Dysphagia Therapy

Number: 0625

(Replaces CPB 439)

 

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses dysphagia therapy.

  1. Medical Necessity

    Aetna considers the following interventions medically necessary for treatment of dysphagia when criteria are met:

    1. Speech therapy for treatment of dysphagia, regardless of the presence of a communication disability, for members who meet the criteria set forth below:

      1. Member exhibits weight loss or malnutrition because he/she has dysphagia and is unable to obtain adequate nutrition orally; or
      2. Member has a history of, or is at high-risk for, recurrent aspirations or choking; or
      3. Member is unable to swallow and has a nasogastric or gastrotomy tube for nutrition;
    2. Esophageal dilation for the treatment of symptomatic obstruction of the esophagus;
    3. Non-biodegradable, non-drug eluting stent placement for refractory (i.e., cannot be dilated to an adequate diameter) malignant esophageal strictures.

  2. Experimental, Investigational, or Unproven

    Aetna considers the following interventions (not an all-inclusive list) experimental, investigational, or unproven for treatment of dysphagia because the effectiveness of these approaches has not been established:

    1. Acupuncture
    2. Artificial intelligence-based technology for the management of dysphagia
    3. Autologous muscle cell therapy for tongue dysphagia
    4. Biodegradable stent
    5. Drug-eluting stents for esophageal strictures (malignant or benign)
    6. Dysphagia therapy for all other indications other than the ones listed in Section I
    7. Electrical stimulation (including neuromuscular electrostimulation, and pharyngeal electrical stimulation)
    8. ERBE electrocautery
    9. Esophageal dilation for the treatment of non-obstructive esophageal dysphagia
    10. Hyperbaric oxygen therapy for the treatment of radiation-induced dysphagia
    11. Intensive dysphagia rehabilitation approach/program (e.g., the Swallow STRONG multi-disciplinary oropharyngeal strengthening program)
    12. Laryngeal manipulation
    13. Mirror therapy
    14. Per oral plication of the esophagus (POPE) for the treatment of dysphagia
    15. Pharyngeal motor cortex stimulation
    16. Repetitive peripheral/transcranial magnetic stimulation
    17. Transcranial direct current stimulation.

  3. Policy Limitations and Exclusions 

    Some plans limit coverage of medically necessary speech therapy services. Members should check their benefit plan descriptions for any applicable benefit plan limitations and exclusions on coverage for speech therapy services. 

  4. Related Policies

Table:

CPT Codes / ICD-10 Codes / HCPCS Codes
Code Code Description

Therapy for the management of dysphagia other than esophageal dilation or stent placement:

CPT codes covered if selection criteria are met:
92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual [not covered for intensive dysphagia rehabilitation program]
92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals [not covered for intensive dysphagia rehabilitation program]
92526 Treatment of swallowing dysfunction and/or oral function for feeding
92610 Evaluation of oral and pharyngeal swallowing function
92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording
92612 Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording
92613     physician interpretation and report only

CPT codes not covered for indications listed in the CPB:
Repetitive peripheral magnetic stimulation, Swallow STRONG multi-disciplinary oropharyngeal strengthening program, pharyngeal electrical stimulation and transcranial direct current stimulation, mirror therapy, per oral plication of the esophagus (POPE), artificial intelligence-based technology - no specific code
43229 Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) [not covered for ERBE electrocautery]
90867 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
90868     subsequent delivery and management, per session
90869     subsequent motor threshold re-determination with delivery and management
97014 Application of a modality to one or more areas; electrical stimulation (unattended)
97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
97810 - 97814 Acupuncture
99183 Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session

HCPCS codes covered if selection criteria are met:
G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
S9128 Speech therapy, in the home, per diem

HCPCS codes not covered for indications listed in the CPB:
A4575 Topical hyperbaric oxygen chamber, disposable
E0446 Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories
E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation
E0745 Neuromuscular stimulator, electronic shock unit
G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

ICD-10 codes covered if selection criteria are met:
I69.091
I69.191
I69.291
I69.391
I69.891
I69.991		 Cerebrovascular disease, dysphagia, sequelae
R13.10 - R13.19 Dysphagia

ICD-10 codes not covered for indications listed in the CPB:
T66.XXXA - T66.XXXS Radiation sickness, unspecified

Esophageal dilation:

CPT codes covered if selection criteria are met:
43196 Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire
43213 Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed)
43214     with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43220 Esophagoscopy, rigid or flexible; with balloon dilation (less than 30 mm diameter)
43226     with insertion of guide wire followed by dilation over guide wire
43229 Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43249 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter)
43253 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial marker(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
43270 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
43450 Dilation of esophagus, by unguided sound or bougie, single or multiple passes
43453 Dilation of esophagus, over guide wire

ICD-10 codes covered if selection criteria are met:
K22.2 Esophageal obstruction
Q39.0 - Q39.4
Q39.8		 Congenital malformations of esophagus

ICD-10 codes not covered for indications listed in the CPB:
I69.091
I69.191
I69.291
I69.391
I69.891
I69.991		 Cerebrovascular disease, dysphagia, sequelae
R13.10 - R13.19 Dysphagia

Stent Placement:

CPT codes covered if selection criteria are met:
43212 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

HCPCS codes covered if selection criteria are met:
C1874 Stent, coated/covered, with delivery system [not covered for biodegradable and drug-eluting stent]
C1875 Stent, coated/covered, without delivery system [not covered for biodegradable and drug-eluting stent]

Other HCPCS codes related to the CPB:
C1876 Stent, noncoated/noncovered, with delivery system
C1877 Stent, noncoated/noncovered, without delivery system

ICD-10 codes covered if selection criteria are met:
C15.3 - C15.9 Malignant neoplasm of esophagus

ICD-10 codes not covered for indications listed in the CPB:
I69.091, I69.191, I69.291, I69.391, I69.891, I69.991 Sequelae of cerebrovascular disease, dysphagia
R13.10 - R13.19 Dysphagia

Autologous muscle cell therapy for tongue dysphagia:

CPT codes not covered for indications listed in the CPB:
0999T Autologous muscle cell therapy, harvesting of muscle progenitor cells, including ultrasound guidance, when performed
1038T Autologous muscle cell therapy, injection(s) of muscle progenitor cells into the tongue, including esophagoscopy, when performed

ICD-10 codes not covered for indications listed in the CPB:
R13.11 Dysphagia, oral phase
R13.12 Dysphagia, oropharyngeal phase

Background

People with dysphagia have difficulty swallowing and may also experience pain while swallowing. Some individuals may be completely unable to swallow or may have trouble swallowing liquids, foods, or saliva.

Dysphagia occurs when there is a problem with any part of the swallowing process. Weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing. Food pieces that are too large for swallowing may enter the throat and block the passage of air.

Other problems include not being able to start the swallowing reflex (a stimulus that allows food and liquids to move safely through the pharynx) because of a stroke or other nervous system disorder. People with these kinds of problems are unable to begin the muscle movements that allow food to move from the mouth to the stomach. Another difficulty can occur when weak throat muscles cannot move all of the food toward the stomach. Bits of food can fall or be pulled into the trachea, which may result in aspiration pneumonia.

Dysphagia may be caused by any condition that weakens or damages the muscles and nerves used for swallowing. For example, people with nervous system diseases, such as cerebral palsy or Parkinson's disease, often have problems swallowing. Additionally, cerebrovascular accidents or traumatic brain injuries may affect the coordination of the swallowing muscles or limit sensation in the mouth and throat. An infection or irritation can cause narrowing of the esophagus. People born with abnormalities of the swallowing mechanism may not be able to swallow normally. Infants who are born with a cleft palate are unable to suck properly, which complicates breastfeeding and drinking from a regular baby bottle. In addition, cancers of the head, neck, or esophagus may cause dysphagia. Sometimes, the treatment for these types of cancers can cause dysphagia. Injuries to the head, neck, and chest may also create swallowing problems.

Physicians and speech-language pathologists who test for and treat swallowing disorders use a variety of tests that allow them to look at the parts of the swallowing mechanism, including fiber optic laryngoscopy, video fluoroscopy, and ultrasound.

Once the cause of the dysphagia is found, surgery or medication may help. If treating the cause of the dysphagia does not help, the patient may be referred to a speech-language pathologist who is trained in testing and treating swallowing disorders. The speech-language pathologist will test the person's ability to eat and drink and may teach the person new ways to swallow.

Oral-motor therapy is directed at correcting abnormal oral muscle behaviors that interfere with feeding. Oral-motor therapy may focus on inducing active suckle movements, coordinating tongue movements, or facilitating normal oral movement patterns such as lip closure.

Oral-motor therapy has also been used in developmentally delayed children to stop drooling, correct abnormal tongue thrust, and improve speech. Speech management of the developmentally delayed child has included training to improve the functioning of oral and pharyngeal muscles. This oral-motor training is usually introduced before the emergence of speech. Most Aetna plans exclude treatment of developmental delay. Please check benefit plan descriptions for details.

Esophageal Dilation

Guidelines on the use of esophageal dilation (Riley and Attwood, 2004) stated that esophageal dilation is indicated in the treatment of symptomatic obstruction of the esophagus. The guidelines explained that obstruction may develop as a consequence of a wide range of anatomical and functional esophageal disorders. Reflux-induced strictures, malignant strictures, and achalasia are the most frequent indications, but patients with anastomotic, sclerotherapy, radiation, medication, and corrosive-induced strictures, as well as those with rings and webs, frequently require dilation. The guidelines stated that patients with diffuse esophageal spasm and other motility disorders may occasionally require dilation of the lower esophageal sphincter when conservative measures fail.

There is inadequate evidence of the clinical utility of esophageal dilation in dysphagia not associated with obstruction. In a randomized controlled trial (n = 96), Lavu et al. (2004) examined the impact of esophageal dilation with a large-diameter dilator on dysphagia and quality of life in such patients. These investigators found that most patients with esophageal dysphagia have a non-obstructing esophageal lumen. Their findings did not support the practice of empiric esophageal dilation for patients with non-obstructive esophageal dysphagia. Improvement in both treatment and control groups suggests that it occurred due to proton pump inhibitor therapy, lending credence to the hypothesis that esophageal hypersensitivity to acid contributes to symptoms in most patients with non-obstructive esophageal dysphagia, which is the predominant category of dysphagia.

Siersema (2008) stated that esophageal strictures are frequently encountered by gastroenterologists and can be caused by benign or malignant lesions. Dysphagia is the symptom experienced by all patients, regardless of the cause of their strictures. The methods most commonly employed for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications, and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, strictures do recur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e., focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e., over 2 cm in length, tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter.

