent dysphagia-associated morbidity. Stroke 2009; 40 (4) 1381-1385
• 119 Harper JR, McMurdo ME, Robinson A. Rediscovering the joy of food: the need for long-term review of swallowing ability in stroke patients. Scott Med J 2001; 46 (2) 54-55
• 120 Kind AJ, Smith MA, Liou JI, Pandhi N, Frytak JR, Finch MD. The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs. J Am Geriatr Soc 2008; 56 (6) 999-1005
• 121 Park JW, Oh JC, Lee JW, Yeo JS, Ryu KH. The effect of 5Hz high-frequency rTMS over contralesional pharyngeal motor cortex in post-stroke oropharyngeal dysphagia: a randomized controlled study. Neurogastroenterol Motil 2013; 25 (4) 324-e250
• 122 Kim L, Chun MH, Kim BR, Lee SJ. Effect of repetitive transcranial magnetic stimulation on patients with brain injury and dysphagia. Ann Rehabil Med 2011; 35 (6) 765-771
• 123 Khedr EM, Abo-Elfetoh N, Rothwell JC. Treatment of post-stroke dysphagia with repetitive transcranial magnetic stimulation. Acta Neurol Scand 2009; 119 (3) 155-161
• 124 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
• 125 Kumar S, Wagner CW, Frayne C , et al. Noninvasive brain stimulation may improve stroke-related dysphagia: a pilot study. Stroke 2011; 42 (4) 1035-1040
• 126 Shigematsu T, Fujishima I, Ohno K. Transcranial direct current stimulation improves swallowing function in stroke patients. Neurorehabil Neural Repair 2013; 27 (4) 363-369