rTMS in Chronic Poststroke Dysphagia

January 3, 2023 updated by: National Taiwan University Hospital

The Effectiveness of Repetitive Transcranial Magnetic Stimulation (rTMS) in Patients With Chronic Poststroke Dysphagia.

The goal of this study is to investigate the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) and intermittent theta burst stimulation (iTBS) applying on suprahyoid motor cortex in chronic poststroke dysphagia, and its effect on hyolaryngeal movement.

Participants will be randomized into three groups. The three experimental groups received either bilateral or ipsilateral rTMS, or iTBS (with contralateral sham stimulation) at suprahyoid motor cortex, while the placebo group received bilateral sham stimulation. Stimulation will be given at 5 hertz(Hz), 1000 pulses of rTMS or 600 pulses of iTBS per session, for a total of 10 sessions. The swallowing function, penetration-aspiration scale of video-fluoroscopic swallowing study, motor evoked potential of suprahyoid muscles, intraoral pressure, and ultrasound swallowing exam will be evaluated before therapy, and at 1, 3, 6 months post therapy.

Study Overview

Detailed Description

Swallowing dysfunction, or dysphagia, is a common complication following stroke. Although spontaneous recovery of swallowing function was seen in most patients in a time course of a few weeks to 6 months after stroke, around 50% of patients recovered slowly and had chronic dysphagia clinically. It is worth noting that dysphagia has great impact on clinical outcome, in terms of not only quality of life but also risk of severe complication such as aspiration pneumonia, malnutrition, and even death.

After damage on swallowing ability, several cause would arise risk of aspiration and one of them was inadequate hyolaryngeal elevation. Suprahyoid muscle played an important role in hyolaryngeal movement so re-training on suprahyoid muscle might be an efficient method.

Conventional treatments of dysphagia focused on restore or improve swallowing functions through oropharyngeal muscle training, swallowing maneuvers, or compensation strategy. However, the effectiveness of traditional therapy was still limited and inconsistent.

Noninvasive brain stimulation (NIBS) has gained increasing attention as a promising neuromodulation therapy which could improve neurological deficit and functional level through inducing the cortical neuroplasticity. Among NIBS, repetitive transcranial magnetic stimulation (rTMS) is the most widely used and delved. It has been utilized in stroke patient for promoting functional reorganization and modulate neural connection in motor and language area. In a previous network meta-analysis, we also indicated that rTMS showed the best efficacy in improving the swallowing function in acute and subacute poststroke dysphagia, when compared with transcranial direct current stimulation, surface neuromuscular electrical stimulation, and pharyngeal electrical stimulation (PES). Despite of the positive results, there was still limited evidence on the effect of rTMS in chronic dysphagia and the mechanism by which rTMS improved dysphagia outcome is unclear. Specifically, whether the rTMS on a representation cortex directly increase functional gain, such as strength and contractility of the target area remained unclear. On the other hand, theta burst stimulation (TBS), consisting of continuous TBS (cTBS) and intermittent TBS (iTBS), is a new stimulation model of TMS and seemed to be helpful on motor recovery in chronic stroke. Furthermore, previous research had showed iTBS was not inferior to rTMS on the improvement of poststroke dysphagia using stimulation at suprahyoid motor cortex of affected hemisphere. In this study, we aim to investigate the therapeutic efficacy of both high frequency rTMS and iTBS applying on suprahyoid motor cortex in chronic poststroke dysphagia, and its effect on hyolaryngeal movement.

In each stage, patients with subcortical stroke will be randomized into three groups. The three experimental groups receive either bilateral or ipsilateral rTMS, or iTBS (with contralateral sham stimulation) at suprahyoid motor cortex, while the placebo group receive bilateral sham stimulation. Stimulation will be given at 5 hertz(Hz), 1000 pulses of rTMS or 600 pulses of iTBS per session, for a total of 10 sessions. The swallowing function, penetration-aspiration scale of video-fluoroscopic swallowing study, motor evoked potential of suprahyoid muscles, intraoral pressure, and ultrasound swallowing exam will be evaluated before therapy, and at 1, 3, 6 months post therapy.

Study Type

Interventional

Enrollment (Anticipated)

150

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

20 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • age > 20 years old, diagnosed of subcortical stroke(including ischemic or hemorrhagic type) by CT or MRI image study
  • sustained the symptoms of dysphagia more than one month after stroke.
  • Functional Oral Intake Scale (FOIS) between 1 to 5 score
  • Maintenance on sitting balance over 15 minutes

Exclusion Criteria:

  • Disturbed consciousness, unable to communicate and obey order through gesture or language
  • Disease or trauma involved central neural system, such as Parkinson's disease, traumatic brain injury, brain tumor or multiple sclerosis
  • Any disorder inducing dysphagia, such as nasopharyngeal cancer(NPC) or cervical cancer
  • Metal Implants or pacemaker
  • Global aphasia or cognitive impairment
  • History of epilepsy
  • Pregnancy