Non-Biodegradable Stent for Malignant Esophageal Strictures

Verschuur and associates (2007) compared small- and large-diameter stents for improvement of dysphagia, complications, and recurrent dysphagia. These investigators prospectively followed 338 patients with dysphagia from obstructing esophageal or gastric cardia cancer who were treated with an Ultra-flex stent (n = 153), a Gianturco Z-stent (n = 89), or a Flamingo Wallstent (n = 96) of either a small diameter (n = 265) or a large diameter (n = 73). Major outcome measurements included dysphagia score (on a scale from 0 [no dysphagia] to 4 [complete dysphagia]), complications, and recurrent dysphagia. Analysis was performed using the Chi-squared test, log-rank test, and Cox regression analysis. Improvement in dysphagia was similar between patients with a small- or a large-diameter stent (p = 0.35). The occurrence of major complications, such as hemorrhage, perforation, fistula, and fever, was increased in patients with a large-diameter Gianturco Z-stent compared with those treated with a small-diameter stent (4 [40%] versus 16 [20%]; adjusted hazard ratio [HR] 5.03, 95% confidence interval [CI]: 1.33 to 19.11) but not in patients with a large-diameter Ultra-flex stent or a Flamingo Wallstent. Moreover, minor complications, particularly pain, were associated with prior radiation and/or chemotherapy in patients with a large- or a small-diameter Gianturco Z-stent (HR 4.27, 95% CI: 1.44 to 12.71) but not in those with an Ultra-flex stent or a Flamingo Wallstent. Dysphagia from stent migration, tissue overgrowth, and food bolus obstruction recurred more frequently in patients with a small-diameter stent than in those with a large-diameter stent (Ultra-flex stent: 54 [42%] versus 3 [13%], adjusted HR 0.16, 95% CI: 0.04 to 0.74; Gianturco Z-stent: 21 [27%] versus 1 [10%], adjusted HR 0.97, 95% CI: 0.11 to 8.67; and Flamingo Wallstent: 21 [37%] versus 6 [15%], adjusted HR 0.40, 95% CI: 0.03 to 4.79). The authors concluded that large-diameter stents reduce the risk of recurrent dysphagia from stent migration, tissue overgrowth, or food obstruction. Increasing the diameter in some stent types may, however, increase the risk of stent-related complications to the esophagus.

Conio et al. (2007) stated that self-expanding metal stents (SEMS) provide effective palliation in patients with malignant dysphagia, although severe complications and mortality may result. These researchers performed a prospective controlled trial to compare a new self-expanding polyester mesh stent (Polyflex) with SEMS (Ultra-flex). A total of 101 patients with unresectable esophageal carcinoma were randomized to placement of a Polyflex (n = 47) or a partially covered Ultra-flex (n = 54) stent. Patients with esophagogastric junction malignancy were excluded. Placement was successful in 46 (98%) patients with the Polyflex and 54 (100%) patients with the Ultra-flex stent. In 1 patient, the Polyflex stent could not be placed. After 1 week, dysphagia was improved by at least 1 grade in 100% of the Polyflex group and in 94% of the Ultra-flex group. Major complications were observed in 48% of the Polyflex group and 33% of the Ultra-flex group. Intra-procedural perforation occurred in 1 Polyflex and 1 Ultra-flex patient; 2 Polyflex patients had post-procedural hemorrhage. Twenty (44%) patients with a Polyflex stent and 18 (33%) with an Ultra-flex stent had recurrent dysphagia because of tumor overgrowth, stent migration, hyperplastic granulomatous reaction, or food bolus impaction. Multivariate analyses showed a significantly higher complication rate with Polyflex than with Ultra-flex stents (odds ratio 2.3, 95% CI: 1.2 to 4.4). However, median survival was 134 days with Polyflex and 122 days with Ultra-flex stents (p = NS). The authors concluded that no difference was seen in palliation of dysphagia between the two stents. Significantly more complications, especially late stent migration, were observed in the Polyflex group.

Verschuur and colleagues (2008) noted that stents are often used for the palliation of inoperable esophageal or gastric cardia cancer. One of the drawbacks of the currently used stents is the high percentage of recurrent dysphagia due to stent migration and tissue growth. New stents have been designed to overcome this unwanted sequela of stent placement. In this randomized trial, these investigators examined if the results of stent placement could be improved with newer stent designs. A total of 125 patients with dysphagia from inoperable carcinoma of the esophagus or gastric cardia were randomized to placement of an Ultra-flex stent (n = 42), Polyflex stent (n = 41), or Niti-S stent (n = 42). Patients were followed by scheduled telephone calls at 14 days after treatment, and then monthly for 6 months or until death. Technical and functional outcomes, complications, recurrent dysphagia, and survival were analyzed using Chi-squared tests, Kaplan-Meier curves, and log-rank tests. Stent placement was technically successful in all patients with an Ultra-flex stent, in 34/41 (83%) patients with a Polyflex stent, and in 40/42 (95%) patients treated with a Niti-S stent (p = 0.008). Dysphagia score improved from a median of 3 (liquids only) to 1 (ability to eat some solid food) in all patients. There were no differences in complications among the three stent types. Recurrent dysphagia, caused by tissue ingrowth or overgrowth, migration, or food obstruction, was significantly different between patients with an Ultra-flex stent and patients with a Polyflex stent or Niti-S stent (22 [52%] versus 15 [37%] versus 13 [31%], p = 0.03). Stent migration occurred more frequently with Polyflex stents, whereas tissue ingrowth or overgrowth was more frequently seen with Ultra-flex stents, and to a lesser degree, Niti-S stents. No differences were found in survival (median survival: Ultra-flex stent 132 days versus Polyflex stent 102 days versus Niti-S stent 159 days) among the three stent types. The authors concluded that all three stents are safe and offer adequate palliation of dysphagia from esophageal or gastric cardia cancer. Nonetheless, Polyflex stents seem the least preferable in this patient group, as placement of this device is technically demanding and associated with a high rate of stent migrations.

Per-Oral Endoscopic Myotomy (POEM) 

See CPB 0678 - Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy for the treatment of achalasia.

Acupuncture

In a meta-analysis, Long and Wu (2012) examined the effect of acupuncture for the treatment of dysphagia in patients affected by a stroke. Randomized controlled trials (RCTs) comparing acupuncture treatment with non-acupuncture treatment of dysphagia in patients with a stroke were identified from the databases of PubMed, Embase, Cochrane Library, and CBM disc (China Biological Medicine Database). Eligible investigations were included, and data on the effectiveness of acupuncture were extracted and synthesized by meta-analysis using RevMan 5.1.4. Results were expressed as odds ratio (OR) for dichotomous data; 95% confidence intervals (CIs) were also calculated. A total of 72 RCTs (3,208 patients in the treatment group and 2,926 patients in the control group) were identified. Details of randomization and blinding were not reported, and information on withdrawals and drop-outs was missing in most of the included reports. Meta-analysis showed that the effectiveness of treatment in the group receiving acupuncture was higher than that in the non-acupuncture group (OR = 5.17, 95% CI: 4.18 to 6.38; p < 0.00001). However, the study quality was generally low and of insufficient quality to make recommendations about using acupuncture in the rehabilitation of patients with dysphagia due to stroke. The authors concluded that acupuncture might be beneficial in the rehabilitation of patients with dysphagia caused by stroke, and the evidence justifies future high-quality studies.

Jiang et al. (2022) stated that post-stroke dysphagia is one of the most common stroke complications, with high morbidity and a long course, while acupuncture treatment is easily accepted by patients due to its reliability, feasibility, simple operation, low price, and quick effect. In a systematic review and meta-analysis, these investigators examined the effectiveness of manual acupuncture in patients with post-stroke dysphagia. Databases including Medline, Web of Science, PubMed, Cochrane Library databases, Embase, CNKI (China National Knowledge Infrastructure), WanFang (WanFang Database), and VIP (Chongqing VIP) were searched from inception until August 19, 2022. Data were analyzed using RevMan 5.3, Stata 14.0, and TSA 0.9.5.10 Beta software. Evidence quality evaluation was carried out by employing GRADE profiler 3.6. A total of 33 RCTs enrolled 2,680 participants. Meta-analysis revealed that compared to rehabilitation, acupuncture decreased water swallow test (WST) and SSA scores. Meanwhile, in contrast to rehabilitation alone, the integration of acupuncture with rehabilitation effectively decreased WST and SSA scores; improved swallowing scores of VFSS, swallowing scores of Fujishima Ichiro, BI, and SWAL-QOL; reduced the aspiration rates and aspiration pneumonia; as well as shortened the duration of empty swallowing and the duration of 5-ml water swallowing. Pooled analysis did not reveal any significant differences in DOSS (p = 0.15 > 0.05) between the acupuncture group combined with the rehabilitation group and the rehabilitation group alone. After the risk-of-bias assessment, these studies were not of low quality, except in terms of allocation concealment and blindness. Evidence quality evaluation showed that allocation concealment and blindness led to a downgrade, and primary outcomes' evaluation of acupuncture combined with rehabilitation were ranked as moderate-quality evidence, while acupuncture alone was ranked as low-quality. The authors concluded that this meta-analysis provided positive evidence that acupuncture and acupuncture combined with rehabilitation were better than using rehabilitation alone in the treatment of post-stroke dysphagia. Moreover, these researchers stated that multi-center RCTs with a large sample and a rigorous design are needed to examine if acupuncture could replace other stimulative therapies in rehabilitation training. Additionally, acupoint combination, frequency, and the total number of treatments may be important factors that could influence therapeutic effect, which can provide guidance for subsequent similar RCTs.

The authors stated that this review had several drawbacks. First, although most of the included studies used clinical success rate as an outcome indicator, there was no uniform international standard for the definition of success rate. Thus, these researchers did not consider clinical response rate as one of the outcome indicators, which may have caused a loss of evidence. Second, post-stroke dysphagia is one of the most prevalent stroke complications with high morbidity and a long disease course. The shortest course of treatment in the included studies was 10 days, while the longest was 8 weeks; and only 1 study had a 3-month follow-up and reported long-term effectiveness. Third, although these investigators used Egger's test to examine publication bias in this review, the fact that all the included RCTs were conducted in China potentially contributed to a publication bias.

Artificial Intelligence in the Management of Dysphagia

Gallano et al. (2025) noted that artificial Intelligence (AI) is transforming speech-language pathology (SLP) and dysphagia management, offering innovative solutions for assessment, diagnosis, and rehabilitation. These investigators examined AI applications in these fields from 2014 to 2024, with an emphasis on implementation challenges in Latin America. They analyzed key AI technologies --including deep learning (DL), machine learning (ML) algorithms, as well as natural language processing -- that have shown high accuracy in detecting voice disorders, analyzing swallowing function, and supporting personalized rehabilitation. These researchers identified 3 primary domains of AI application: diagnostic tools with improved sensitivity for speech-language disorders, rehabilitation technologies that enable customized therapy, and tele-health platforms that expand access to specialized care in under-served regions. However, significant barriers persist, especially in Latin America, where limited infra-structure, insufficient linguistic adaptation, and scarce regional data-sets hamper widespread implementation. In a pilot study, these investigators examined commercially available large language models for rehabilitation planning demonstrated their potential utility in generating structured therapy activities, especially in resource-constrained settings. The authors concluded that while AI shows promise in enhancing clinical work-flows and expanding service delivery, the evidence suggests that current applications remain predominantly focused on diagnosis rather than integrated rehabilitation. These researchers highlighted the need for culturally and linguistically adapted AI models, expanded regional research collaborations, as well as regulatory frame-works that ensure ethical AI integration into SLP and dysphagia care, positioning these technologies as complementary tools that enhance rather than replace clinical expertise.

Furthermore, UpToDate reviews on “Oropharyngeal dysphagia: Clinical features, diagnosis, and management” (Lembo, 2025), and “Approach to the evaluation of dysphagia in adults” (Fass, 2025) do not mention artificial Intelligence as a management tool.

Autologous Muscle Cell Therapy for Tongue Dysphagia 

Autologous muscle cell therapy (Autologous Muscle Derived Cells for Gastro-Intestinal Repair (AMDC-GIR) or Iltamiocel) is an experimental, regenerative treatment for tongue dysphagia caused by head/neck cancer treatments. It involves harvesting a patient's own muscle cells, growing them, and injecting them into the tongue to restore strength, often guided by endoscopy. A small muscle sample (50–250 mg) is taken from the patient's thigh (vastus lateralis), and progenitor cells are expanded in a lab. These autologous muscle derived cells (AMDC) are injected into the tongue muscles (often 150-300 million cells). Transnasal endoscopy (often a flexible video naso-pharyngo-laryngoscope) is used to visualize the larynx and ensure precise needle localization at the base of the tongue, frequently with lingual nerve blocks. Patients with chronic dysphagia (swallowing, tongue weakness) specifically following surgery, chemotherapy, or radiation for oropharyngeal cancer. The injected cells act as "myocytes" to rebuild muscle fiber, aimed at repairing fibrosis and muscle damage.

Phase I trials have shown this improve tongue pressure and, consequently, swallow function for up to 2 years. A phase I clinical trial evaluated the safety and potential efficacy of autologous muscle-derived cell (AMDC) therapy for treating swallowing impairment in patients who had undergone treatment for oropharyngeal cancer (Nativ-Zeltzer et al., 2022). The objective was to determine whether injection of AMDCs into the tongue could improve swallowing-related outcomes in patients with chronic dysphagia following chemoradiation or surgery. The investigators conducted a prospective, open-label study enrolling 10 disease-free male participants (mean age 65 years) at least two years post-treatment who had moderate swallowing impairment but were not feeding tube–dependent. Autologous muscle tissue was harvested from the thigh, expanded ex vivo to 150×10⁶ cells, and injected into multiple sites in the intrinsic tongue musculature, with follow-up assessments conducted over 24 months using safety monitoring and objective (e.g., tongue pressure, videofluoroscopic measures, manometry) and patient-reported outcomes. Results demonstrated no serious adverse events, indicating a favorable safety profile; minor procedure-related effects (e.g., transient pain, swelling) resolved with conservative management. Efficacy findings showed a statistically significant increase in mean tongue pressure (from 26.3 to 31.8 kPa, p=0.017), suggesting improved tongue strength, but there were no significant improvements in swallowing function measures (e.g., penetration-aspiration scale, FOIS) or patient-reported outcomes (e.g., EAT-10), and pneumonia occurred in 30% of participants. The authors concluded that while AMDC injection appears safe and may enhance tongue strength, its clinical impact on functional swallowing remains uncertain. Key limitations include the very small sample size, lack of a control group, open-label design, homogeneous population (all male), and limited statistical power to detect changes in secondary endpoints, all of which restrict generalizability and preclude definitive conclusions regarding efficacy, highlighting the need for larger randomized controlled trials. A randomized clinical trial, Autologous Muscle Derived Cells for Treatment of Tongue Dysphagia (REVIVE) (NCT05421689), is currently ongoing.

Biodegradable Stent

Griffiths et al. (2012) noted that biodegradable (BD) esophageal stents have been available commercially only since 2008, and previously published research is limited. These researchers reviewed the use of BD stents to treat dysphagia in benign or malignant esophageal strictures. Patients were identified from a prospective interventional radiological database. Biodegradable stents were inserted radiologically under fluoroscopic control. Between July 2008 and February 2011, a total of 25 attempts at placing SX-ELLA BD esophageal stents were made in 17 males and 5 females, with a median age of 69 (range of 54 to 80) years. Two patients required more than one BD stent. Indications were benign strictures (n = 7) and esophageal cancer (n = 17). One attempt was unsuccessful, resulting in a technical success rate of 96% with no immediate complications. The clinical success rate was 76%. The median dysphagia score before stent insertion was 3 (range of 2 to 4) compared to 2 (range of 0 to 3) after stent insertion (p = 0.0001). The authors concluded that BD stents provide good dysphagia relief for the lifetime of the stent. They may help avoid the use of feeding tubes in patients undergoing radical chemoradiotherapy or awaiting esophagectomy. They do not require removal or interfere with radiotherapy planning via imaging. However, the re-intervention rate was high after the stent dissolves.

Krokidis et al. (2013) evaluated the clinical results of the use of BD esophageal stents in malignant strictures. A total of 11 patients were included in this prospective analysis in which a woven polydioxanone BD esophageal stent was used. The inclusion criterion was that the patient underwent neoadjuvant treatment or radical radiotherapy after the stent insertion. Primary endpoints were dysphagia score at discharge, stent patency, and complication rate. Secondary endpoints were overall survival and surgical outcome. There was a 100% procedure technical success rate. Early complications occurred in 3 patients, resulting in failure to restore oral nutrition. In the remaining 8 patients, dysphagia was significantly improved at discharge. The mean stent patency rate in this group was 71.5 days. Stent dysfunction occurred in 5 of 8 patients (62.5%); in 2 of 5 patients, this was due to a local inflammatory reaction, and in 3 of 5 patients, it was due to tumor growth after a mean time of 97.8 days, and a new metallic stent was consequently placed in 4 of 5 patients. One patient was successfully treated with esophagectomy. At the end of follow-up (mean time of 102.1 days), 3 of 8 stents were patent. The overall patient survival rate was 81.8%. The authors concluded that although short-term dysphagia scores improved, BD stents do not appear to offer a clear beneficial effect in most cases of malignant strictures, particularly due to a local inflammatory reaction that may be induced. Technical improvement of the device and delineation of the patient group that would benefit from its use is necessary if further studies are to be conducted in the future.

Electrical Stimulation (Including Neuromuscular Electrostimulation)

Electrical stimulation (ES) has been examined for the treatment of dysphagia. However, there is currently insufficient evidence to support the effectiveness of ES in treating this condition. Park et al. (1997) reported a pilot study of oral ES on swallow function in post-stroke patients. They found that oral ES resulted in an improvement in swallow function in 2 of the 4 patients. The authors concluded that these early results are promising, but further research is needed. In a controlled study, Freed et al. (2001) compared the effectiveness of transcutaneous ES to thermal-tactile stimulation (TS) in patients with dysphagia caused by stroke. The investigators concluded that transcutaneous ES appears to be a safe and effective treatment for dysphagia due to stroke and results in better swallow function than conventional TS treatment. However, there were no follow-up data in this study. Grill et al. (2001) reviewed emerging clinical applications of ES and concluded that functional ES has great potential for increasing life support as well as for quality of life in chronic ailments, particularly obstructive sleep apnea and dysphagia.

In a non-concurrent cohort study, Blumenfeld et al. (2006) assessed the effectiveness of ES in treating persons with dysphagia and aspiration. The charts of 40 consecutive subjects undergoing ES and 40 consecutive persons undergoing traditional dysphagia therapy (TDT) were reviewed. Pre- and post-therapy treatment success was compared utilizing a previously described swallow severity scale. A linear regression analysis was employed to adjust for potential confounding variables. The swallow severity scale improved from 0.50 to 1.48 in the TDT group (p < 0.05) and from 0.28 to 3.23 in the ES group (p < 0.001). After adjusting for potential confounding factors, persons receiving ES did significantly better in regard to improvement in their swallowing function than persons receiving TDT (p = 0.003). The authors concluded that the findings of this non-concurrent cohort study suggested that dysphagia therapy with transcutaneous ES is superior to traditional dysphagia therapy alone in individuals in a long-term acute care facility. They also stated that confirmation of these findings with a prospective, placebo-controlled, randomized clinical trial is needed before a definitive determination regarding the effectiveness of ES dysphagia therapy can be made.

Kiger et al. (2006) compared the outcomes using transcutaneous neuromuscular ES (VitalStim therapy) to outcomes using traditional swallowing therapy for deglutition disorders. A total of 22 patients had an initial and a follow-up video-fluoroscopic swallowing study or fiberoptic endoscopic evaluation of swallowing and were divided into an experimental group that received VitalStim treatments and a control group that received traditional swallowing therapy. Outcomes were analyzed for changes in oral and pharyngeal phase dysphagia severity, dietary consistency restrictions, and progression from non-oral to oral intake. Results of chi-square analysis showed no statistically significant difference in outcomes between the experimental and control groups.

Shaw and colleagues (2007) carried out a retrospective analysis of 18 patients with dysphagia who received VitalStim therapy. All subjects underwent pre-therapy evaluation by speech-language pathologists, including modified barium swallow and/or functional endoscopic evaluation of swallowing and clinical evaluation of swallowing that included assessment of laryngeal elevation, diet tolerance, and swallowing delay, and were then assigned an overall dysphagia severity score. After therapy, all patients underwent the same assessments. Twelve of the 18 subjects also underwent a functional swallowing telephone survey months (range of 1 to 21 months) after their therapy to evaluate if the improvement was worthwhile and sustained. Eleven of the 18 patients (61%) demonstrated some improvement in their swallowing; 6 of the 18 patients (33%) were improved enough to no longer require a feeding tube. However, of the 5 patients categorized as having "severe dysphagia" before therapy, only 2 showed any improvement, and these patients still required a feeding tube for adequate nutrition. Telephone surveys did confirm that those who improved with their therapy seemed to maintain their progress and that most patients were satisfied with their therapy. The authors concluded that VitalStim therapy seems to help those with mild-to-moderate dysphagia. However, the patients with the most severe dysphagia did not gain independence from their feeding tubes.

Miller et al. (2014) performed a systematic literature search in the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the DAHTA database, the Health Technology Assessment Database, and MEDLINE or PubMed, considering studies on the use of neuromuscular electrostimulation (NMES) in otorhinolaryngology that have been published in German or English. The search identified 180 studies. These were evaluated, and relevant studies were included in the further evaluation. The authors concluded that in the fields of otorhinolaryngology and phoniatry/pediatric audiology, clinical studies investigating the effects of NMES on facial and laryngeal paresis, as well as dysphonia and dysphagia, have been carried out. The evidence collected to date is encouraging, particularly for the treatment of certain forms of dysphagia and laryngeal paresis.

Frost and associates (2018) stated that previous research has suggested that treatment using NMES, when used in conjunction with conventional therapy, is effective. These investigators described the recent literature and a small prospective case series performed in the United Kingdom (UK). This study contributed to support National Institute of Clinical Excellence (NICE) guidance for clinicians who wish to include NMES in a rehabilitation program for dysphagic patients, specifically with reference to safety and the impact on swallowing function of this intervention. In 2014, the UK NICE issued guidelines enabling UK therapists to trial the use of NMES, but the guidelines also sought additional evidence on the impact on swallowing function of NMES and the incidence of side effects. This small prospective case series investigated both of these aspects with a group of patients with dysphagia of neurological origin who had not achieved adequate swallowing function with traditional therapy alone. This study recruited 10 adult patients with dysphagia of neurological origin. All had previously received traditional swallowing therapy for at least 6 months but only achieved a Functional Oral Intake Scale (FOIS) of 4 or less (a scale for amounts and types of oral intake). The total study period was 10 weeks for each subject, comprising 5 weeks of traditional therapy delivered 3 times a week, followed by 5 weeks of NMES concurrent with traditional therapy (NMES + traditional therapy) delivered 3 times a week using the VitalStim stimulator (VitalStim Therapy, UK). In addition, the Quality of Life in Swallowing and Eating Assessment Tool 10 (QOL scales) were determined to allow comparison between studies. A total of 9 subjects achieved an improvement in swallowing function after NMES + traditional therapy was measured using the FOIS, giving a statistically significant improvement (p < 0.001) when NMES + traditional therapy was compared with traditional therapy. In addition, there was a low incidence of adverse events (AEs), with only minor AEs occurring in 1.3% of electrode pair placements. The authors concluded that the current preliminary study suggested that NMES + traditional therapy had a good safety record and may improve oral intake and patient-reported swallowing outcomes for subjects with long-standing dysphagia of neurological cause, which has not responded to traditional therapy. They stated that provided care is taken with skin preparation and electrode placement, the risk of AEs from the treatment was minimal. Significantly, in 30% of the subjects, an improvement in voice quality was found. These findings need to be validated by well-designed studies.