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Factorial Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: bilateral rTMS
5 hertz(Hz), 1000 pulses, 90% resting motor threshold(RMT) stimulation on bilateral motor cortex of suprahyoid muscle for 15 minutes.
5 hertz(Hz), 1000 pulses, 90% RMT stimulation; 15 minutes per session; for a total of 10 sessions
Experimental: unilateral rTMS
5 hertz(Hz), 1000 pulses, 90% RMT stimulation on motor cortex of suprahyoid muscle at ipsilateral side as the lesion for 15 minutes; sham stimulation on motor cortex of suprahyoid muscle at contra-lateral side as the lesion for 15 minutes.
5 hertz(Hz), 1000 pulses, 90% RMT stimulation; 15 minutes per session; for a total of 10 sessions
Experimental: bilateral iTBS
600 pulses iTBS stimulation on bilateral motor cortex of suprahyoid muscle for 15 minutes.
3 pulses of stimulation delivered at 50 Hz and repeated at 5 Hz; 2s train of TBS with repetitive interval of every 10s, 70% RMT; 600 pulses in total; 15 minutes per session; for a total of 10 sessions
Experimental: unilateral iTBS
600 pulses iTBS on motor cortex of suprahyoid muscle at ipsilateral side as the lesion for 15 minutes; sham stimulation on motor cortex of suprahyoid muscle at contra-lateral side as the lesion for 15 minutes.
3 pulses of stimulation delivered at 50 Hz and repeated at 5 Hz; 2s train of TBS with repetitive interval of every 10s, 70% RMT; 600 pulses in total; 15 minutes per session; for a total of 10 sessions
Placebo Comparator: control group of rTMS
Sham stimulation on motor cortex of suprahyoid muscle at contra-lateral side as the lesion for 15 minutes.
Set-up the coil without true stimulation; 15 minutes per session; for a total of 10 sessions
Placebo Comparator: control group of iTBS
Sham stimulation on motor cortex of suprahyoid muscle at contra-lateral side as the lesion for 15 minutes.
Set-up the coil without true stimulation; 15 minutes per session; for a total of 10 sessions

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
penetration-aspiration scale(PAS)
Time Frame: Day 30 (change of PAS, comparing with the data in baseline) of each section
Penetration-aspiration scale will be calculated by videofluoroscopic swallow study with measurement of the depth of penetrated or aspirated material and the patient's response to airway invasion. Score range is 1 to 8; higher score means more severe on penetration and aspiration.
Day 30 (change of PAS, comparing with the data in baseline) of each section
penetration-aspiration scale(PAS)
Time Frame: Day 90 (change of PAS, comparing with the data in baseline and Day 30) of each section
Penetration-aspiration scale will be calculated by videofluoroscopic swallow study with measurement of the depth of penetrated or aspirated material and the patient's response to airway invasion. Score range is 1 to 8; higher score means more severe on penetration and aspiration.
Day 90 (change of PAS, comparing with the data in baseline and Day 30) of each section

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The Swallowing Quality-of-Life questionnaire(SWAL-QOL)
Time Frame: Day 14, Day 30, Day 90, Day 180 (comparing with the data in baseline) of each section
The questionnaire to assess ten quality-of-life concepts about dysphagia, containing 44-items and dividing into 10 domains. The score of each item ranges from 0 to 4 and total score ranges from 0 to 100. Higher score means better swallow-specific quality of life.
Day 14, Day 30, Day 90, Day 180 (comparing with the data in baseline) of each section
The Functional Oral Intake Scale (FOIS)
Time Frame: Day 14, Day 30, Day 90, Day 180 (comparing with the data in baseline) of each section
Measurement of functional level of oral intake of food and liquid with 7-point ordinal scale, level 1 to level 7. Higher level means better performance and lower limitation on oral intake.
Day 14, Day 30, Day 90, Day 180 (comparing with the data in baseline) of each section
The Dysphagia Severity Scale (DSS)
Time Frame: Day 14, Day 30, Day 90, Day 180 (comparing with the data in baseline) of each section
Combination of objective evaluation of the functional severity of dysphagia and recommendations for diet level. Level range is from 1 to 7; lower level means more severe on dysphagia and aspiration.
Day 14, Day 30, Day 90, Day 180 (comparing with the data in baseline) of each section
Iowa Oral Performance Instrument (IOPI)
Time Frame: Baseline, Day 14, Day 30, Day 90, Day 180
Objectively evaluate and measure tongue and lip strength and endurance
Baseline, Day 14, Day 30, Day 90, Day 180
Swallowing ultrasound
Time Frame: Baseline, Day 14, Day 30, Day 90, Day 180
The ultrasound of swallowing to evaluate the movement of hyoid bone
Baseline, Day 14, Day 30, Day 90, Day 180
Motor evoked potential (MEP)
Time Frame: Baseline, Day 14
Record the MEP of suprahyoid muscle under rTMS
Baseline, Day 14

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Study Chair: Ming-Yen Hsiao, PHD, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Anticipated)

January 10, 2023

Primary Completion (Anticipated)

May 1, 2024

Study Completion (Anticipated)

August 31, 2024

Study Registration Dates

First Submitted

October 6, 2022

First Submitted That Met QC Criteria

October 18, 2022

First Posted (Actual)

October 21, 2022

Study Record Updates

Last Update Posted (Actual)

January 5, 2023

Last Update Submitted That Met QC Criteria

January 3, 2023

Last Verified

September 1, 2022

More Information

Terms related to this study

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

No

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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