In a randomized, single-blind, placebo-controlled trial, Park and colleagues (2018) examined the effect of effortful swallowing combined with NMES as a novel treatment approach in dysphagic patients with Parkinson's disease. Participants were randomly allocated to an experimental group (n = 9) or a placebo group (n = 9). The experimental group simultaneously received NMES with effortful swallowing, while the placebo group received sham NMES with effortful swallowing. All participants received the treatment for 30 minutes per day at 5 sessions per week for 4 weeks. Both groups also received the same conventional dysphagia therapy. The experimental group showed significant differences in horizontal movement (p = 0.038) and vertical movement (p = 0.042) compared to the placebo group, but showed no significant differences in the oral (p = 0.648) or pharyngeal phase (p = 0.329) of the video-fluoroscopic dysphagia scale compared to the placebo group, except for the penetration-aspiration scale (p = 0.039). The authors concluded that the findings of this study demonstrated that NMES applied to the infra-hyoid region combined with effortful swallowing effectively increased hyoid bone movement and reduced aspiration in dysphagic patients with Parkinson's disease. These findings need to be validated by studies with a larger sample size.

ERBE Electrocautery

Siersema (2008) stated that esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications, and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e., focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e., long [greater than 2 cm], tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.

Hordijk and colleagues (2009) stated that benign gastro-esophageal anastomotic strictures are common and often refractory to treatment. Various endoscopic dilation techniques have been reported, but none of these methods has been proven to be superior. In a randomized, prospective, multi-center study, these researchers compared the safety and effectiveness of dilation of previously untreated anastomotic strictures by using electrocautery incision (EI) and Savary bougienage (SB). A total of 62 patients with an anastomotic stricture after esophago-gastrostomy and dysphagia Atkinson grades II to IV were included. Patients were treated with EI or SB. Objective and subjective results were compared with baseline and at 1, 3, and 6 months after the first treatment. Complications of both treatments were noted. Primary endpoints after 6 months were the mean number of dilation sessions and success rate (percentage of patients with less than or equal to 5 dilations in 6 months). Study participation ended after 6 months or if dysphagia grades II to IV recurred despite 5 treatment sessions. No complications occurred with either treatment. There was no significant difference between the EI and SB groups in the mean number of dilations (2.9; 95% CI: 2.7 to 4.1 versus 3.3; 95% CI: 2.3 to 3.6; p = 0.46) or the success rate (80.6% versus 67.7%, p = 0.26 and 96.2% versus 80.8%, p = 0.19). The authors concluded that this prospective trial demonstrated that EI of gastro-esophageal anastomotic strictures is a safe therapy and equivalent to SB as a primary therapy. EI can be used as an alternative or additional therapy to SB. Limitations of this trial include that in a small study with negative primary endpoints, secondary endpoints and subgroup analyses are hypothesis-generating only.

Alonso-Larraga et al. (2011) stated that dysphagia is a common problem after surgical stenosis (5% to 55%) and can be refractory to conventional endoscopic treatment in 22% of cases. It has been proposed that electro-incision is an alternative and effective treatment. These researchers evaluated the effectiveness of electro-incision with the insulation-tipped diathermic Knife-2 (IT-Knife-2) in the treatment of dysphagia produced by surgical anastomotic strictures. Longitudinal and case-series studies from August 2009 to June 2010 were selected for analysis. A total of 8 consecutive patients with anastomotic stricture-associated dysphagia and naive to endoscopic treatment were included. These investigators performed 3 or more radiated cuts in the stricture until passage of the gastroscope was achieved with IT-Knife-2 and electrocautery (ERBE IC 200) with a 70-100 W energy cut-off and 25 W coagulation. These researchers carried out measurements at baseline and 15 days after the intervention, evaluating dysphagia by the Atkinson grading scale and endoscopic changes. The majority of patients were at clinical stage IV with an Eastern Cooperative Oncology Group score of 1 to 3 and Karnofsky between 40 and 90. At the time of endoscopic diagnosis, patients had dysphagia grade II and III. Strictures in all of the cases were short in length and had a diameter of less than 5 mm. At 15 days after the intervention, no patient demonstrated dysphagia (p = 0.0013), and the anastomotic diameters were more than 9.5 mm and without evidence of stenosis (p = 0.0001). None of the patients presented post-incisional complications. The authors concluded that electro-incision with IT-Knife-2 is effective as primary treatment for the relief of benign dysphagia associated with post-surgical anastomotic stenosis. This was a small study (n = 8) with short-term follow-up (15 days). These preliminary findings need to be validated by well-designed studies.

Hyperbaric Oxygen Therapy for the Treatment of Radiation-Induced Dysphagia

In a systematic review, Philipsen et al. (2024) examined the role of hyperbaric oxygen therapy (HBOT) in patients with dysphagia following radiation therapy (RT) for head and neck cancer (HNC). These investigators carried out a systematic search in the electronic databases Ovid Medline, Ovid Embase, and Cochrane Central Register of Controlled Trials for relevant studies until March 14, 2023. No restriction on language or publication date. The criteria for inclusion: patients with HNC who had received both RT and HBOT as a preventive treatment against swallowing difficulties; to preserve swallowing function, or to promote swallowing difficulties. These researchers identified 1,396 records.  After removal of 31 duplicates, 1,365 records were accessible for title and abstract screening yielding 53 studies for full-text assessment. A total of 6 studies met the eligibility criteria and were included for qualitative analysis. The authors concluded that evidence of HBOT benefits in patients with dysphagia following RT for HNC was inconsistent. These researchers stated that well-designed clinical trials using validated outcome measures and long-term follow-up are needed.

Intensive Dysphagia Rehabilitation Approach (e.g., the Swallow STRONG Multi-Disciplinary Oropharyngeal Strengthening Program)

Rogus-Pulia et al. (2016) noted that dysphagia is associated with malnutrition, aspiration pneumonia, and mortality in older adults. Strengthening interventions have shown promising results, but the effectiveness of treating dysphagia in older adults remains to be established. The Swallow STRengthening OropharyNGeal (Swallow STRONG) Program is a multi-disciplinary program that employs a specific approach to oropharyngeal strengthening, device-facilitated (D-F) isometric progressive resistance oropharyngeal (I-PRO) therapy, with the goal of reducing health-related sequelae in veterans with dysphagia. Participants completed 8 weeks of D-F I-PRO therapy while receiving nutritional counseling and respiratory status monitoring. Assessments were completed at baseline, 4, and 8 weeks. At each visit, video-fluoroscopic swallowing studies were carried out. Dietary and swallowing-related quality of life questionnaires were administered. Long-term monitoring for 6 to 17 months after enrollment allowed for comparison of pneumonia incidence and hospitalizations to the 6 to 17 months before the program. Veterans with dysphagia confirmed with videofluoroscopy (n = 56; 55 males, 1 female; mean age of 70 years) were enrolled. Lingual pressures increased at anterior (effect estimate = 92.5, p < 0.001) and posterior locations (effect estimate = 85.4, p < 0.001) over 8 weeks. Statistically significant improvements occurred on 8 of 11 subscales of the Quality of Life in Swallowing Disorders (SWAL-QOL) Questionnaire (effect estimates = 6.5 to 19.5, p < 0.04) and in self-reported sense of effort (effect estimate = -18.1, p = 0.001). Higher Functional Oral Intake Scale scores (effect estimate = 0.4, p = 0.02) indicated that participants were able to eat less-restrictive diets. There was a 67% reduction in pneumonia diagnoses, although the difference was not statistically significant. The number of hospital admissions decreased significantly (effect estimate = 0.96; p = 0.009) from before to after enrollment. The authors concluded that the findings of this study suggested that the Swallow STRONG multi-disciplinary oropharyngeal strengthening program may be an effective treatment for older adults with dysphagia. These preliminary findings need to be validated by well-designed studies.

In an intervention study (before-after trial) with a 4-week follow-up through an online survey, Malandraki and colleagues (2016) examined the effects of the Intensive Dysphagia Rehabilitation approach on physiological and functional swallowing outcomes in adults with neurogenic dysphagia. A consecutive sample of subjects (n = 10) recruited from outpatient university clinics was included in this analysis. All subjects were diagnosed with adult-onset neurologic injury or disease. Dysphagia diagnosis was confirmed through clinical and endoscopic swallowing evaluations. No subjects withdrew from the study. Participants completed the 4-week Intensive Dysphagia Rehabilitation protocol, including 2 oropharyngeal exercise regimens, a targeted swallowing routine using salient stimuli, and caregiver participation. Treatment included hourly sessions twice weekly and home practice for approximately 45 minutes per day. Outcome measures evaluating pre- and post-treatment included airway safety using an 8-point Penetration Aspiration Scale, lingual isometric pressures, self-reported swallowing-related quality of life, and level of oral intake. Patients were also monitored for adverse dysphagia-related effects; quality of life and adverse effects were assessed at the 4-week follow-up (online survey). The Intensive Dysphagia Rehabilitation approach was effective in improving maximum and mean Penetration Aspiration Scale scores (p < 0.05, η² = 0.8146 and p < 0.05, η² = 0.799708, respectively) and level of oral intake (p < 0.005, Cohen d = -1.387). Of the 5 patients who were feeding tube-dependent initially, 2 progressed to total oral nutrition, and 2 progressed to partial oral nutrition; 1 patient remained tube-dependent. Quality of life was significantly improved at the 4-week follow-up (95% CI: 6.38 to 14.5; p < 0.00), but not at the post-treatment. No adverse effects were observed or reported. The authors concluded that the Intensive Dysphagia Rehabilitation approach was safe and improved physiological and some functional swallowing outcomes in this sample; however, further investigation is needed before it can be widely applied.

Laryngeal Manipulation

In a retrospective, single-center, case-series study, DePietro and associates (2018) described the use of laryngeal manipulation as a treatment for dysphagia resulting from excessive para-laryngeal muscle tension and identified the patients likely to have symptomatic improvement. This trial identified patients from 2007 to 2013 with laryngeal manipulation for muscle tension dysphagia in an academic otolaryngology practice. Subjects with dysphagia not attributable to an anatomic cause who attended therapy at least 1 time were included in the study. The primary outcome of the study was subjective improvement in dysphagia symptoms (yes/no) during follow-up. Symptoms, demographic information, treatment, and response to therapy were recorded. The Kruskal-Wallis test was used for analysis of continuous variables, while a Chi-squared test or Fisher's exact test was used for analysis of all categorical variables. A total of 44 subjects were included, consisting of 37 women and 7 men. Subjective improvement in dysphagia was seen in 34 subjects (77.3%). No significant differences were seen in improvement based on gender (p = 0.3223), race (p = 0.4317), number of sessions with a speech pathologist (p = 0.3198), or presenting symptoms including hoarseness (p = 0.0853), pain (p = 1.000), globus (p = 0.2834), and cough (p = 1.000). The authors found subjective improvement with laryngeal manipulation as reported during follow-up visits to clinic among individuals with muscle tension dysphagia. Patient age, presenting symptoms, and number of therapy sessions were not found to be significantly associated with resolution of symptoms. This was a retrospective, case-series study with relatively small sample size (n = 44). It is also interesting to note that the number of therapy sessions was not significantly associated with resolution of symptoms. These findings need to be validated by well-designed studies.

Mirror Therapy

He et al. (2022) stated that post-stroke dysphagia is a common symptom following stroke and one of the most frequent and severe complications of stroke. In the past several years, mirror therapy has generated significant research interest as a non-invasive therapeutic and rehabilitative intervention for the treatment of post-stroke dysphagia and has been examined in several single-center randomized controlled trials (RCTs). In a systematic review and meta-analysis, these investigators examined the safety and effectiveness of mirror therapy for the treatment of patients with post-stroke dysphagia. A total of 7 databases were searched from inception to December 31, 2021, including PubMed, the Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Service System (SinoMed), Wanfang database, and the Chinese Scientific Journals Database (VIP). The primary outcome measure was effectiveness, as measured by the clinical effectiveness rate. Secondary outcomes included the water swallowing test and the incidence of pneumonia. Furthermore, these researchers employed the Cochrane Risk of Bias Tool to examine the risk of bias. Potential publication bias was evaluated by applying Egger's bias indicator test and by assessing the symmetry of data when visualized as funnel plots. A total of 5 RCTs (135 subjects in the experimental and control groups) were found to report the use of mirror therapy for post-stroke dysphagia and were included in this study. No publication bias was detected. Meta-analysis showed that mirror therapy had a positive effect on the rate of clinical effectiveness [OR = 4.22; 95% CI: 2.3 to 7.73] and the water swallowing test (MD = -0.76; 95% CI: -1.29 to -0.22). Moreover, mirror therapy reduced the incidence of pneumonia (OR = 0.13; 95% CI: 0.03 to 0.49). Subgroup analyses indicated that mirror therapy during the acute phase was robust but was unstable during the convalescent phase. Sensitivity analysis revealed that the results generated by this meta-analysis were robust and stable. The authors concluded that available evidence appeared to suggest that mirror therapy may have a role in the management of post-stroke dysphagia but has yet to be fully confirmed. These researchers stated that existing evidence from clinical trials suggested that evidence relating to the safety of mirror therapy for patients with post-stroke dysphagia is insufficient. They stated that there is a need to perform further studies with a larger sample size using more objective indicators.

The authors stated that this study had several drawbacks. First, the currently available evidence related to the use of mirror therapy for post-stroke dysphagia originated from a relatively small sample size. Second, there were limited numbers of subjects in each trial and limited analysis of outcome data. Third, safety indicators may not be optimal, and follow-up data are lacking; thus, these investigators could not fully examine the safety profile of mirror therapy or the long-term effectiveness of this technique in the target patient population. Fourth, although the authors carried out specific searches in a wide range of databases, all of the included trials were conducted in China; as such, these findings may not be representative on a wider scale.

Neuromuscular Electrical Stimulation

In a meta-analysis, Carnaby-Mann and Crary (2007) evaluated the effect of transcutaneous neuromuscular electrical stimulation (NMES) on swallowing rehabilitation. The authors concluded that this preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing. Because of the small number of studies and low methodological grading for these studies, caution should be taken in interpreting this finding. These results support the need for more rigorous research in this area. This is in agreement with the observation of Steel et al. (2007), who noted that although electrical stimulation (ES) approaches to the restoration and rehabilitation of swallowing are an exciting area of research that holds promise for future clinically relevant technology and/or therapy, the implementation of ES in clinical swallowing rehabilitation settings still remains premature.

Miller et al. (2022) stated that NMES has been used as a therapeutic option in the treatment of dysphagia for several years. In a previous review of the literature, it was concluded that NMES might be a valuable adjunct in patients with dysphagia and in patients with vocal fold paresis. However, due to different stimulation protocols, electrode positioning, and various underlying pathological conditions, it was difficult to compare the studies that were identified; and it was concluded that more empirical data are needed to fully understand the benefits provided by NMES. In a systematic review, these researchers assessed recent studies regarding the potential effectiveness of transcutaneous NMES applied to the anterior neck as a treatment for dysphagia, considering these different aspects. For this systematic review, a selective literature search in PubMed was performed on May 5, 2021, using the terms "electrical stimulation AND dysphagia" and screened for inclusion criteria by 2 reviewers in Rayyan. The search resulted in 62 hits. Studies were excluded due to their publication language, because they did not meet inclusion criteria, because the topical focus was different, or because they did not qualify as level 2 studies. A total of 18 studies were identified with varying patient groups, stimulation protocols, electrode placement, and therapy settings. However, 16 studies reported beneficial outcomes in relation to NMES. The authors concluded that there is a considerable amount of level 2 studies suggesting that NMES is an effective therapeutic option, especially when combined with traditional dysphagia therapy (TDT) for patients with dysphagia following stroke and patients with Parkinson's disease, or with different kinds of brain injuries. Moreover, these researchers stated that further investigation is needed to clarify which stimulation protocols, parameters, and therapy settings are most beneficial for certain patient groups and degrees of impairment. They also noted that in this systematic review, data pooling and statistical analysis could not be performed due to the inhomogeneity of study protocols.

Non-Pharmacological, Non-Surgical Treatments for Dysphagia

Eskildsen et al. (2021) noted that dysphagia is a common and critical consequence of acquired brain injury (ABI) and could result in severe complications. Dysphagia rehabilitation is transforming from mainly compensatory strategies to the retraining of swallowing function using principles from neuroscience; however, there are no studies that map interventions available to retrain swallowing function in patients with moderate-to-severe ABI. These researchers systematically mapped the accessible scientific literature to address the research question: Which non-surgical, non-pharmacological interventions are used in the treatment of dysphagia in individuals with moderate and severe ABI in the acute and subacute phase? They carried out a scoping review based on the methodology of Arksey and O'Malley and methodological advancement by Levac et al. Data sources included Medline, Embase, Cochrane Library, CINAHL, PsycINFO, Web of Science, OTseeker, speechBITE, and PEDro; they were searched up until March 14, 2021. All studies reporting rehabilitative interventions within 6 months of injury for patients with moderate-to-severe ABI and dysphagia were included. Data were extracted by 2 independent reviewers, and studies were categorized based on treatment modality. A total of 21,396 records were retrieved, and a final total of 26 studies were included. Interventions were categorized into cortical or non-cortical stimulation of the swallowing network. Cortical stimulation interventions were rTMS and tDCS. Non-cortical interventions included complex swallowing interventions, neuromuscular electrical stimulation, pharyngeal electrical stimulation (PES), sensory stimulation, strengthening exercises, and respiratory muscle training. The authors concluded that this scoping review provided an overview of rehabilitative dysphagia interventions for patients with moderate and severe ABI, predominantly due to stroke, in the acute and subacute phase. Positive tendencies towards beneficial effects were found for rTMS, complex swallowing interventions, PES, and cervical strengthening. Moreover, these researchers stated that future studies could benefit from clear reporting of patient diagnosis and disease severity, the use of more standardized treatment protocols or algorithms, and fewer but standardized outcome measures to enable comparison of effects across studies and interventions.

The authors stated that this review had several drawbacks. First, missing data on brain injury severity in several studies led to the exclusion of some possibly relevant studies. This information was often unavailable from the corresponding authors. Second, the timing of the assessment of brain injury severity was often not reported or consistent between studies, making it difficult to determine whether the study met the inclusion criteria. Third, the limitations due to necessary language restrictions caused the exclusion of Asian language papers, potentially excluding some relevant studies. Fourth, given that the included studies have not been quality evaluated, the summarization of results should be interpreted with caution and could not be directly applied to guide clinical practice.

International best practice consensus recommendations for dysphagia management (Jesus Oliveira et al., 2021) state that "[i]t is recommended to consider behavioral intervention, including compensatory strategies (modification of food consistencies and liquid viscosity, postural and swallowing techniques) and rehabilitation (muscle-strengthening exercises, resistance or skills training), as a treatment component of dysphagia in stroke patients. . . . The systematic performance of different exercises and maneuvers, provided for in an individualized therapeutic plan and adjusted to the clinical condition, is recommended in stroke patients with dysphagia."

The American Speech-Language-Hearing Association (ASHA, 2022) stated that "Patients who are tactically defensive may need approaches that reduce the level of sensory input initially, with incremental increases as tolerance improves. Sensory stimulation may be useful for those with reduced response, overactive response, or limited opportunity for sensory experience."

Palliative Radiotherapy (Including Intra-Cavitary Radiotherapy and Intra-Luminal Brachytherapy)

Adamson et al. (2014) noted that the single most distressing symptom for patients with advanced esophageal cancer is dysphagia. Among the more effective treatments for relief of dysphagia is the insertion of a self-expanding metal stent (SEMS). It is possible that the addition of a palliative dose of external beam radiotherapy may prolong the relief of dysphagia and provide additional survival benefit. The ROCS (Radiotherapy after Oesophageal Cancer Stenting) trial will assess the effect of adding palliative radiotherapy after esophageal stent insertion. The study is a randomized multi-center phase III trial, with an internal pilot phase, comparing stent alone versus stent plus palliative radiotherapy in patients with incurable esophageal cancer. Eligible participants are those with advanced esophageal cancer who are in need of stent insertion for primary management of dysphagia. Radiotherapy will be administered as 20 Gray (Gy) in 5 fractions over 1 week or 30 Gy in 10 fractions over 2 weeks, within 4 weeks of stent insertion. The internal pilot will assess rates and methods of recruitment; pre-defined criteria will determine progression to the main trial. In total, 496 patients will be randomized in a 1:1 ratio with follow-up until death. The primary outcome is time to progression of patient-reported dysphagia. Secondary outcomes include survival, toxicity, health resource utilization, and quality of life. An embedded qualitative study will explore the feasibility of patient recruitment by examining patients' motivations for involvement and their experiences of consent and recruitment, including reasons for not consenting. It will also explore patients' experiences of each trial arm. These investigators stated that the ROCS study will be a challenging trial studying palliation in patients with a poor prognosis. The internal pilot design will optimize methods for recruitment and data collection to ensure that the main trial is completed on time. As a pragmatic trial, study strengths include the collection of all follow-up data in the usual place of care and a focus on patient-reported, rather than disease-oriented, outcomes. Exploration of patient experience and health economic analyses will be integral to the assessment of benefit for patients and the National Health Service (NHS). The trial was registered with Current Controlled Trials (registration number: ISRCTN12376468) on July 10, 2012.

In a Cochrane review, Dai and associates (2014) analyzed the effectiveness of different interventions used in the palliation of dysphagia in primary esophageal and gastro-esophageal carcinoma. In this updated review (January 2014), these investigators searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, and CINAHL; and major conference proceedings (up to January 2014). Only RCTs were included in which patients with inoperable or unresectable primary esophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, SEMS insertion, brachytherapy, external beam radiotherapy, chemotherapy, esophageal bypass surgery, and chemical and thermal ablation therapy, either head-to-head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure-related mortality, 30-day mortality, adverse effects, and quality of life. Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. These researchers included 3,684 patients from 53 studies. Self-expanding metallic stent insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re-interventions and for adverse effects. Anti-reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might have reduced gastro-esophageal reflux and complications. Newly designed double-layered nitinol (Niti-S) stents were preferable due to longer survival time and fewer complications compared to simple Niti-S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. The authors concluded that SEMS insertion is safe, effective, and quicker in palliating dysphagia compared to other modalities. However, high-dose intra-luminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti-reflux stents and newly designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with SEMS insertion or radiotherapy are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

Yamashita and colleagues (2015) stated that intra-cavitary radiotherapy (ICRT) for the palliative treatment of advanced esophageal cancer with dysphagia is currently performed at the University of Tokyo Hospital (Tokyo, Japan). In the present study, 24 patients exhibiting advanced esophageal cancer with dysphagia received palliative ICRT, which was delivered 5 mm below the esophageal mucous membrane, with the exception of 1 case, and was administered at a dose of 6 Gy/fraction. Specific patients additionally underwent definitive or palliative external beam radiation therapy for esophageal cancer a minimum of 3 months prior to ICRT. The effect of treatment on symptom alleviation was examined by comparing the dysphagia score prior to and following ICRT, with the patients' medical records and a questionnaire used to calculate a dysphagia score ranging from 0 (no dysphagia) to 4 (total dysphagia). In consideration of the individual efficacy of the treatment, the maximum number of repeated ICRT fractions was 4 (median of 1.7 times). A trend in the improvement of the symptom of dysphagia was observed in response to esophageal ICRT, with the average dysphagia score markedly decreasing from 2.54 to 1.65; however, the difference was not significant (p = 0.083). Furthermore, pain was the most frequent side effect of the esophageal ICRT, and no patients exhibited severe complications. The authors concluded that esophageal ICRT at a dose of 6 Gy/fraction may present an effective strategy for relieving the symptom of dysphagia in cases of advanced esophageal cancer. These preliminary findings need to be validated by well-designed studies.

Peripheral Magnetic Stimulation

In a pilot study, Momosaki et al. (2015) examined the safety and feasibility of a 6-day protocol of in-hospital repetitive peripheral magnetic stimulation combined with intensive swallowing rehabilitation (rPMS-ISR) for post-stroke dysphagia. Subjects were 8 patients with dysphagia caused by bilateral cerebral infarction (ages 62 to 70 years; time from onset of stroke: 27 to 39 months). Repetitive peripheral magnetic stimulation (PMS) was applied to the suprahyoid muscles, with strength set at 90% of the minimal intensity that elicited pain using a parabolic coil. One train of stimuli comprised 20 Hz for 3 seconds, followed by a 27-second rest. A single session included the delivery of repetitive 20 trains of stimuli over 10 minutes, followed by 20 minutes of swallowing rehabilitation. Each patient received this combination treatment twice daily, in the morning and afternoon, over 6 consecutive days. Swallowing function was evaluated before and after the intervention. Repetitive PMS-ISR induced significant improvement in swallowing ability, laryngeal elevation delay time, penetration aspiration scale, and swallowing quality of life (p < 0.01), but had no significant effect on the functional oral intake scale. The authors concluded that the 6-day in-hospital rPMS-ISR protocol appeared safe and feasible for post-stroke patients with dysphagia. The combination protocol improved swallowing function. They stated that further larger studies are needed to confirm its effectiveness.

Hwang et al. (2022) stated that recently, a therapeutic method to stimulate the suprahyoid muscle using PMS for dysphagia rehabilitation has been reported; however, clinical evidence, application protocol, and intervention method remain unclear. In a systematic review, these investigators evaluated clinical studies of PMS used for the rehabilitation of dysphagia. They carried out a literature search of 4 databases (Medline, Embase, CINAHL, and Web of Science) to identify relevant studies published on the use of repetitive PMS (rPMS) for swallowing-related muscles between 2010 and 2022. A total of 7 studies were reviewed; randomized controlled trials (RCTs) and 1-group pre-post, case study designs were included. In the included studies, rPMS was employed to strengthen the submental suprahyoid muscles. The intervention regimen varied. The rPMS was used at a frequency of 30 Hz for 2 seconds. Rest time ranged from 8 seconds to 27-28 seconds. The number of intervention sessions ranged from 2-3 to 30. The intensity ranged from pain-inducing minimum intensity (90% of maximum stimulus output) to non-painful intensity (70% to 80% of maximum intensity). The rPMS on the suprahyoid muscles had positive effects on physiological changes in swallowing function, such as displacement of the hyoid bone, muscle strength (cervical flexor, jaw-opening force), swallowing safety, swallowing performance, and swallowing-related quality of life (QOL). Participants also reported little pain and adverse reactions during rPMS. The authors concluded that although rPMS is a therapeutic option that can help improve swallowing function as a non-invasive stimulation method in the rehabilitation of dysphagia, clinical evidence is needed for the development of clear stimulation protocols and guidelines. Moreover, these researchers stated that there are issues to be considered when applying PMS to patients with dysphagia. First, since the swallowing muscle is a very small muscle located in a narrow space under the hyoid bone and chin, accurate stimulation focusing is important. However, the PMS equipment currently used is not a device developed for stimulating the swallowing muscle; thus, it is not a dedicated device considering the anatomical structure and characteristics of the swallowing muscle. Furthermore, the protocol for optimal stimulation is still unclear. As a consequence, clearer evidence is needed via coil design, which reflects the structure and characteristics of the swallowing muscle and various stimulation protocols for the effective rehabilitation of dysphagia.

Per Oral Plication of the Esophagus (POPE)

Hedberg et al. (2023) noted that endoscopic sleeve gastroplasty is an example of endoscopic sutured plications being used to remodel a gastrointestinal (GI) organ. With per-oral plication of the esophagus (POPE), similar plications are used to remodel the dilated and redundant mega-esophagus of end-stage achalasia. Redundancies and dilations can also develop in the neo-esophagus of a patient with prior esophagectomy. Mega-esophagus and a redundant neo-esophagus can both lead to debilitating dysphagia, regurgitation, and recurrent aspiration pneumonia. Traditionally, this anatomic problem requires complex revisional or excisional surgery, to which POPE offers an incisionless alternative. This article was a dynamic manuscript with a video demonstration of POPE, as well as a review of 5 cases performed in 1 year. Data were collected in a prospectively maintained database, and the institutional review board (IRB)-approved retrospective review for this publication. The procedure was carried out using a dual-channel upper endoscope fixed with an endoscopic suturing device, with the patient in a supine position under general anesthesia. POPE was technically completed in all cases with no serious complications, and patients either went home the same day or spent 1 night for observation. Most patients reported immediate and substantial symptomatic improvement. Objective pre- and post-measures included esophagram and nuclear gastric emptying studies. The authors discussed early experience at 1 center with POPE, providing a detailed description of the procedure and technical considerations. An accompanying video reviewed 2 cases, 1 with mega-esophagus and 1 with a gastric conduit. These researchers stated that while this novel procedure has limited and rare indications, it offers a low-morbidity solution to a challenging anatomic problem that traditionally requires invasive surgery.

The authors stated that this study had several drawbacks. First, this was a very limited case series (n = 5), intended as a descriptive study of the POPE procedure and its indications. Second, these investigators could draw no conclusions regarding the superiority of this approach to end-stage achalasia/neo-esophageal anatomic issues over traditional esophagectomy or surgical conduit revision. While they presented some objective data showing improvement of emptying following POPE, there was no standardized pre- and post-procedure evaluation for these 5 patients. Third, given the subjective nature of symptomatic assessment and the execution of the procedure itself, standardized pre- and post-operative assessment by timed barium esophagography would be valuable in further examination of this technique.

Crafts et al. (2024) stated that POPE is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms and quality of life (QOL). As this procedure has only been carried out in the U.S. for the past 4 years, safety and effectiveness have not been well established. In a retrospective, case-series, single-center study, these researchers examined the effectiveness of POPE for the treatment of impaired emptying in achalasia and post-esophagectomy patients. This trial included patients who underwent POPE between 2019 and 2023. Data collected included demographics, pre-operative diagnoses and treatments, imaging, endoscopic data, operative intervention, 90-day complications, and response to treatment. QOL and patient satisfaction data were collected by phone survey. A total of 17 cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). A total of 8 patients had end-stage achalasia, and 5 had impaired gastric emptying following esophagectomy with gastric conduits. The median age of this cohort was 65 years, and the median ASA score was 3, with 38.5% women. POPE was carried out with 2 to 6 plication sutures in an average of 75 minutes. The majority of patients were discharged home on the same day. For the 17 procedures, there were 4 complications—2 patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Pre-operative symptoms improved or resolved at initial follow-up in 82.3% of patients; 4 patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none had required esophagectomy since the introduction of POPE. The authors concluded that POPE is an endoscopic procedure that was effective in relieving emptying difficulties for the end-stage esophagus and gastric conduit. It may obviate the need for esophagectomy or conduit replacement. Furthermore, it can be repeated in select patients. Moreover, these researchers noted that while the risk profile of complications was favorable compared to alternative operations, patients with gastric conduits were at higher risk.

Uchima et al. (2025) noted that delayed gastric conduit emptying (DGCE) affects 15% to 39% of patients following esophagectomy, increasing the risk of aspiration, pneumonia, and malnutrition. “Sump” formation with chronic dilation often necessitates surgical intervention. POPE is a novel endoscopic technique adapted from endoscopic sleeve gastroplasty (ESG) to remodel the neo-esophagus (and end-stage achalasia mega-esophagus) and improve emptying, with 82.3% symptom improvement, although 23.5% required repeat intervention. Studies of ESG have shown that 83.64% of sutures persist at 12 months, with 70.9% maintaining adequate tension. Combining mucosal denudation techniques like argon plasma coagulation (APC) or endoscopic mucosal resection (EMR) may enhance submucosa-to-submucosa apposition, resulting in better suture retention and durability. These investigators presented a modified POPE by combining mucosal denudation techniques to address sump-related retention and improve gastric emptying in a patient with refractory DGCE. This case involved a 72-year-old woman with esophageal adenocarcinoma who underwent partial esophagectomy with gastric conduit reconstruction in 2019. She developed early satiety, worsening heartburn when supine, and progressive oral intolerance, necessitating total parenteral nutrition. Imaging confirmed a neo-esophageal sump with significant retention. Dietary adjustments, prokinetics, and pyloric BTX injection failed, with worsening symptoms and bile reflux. A multidisciplinary team recommended POPE for sump remodeling. Modified POPE was carried out under general anesthesia in the supine position, using a suturing device without an over-tube, combined with EMR and APC. Endoscopic and radiologic assessment confirmed improved conduit alignment and pyloric passage. The patient was discharged after 48 hours without complications and was tolerating diet. At a 4-month follow-up, endoscopy confirmed sustained remodeling with symptom improvement and no retention. The authors concluded that modified POPE was a feasible, minimally invasive technique for refractory DGCE due to sump formation. Moreover, these researchers stated that further investigations are needed to evaluate long-term effectiveness.

Pharyngeal Electrical Stimulation

Restivo and Hamdy (2018) stated that neurogenic dysphagia (ND) can occur in patients with nervous system diseases of varying etiologies. Moreover, recovery from ND is not guaranteed. The therapeutic approaches for oropharyngeal ND have drastically changed over past 10 years, mainly due to a better understanding of the neurophysiology of swallowing along with the progress of neuroimaging and neurophysiological studies. Thus, it is a priority to develop a treatment that is safe, repeatable, and can be performed at the bedside as well as for out-patients. Pharyngeal electrical stimulation (PES) is a novel rehabilitation treatment for ND; it is performed via location-specific intraluminal catheters that are introduced trans-nasally and enable clinicians to stimulate the pharynx directly. This technique has demonstrated increasingly promising evidence in improving swallowing performance in patients with ND associated with stroke and multiple sclerosis (MS), probably by increasing the cortico-bulbar excitability and inducing cortical re-organization of swallowing motor cortex. The authors concluded that in comparison with other techniques, PES has been demonstrated to be a promising therapeutic option for dysphagia in stroke and MS patients. Although in a recent large trial of dysphagic stroke patients, PES was unable to demonstrate superiority on radiological aspiration or on clinical dysphagia, several factors including under-treatment of patients receiving PES may have contributed to these results. Indeed, the above results differ from the findings of a previous meta-analysis of 3 smaller RCTs, which showed an effect at 2 weeks compared to sham. They stated that further studies selecting stroke patients with more severe dysphagia or those requiring intensive care ventilation need to be designed. In addition, studies evaluating the effect of PES on dysphagia due to different neurological disorders, as well as the association of PES in combination with other rehabilitative treatments, are needed.

Pharyngeal Motor Cortex Stimulation

Michou et al. (2012) examined the behavioral and neurophysiological effects of a new neuro-stimulation technique (paired associative stimulation [PAS]), applied to the pharyngeal motor cortex, on swallowing function in healthy individuals and patients with dysphagia from stroke. These researchers examined the optimal parameters of PAS to promote plasticity by combining peripheral pharyngeal (electrical) with cortical stimulation. A virtual lesion was used as an experimental model of stroke, created with 1-Hz repetitive transcranial magnetic stimulation over the pharyngeal cortex in 12 healthy individuals. They tested whether hemispheric targeting of PAS altered swallowing performance before applying the technique to 6 patients with severe, chronic dysphagia from stroke (mean of 38.8 +/- 24.4 weeks post-stroke). Ten minutes of PAS to the unlesioned pharyngeal cortex reversed (bilaterally) the cortical suppression induced by virtual lesion (lesioned: F(1,9) = 21.347, p = 0.001; contralesional: F(1,9) = 9.648, p = 0.013; repeated-measures analysis of variance) compared with sham PAS. It promoted changes in behavior responses measured with a swallowing reaction time task (F(1,7) = 21.02, p = 0.003; repeated-measures analysis of variance). In patients with chronic dysphagia, real PAS induced short-term bilateral changes in the brain; the unaffected pharyngeal cortex had increased excitability (p = 0.001; 95% CI: 0.21 to 0.05; post-hoc paired t test) with reduced penetration-aspiration scores and changes in swallowing biomechanics determined by videofluoroscopy. The authors concluded that the beneficial neurophysiological and behavioral properties of PAS, when applied to unlesioned brain, provide the foundation for further investigation into the use of neurostimulation as a rehabilitative approach for patients with dysphagia from stroke.

Progressive Muscle Diseases

In a Cochrane review, Jones and colleagues (2016) examined the effects of interventions for dysphagia in people with long-term, progressive muscle disease. On January 11, 2016, these investigators searched the Cochrane Neuromuscular Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, AMED, LILACS, and CINAHL. They checked references in the identified trials for additional RCTs and quasi-RCTs. They also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform on January 12, 2016 for ongoing or completed but unpublished clinical trials. These researchers included RCTs and quasi-RCTs that evaluated the effect of interventions for managing dysphagia in adults and children with long-term, progressive muscle disease, compared to other interventions, placebo, no intervention, or standard care. In this review update, the authors decided to include trials of people with sporadic inclusion body myositis (IBM) on the basis that it presents as a long-term, progressive muscle disease with uncertain degenerative and inflammatory etiology and is typically refractory to treatment. They applied standard Cochrane methodological procedures. There were no RCTs that reported results in terms of the review's primary outcome of interest, weight gain or maintenance. However, these researchers identified 1 RCT that assessed the effect of intravenous immunoglobulin (IVIG) on swallowing function in people with IBM. The trial authors did not specify the number of subjects who had dysphagia. There was also incomplete reporting of findings from video-fluoroscopic investigations, which was one of the review's secondary outcome measures. The study did report reductions in the time taken to swallow, as measured using ultrasound. No serious adverse events (AEs) occurred during the study, although data for the follow-up period were lacking. It was also unclear whether the non-serious AEs reported occurred in the treatment group or the placebo group. These investigators assessed this study as having a high risk of bias and uncertain CIs for the review outcomes, which limited the overall quality of the evidence. Using GRADE criteria, the authors down-graded the quality of the evidence from this RCT to "low" for efficacy in treating dysphagia, due to limitations in study design and implementation, and indirectness in terms of the population and outcome measures. Similarly, they assessed the quality of the evidence for AEs as "low". From their search for RCTs, these researchers identified 2 other non-randomized studies, which reported the effects of long-term IVIG therapy in adults with IBM and lip-strengthening exercises in children with myotonic dystrophy type 1. Headaches affected 2 participants treated with long-term IVIG therapy, who received a tailored dose reduction; there were no AEs associated with lip-strengthening exercises. Both non-randomized studies identified improved outcomes for some participants following the intervention, but neither study specified the number of participants with dysphagia or demonstrated any group-level treatment effect for swallowing function using the outcomes pre-specified in this review. The authors concluded that there is insufficient and low-quality RCT evidence to determine the effect of interventions for dysphagia in long-term, progressive muscle disease. Clinically relevant effects of IVIG for dysphagia in patients with IBM can neither be confirmed or excluded using the evidence presented in this review. They stated that standardized, validated, and reliable outcome measures are needed to assess dysphagia and any possible treatment effect. Clinically meaningful outcomes for dysphagia may require a shift in focus from measures of impairment to disability associated with oral feeding difficulties.

Repetitive Peripheral/Transcranial Magnetic Stimulation

Khedr and Abo-Elfetoh (2010) examined the effect of repetitive transcranial magnetic stimulation (rTMS) applied to the motor area of both hemispheres in patients with acute lateral medullary infarction (LMI) or other brainstem infarctions. The study included 22 patients with acute ischemic stroke who had severe bulbar manifestations. Eleven patients had LMI, and 11 had another brainstem infarction. They were randomly allocated to receive active (n = 11) or sham (n = 11) rTMS of the esophageal motor cortex. Each patient received 300 rTMS pulses at 3 Hz and an intensity of 130% resting motor threshold to each hemisphere for 5 consecutive days. Clinical ratings of dysphagia and motor disability were assessed before and immediately after the last session, and then again after 1 and 2 months. There were no significant differences in baseline clinical assessment of swallowing between active and sham groups. Active rTMS improved dysphagia compared with sham rTMS in both groups of patients (p = 0.001 for both); the LMI group also improved the scores in the Barthel Index. All improvements were maintained over 2 months of follow-up (p = 0.001). The authors concluded that these findings suggested that rTMS could be a useful adjuvant strategy in neurorehabilitation of dysphagia due to LMI or other brainstem infarctions, although further assessment is needed in multi-center clinical trials.

Momosaki et al. (2014) examined the safety and feasibility of a 6-day protocol of bilateral rTMS combined with intensive swallowing rehabilitation for chronic post-stroke dysphagia. In-hospital treatment was provided to 4 post-stroke patients (age at treatment ranged from 56 to 80 years; interval between onset of stroke and treatment: 24 to 37 months) with dysphagia. Over 6 consecutive days, each patient received 10 sessions of rTMS at 3 Hz applied to the pharyngeal motor cortex bilaterally, followed by 20 minutes of intensive swallowing rehabilitation exercise. The swallowing function was evaluated by the Penetration Aspiration Scale (PAS), Modified Mann Assessment of Swallowing Ability (MMASA), Functional Oral Intake Scale (FOIS), laryngeal elevation delay time (LEDT), and Repetitive Saliva-Swallowing Test (RSST) on admission and at discharge. All patients completed the 6-day treatment protocol, and none showed any adverse reactions throughout the treatment. The authors concluded that the combination treatment improved laryngeal elevation delay time in all patients. They stated that the proposed protocol of rTMS plus swallowing rehabilitation exercise seemed to be safe and feasible for chronic post-stroke dysphagia, although its effectiveness needs to be confirmed in a large number of patients.

Pisegna and colleagues (2016) evaluated the effects of non-invasive brain stimulation on post-stroke dysphagia. A total of 13 databases were systematically searched through July 2014. Studies had to meet pre-specified inclusion and exclusion criteria. Each study's methodological quality was examined. Effect sizes were calculated from extracted data and combined for an overall summary statistic. A total of 8 RCTs were included. These trials revealed a significant, moderate pooled effect size (0.55; 95% CI: 0.17 to 0.93; p = 0.004). Studies stimulating the affected hemisphere had a combined effect size of 0.46 (95% CI: -0.18 to 1.11; p = 0.16); studies stimulating the unaffected hemisphere had a combined effect size of 0.65 (95% CI: 0.14 to 1.16; p = 0.01). At long-term follow-up, 3 studies demonstrated a large but non-significant pooled effect size (0.81, p = 0.11). The authors concluded that this review found evidence for the effectiveness of non-invasive brain stimulation on post-stroke dysphagia. A significant effect size resulted when stimulating the unaffected rather than the affected hemisphere. This finding is in agreement with previous studies implicating the plasticity of cortical neurons in the unaffected hemisphere. The authors stated that non-invasive brain stimulation appeared to assist cortical reorganization in post-stroke dysphagia; however, emerging factors highlighted the need for more data.

Kim and colleagues (2020) examined evidence from published systematic reviews of clinical trials to assess the effectiveness of rTMS in the stroke population. The Cochrane Library, Medline, CINAHL, Embase, and PubMed were searched for systematic reviews up to January 15, 2019. Three authors independently screened the reviews and assessed the methodological quality using the Assessment of Multiple Systematic Reviews (AMSTAR) appraisal tool. Quality of evidence for outcomes evaluated within the reviews was appraised with the Grade of Recommendation, Assessment, Development and Evaluation (GRADE) tool. A total of 12 reviews (n = 9,117 subjects) examined the effectiveness of rTMS on motor and non-motor (aphasia, depression, dysphagia, and cognition) functions. The rTMS protocols applied and outcomes measured were diverse among the selected reviews. The findings suggested a beneficial effect of rTMS with "moderate quality" evidence for dysphagia and hemineglect, "low to moderate quality" evidence for motor function (upper limb function, daily activities), and "low quality" evidence for aphasia and post-stroke depression. The authors concluded that despite the widespread use of rTMS, high-quality evidence for its routine use for the treatment of stroke survivors is lacking. These researchers stated that further studies are needed to establish the differential roles of various protocols and the long-term effects of rTMS in the stroke population.

Xie et al. (2022) stated that there is no reliable evidence-based medicine to support the effect of rTMS on post-stroke dysphagia. In a meta-analysis, these researchers examined the safety and effectiveness of rTMS on post-stroke dysphagia. English-language literature published before December 20, 2021, was searched in 6 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. A total of 10 studies with 246 patients were included. Meta-analysis showed that rTMS significantly improved overall swallowing function (SMD -0.76, 95% CI: -1.07 to -0.46, p < 0.0001, n = 206; moderate-quality evidence), Penetration Aspiration Scale (PAS) (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 rTMS targeting the affected hemisphere and targeting both hemispheres significantly enhanced overall swallowing function and reduced aspiration. Low-frequency rTMS significantly enhanced overall swallowing function and reduced aspiration, and there was no significant difference between high-frequency rTMS and the control group in reducing aspiration (p = 0.09). There was no statistical difference in the drop-out rate (low-quality evidence) and adverse effects (moderate-quality evidence) between the rTMS group and the control group. The authors concluded that the findings of this meta-analysis study suggested that rTMS had a favorable effect on swallowing function in patients with post-stroke dysphagia; however, there were many parameters that could influence the effectiveness (e.g., the frequency and the site of stimulation). These investigators stated that further research on the mechanism of rTMS and the setting of optimal parameters is needed for the development of this novel intervention in clinical practice.

The authors stated that this study had several drawbacks. First, the small sample size (n = 12 to 29) of the included studies may limit the statistical power to detect the effects of rTMS on swallowing function in patients with post-stroke dysphagia. Second, there was considerable heterogeneity in the stimulation parameters (e.g., frequency, intensity, and pulse) in the included studies; thus, the optimal stimulation parameters for rTMS were unclear. Third, this study only carried out subgroup analyses for frequency and stimulation site; however, there was heterogeneity in the results of some of the subgroup analyses. Furthermore, the effectiveness of rTMS may also be influenced by other parameters (e.g., brain injury severity and time to stroke onset).

Swallowing Therapy With or Without Biofeedback

Bath and associates (2018) noted that dysphagia, which is common in patients following stroke, is associated with an increased risk of death or dependency, occurrence of pneumonia, poor quality of life (QOL), and longer hospital stays. Treatments provided to improve dysphagia are aimed at accelerating recovery of swallowing function and reducing these risks. In an update of previous Cochrane reviews (first published in 1999 and updated in 2012), these investigators examined the effects of swallowing therapy on death or dependency among stroke survivors with dysphagia within 6 months of stroke onset. They searched the Cochrane Stroke Group Trials Register (June 26, 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library (searched June 26, 2018), Medline (June 26, 2018), Embase (June 26, 2018), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 26, 2018), Web of Science Core Collection (June 26, 2018), SpeechBITE (June 28, 2016), ClinicalTrials.gov (June 26, 2018), and the World Health Organization International Clinical Trials Registry Platform (June 26, 2018). They also searched Google Scholar (June 7, 2018) and the reference lists of relevant trials and review articles. These researchers included RCTs of interventions for people with dysphagia and recent stroke (within 6 months). Two review authors independently applied the inclusion criteria, extracted data, assessed risk of bias, used the GRADE approach to assess the quality of evidence, and resolved disagreements through discussion with the third review author. They used random-effects models to calculate odds ratios (ORs), mean differences (MDs), and standardized mean differences (SMDs), and provided 95% confidence intervals (CIs) for each. The primary outcome was functional outcome, defined as death or dependency (or death or disability), at the end of the trial. Secondary outcomes were case fatality at the end of the trial, length of inpatient stay, proportion of subjects with dysphagia at the end of the trial, swallowing ability, penetration aspiration score, pneumonia, pharyngeal transit time, institutionalization, and nutrition. These investigators added 27 new studies (1,777 subjects) to this update to include a total of 41 trials (2,660 subjects). They evaluated the efficacy of swallowing therapy overall and in subgroups by type of intervention: acupuncture (11 studies), behavioral interventions (9 studies), drug therapy (3 studies), neuromuscular electrical stimulation (NMES; 6 studies), pharyngeal electrical stimulation (PES; 4 studies), physical stimulation (3 studies), transcranial direct current stimulation (tDCS; 2 studies), and transcranial magnetic stimulation (TMS; 9 studies). Swallowing therapy had no effect on the primary outcome (death or dependency/disability at the end of the trial) based on data from 1 trial (2 data sets) (OR 1.05, 95% CI: 0.63 to 1.75; 306 participants; 2 studies; I² = 0%; p = 0.86; moderate-quality evidence). Swallowing therapy had no effect on case fatality at the end of the trial (OR 1.00, 95% CI: 0.66 to 1.52; 766 subjects; 14 studies; I² = 6%; p = 0.99; moderate-quality evidence). Swallowing therapy probably reduced the length of inpatient stay (MD -2.9, 95% CI: -5.65 to -0.15; 577 subjects; 8 studies; I² = 11%; p = 0.04; moderate-quality evidence). Researchers found no evidence of a subgroup effect based on testing for subgroup differences (p = 0.54). Swallowing therapy may have reduced the proportion of subjects with dysphagia at the end of the trial (OR 0.42, 95% CI: 0.32 to 0.55; 1,487 participants; 23 studies; I² = 0%; p = 0.00001; low-quality evidence). Trial results showed no evidence of a subgroup effect based on testing for subgroup differences (p = 0.91). Swallowing therapy may improve swallowing ability (SMD -0.66, 95% CI: -1.01 to -0.32; 1,173 participants; 26 studies; I² = 86%; p = 0.0002; very low-quality evidence). These researchers found no evidence of a subgroup effect based on testing for subgroup differences (p = 0.09). They noted moderate to substantial heterogeneity between trials for these interventions. Swallowing therapy did not reduce the penetration aspiration score (i.e., it did not reduce radiological aspiration) (SMD -0.37, 95% CI: -0.74 to -0.00; 303 subjects; 11 studies; I² = 46%; p = 0.05; low-quality evidence). Swallowing therapy may reduce the incidence of chest infection or pneumonia (OR 0.36, 95% CI: 0.16 to 0.78; 618 subjects; 9 studies; I² = 59%; p = 0.009; very low-quality evidence). The authors concluded that moderate- and low-quality evidence suggested that swallowing therapy did not have a significant effect on the outcomes of death or dependency/disability, case fatality at the end of the trial, or penetration aspiration score. However, swallowing therapy may have reduced length of hospital stay, dysphagia, and chest infections, and may have improved swallowing ability. However, these researchers stated that these findings were based on evidence of variable quality, involving a variety of interventions; they stated that further high-quality trials are needed to examine if specific interventions are effective.

In a systematic review and meta-analysis, Benfield and colleagues (2019) evaluated the current evidence on the effects of swallow therapy augmented by biofeedback in adults with dysphagia. Two independent reviewers conducted searches that included Medline, Embase, trial registries, and gray literature up to December 2016; RCTs and non-RCTs were assessed, including for risk of bias and quality. Data were extracted by 1 reviewer and verified by another on biofeedback type, measures of swallow function, physiology and clinical outcome, and analyzed using Cochrane Review Manager (random effects models); results were expressed as weighted mean difference (WMD) and odds ratio (OR). Of 675 articles, these researchers included 23 studies (n = 448 subjects); and 3 main types of biofeedback were used: accelerometry, surface electromyography (sEMG), and tongue manometry. Exercises included saliva swallows, maneuvers, and strength exercises. Dose varied between 6 and 72 sessions for 20 to 60 minutes; 5 controlled studies (stroke n = 95; head and neck cancer n = 33; mixed etiology n = 10) were included in meta-analyses. Compared to control, biofeedback-augmented dysphagia therapy significantly enhanced hyoid displacement (3 studies, WMD = 0.22 cm; 95% CI: 0.04 to 0.40, p = 0.02); but there was no significant difference in functional oral intake (WMD = 1.10; 95% CI: -1.69 to 3.89, p = 0.44) or dependency on tube feeding (OR = 3.19; 95% CI: 0.16 to 62.72, p = 0.45). Risk of bias was high, and there was significant statistical heterogeneity between trials in measures of swallow function and number tube fed (I² = 70% to 94%). Several non-validated outcome measures were used. Subgroup analyses were not possible due to a paucity of studies. The authors concluded that dysphagia therapy augmented by biofeedback using sEMG and accelerometry enhanced hyoid displacement, but functional improvements in swallowing were not evident. These researchers stated that available data are extremely limited and further larger, well-designed RCTs are needed.

Duncan and colleagues (2020) examined the effectiveness of dysphagia interventions compared to standard care in improving oral intake and reducing aspiration for adults in acute and critical care. These investigators searched electronic literature for randomized and quasi-randomized trials and bibliography lists of included studies to March 2020. Study screening, data extraction, risk of bias, and quality assessments were conducted independently by 2 reviewers. Meta-analysis used fixed effects modeling. These researchers identified 22 studies (19 stroke, 2 intensive care stroke, and 1 general intensive care) testing 9 interventions and representing 1,700 patients. Swallowing treatment showed no evidence of a difference in the time to return to oral intake (n = 33, MD (days) -4.5, 95% CI: -10.6 to 1.6, 1 study, p = 0.15) (very low certainty) or in aspiration following treatment (n = 113, RR 0.79, 95% CI: 0.44 to 1.45, 4 studies, I² = 0%, p = 0.45) (low certainty). Swallowing treatment showed evidence of a reduced risk of pneumonia (n = 719, RR 0.71, 95% CI: 0.56 to 0.89, 8 studies, I² = 15%, p = 0.004) (low certainty); but no evidence of a difference in swallowing quality of life scores (n = 239, MD -11.38, 95% CI: -23.83 to 1.08, I² = 78%, p = 0.07) (very low certainty). The authors concluded that there is limited evidence for the effectiveness of swallowing treatments in the acute and critical care setting; clinical trials consistently measuring patient-centered outcomes are needed.

Telerehabilitation

Nordio and colleagues (2018) stated that some recent studies have shown positive effects of tele-rehabilitation of swallowing disorders, yet there are no systematic reviews verifying the evidence. In a systematic review, these researchers examined the effects of tele-rehabilitation in the field of dysphagia as an alternative to face-to-face patient care, considering swallowing recovery and/or quality of life (QOL) in different patient populations. They searched the Cochrane Library, Medline, Embase, Google Scholar, Google Search, and the grey literature from inception until December 2016 for publications written in English (keywords: tele-rehabilitation, telemedicine, dysphagia, swallowing disorders), which resulted in 330 records. Abstract screening and data extraction were performed independently by 2 reviewers; 4 papers were selected to be read in full, and the methodological quality of the studies included was evaluated using Cochrane Collaboration's tool for assessing risk of bias. One study met the inclusion criteria, which showed that tele-rehabilitation improved adherence to treatment compared to patient-directed intervention. Although adherence is an important factor that influences treatment outcomes, clinical outcomes had to be examined in RCTs in order to reach evidence in this field. Lastly, this systematic review did not demonstrate the efficacy of tele-rehabilitation compared with face-to-face therapy. These researchers stated that additional research in the field of dysphagia is needed to define the benefits and risks associated with assisting patients in tele-rehabilitation modality. They noted that future trials need to have a more robust design and evaluate the effectiveness of treatments based on specific clinical outcomes and QOL, in different populations of patients with different types and severity of dysphagia, and associated with cost accountability and cost-effectiveness analysis.

The authors stated that this review had several drawbacks. First, most of the studies in tele-rehabilitation concerning dysphagia are characterized by small sample sizes, large variability of illnesses included, heterogeneity of treatments and outcomes, and the consistent presence of biases. The drawback of small samples was common in the rehabilitation literature concerning dysphagia because of the different diagnoses that can cause it, the large range of severity and disability experienced by patients, and the long time needed to observe changes in clinical outcomes. In addition, these investigators chose to distinguish tele-rehabilitation from other telemedicine applications (e.g., telemonitoring, teleradiology) because of the possibility of providing therapeutic interventions, remotely controlled by healthcare professionals, with rehabilitation intent. Moreover, the authors only considered trials reported in English, which restricted the raw dataset of records used for screening.

Transcranial Direct Current Stimulation

In a double-blind, randomized study, Suntrup-Krueger and colleagues (2018) examined if transcranial direct current stimulation (tDCS) is able to enhance dysphagia rehabilitation following stroke. Besides relating clinical effects with neuroplastic changes in cortical swallowing processing, these researchers identified factors influencing treatment success. A total of 60 acute dysphagic stroke patients received contralesional anodal (1 mA, 20 minutes) or sham tDCS on 4 consecutive days. Swallowing function was thoroughly assessed before and after the intervention using the validated fiberoptic endoscopic dysphagia severity scale (FEDSS) and clinical assessment. In 10 patients, swallowing-related brain activation was recorded using magnetoencephalography before and after the intervention. Voxel-based statistical lesion pattern analysis was also performed. Study groups did not differ according to demographic data, stroke characteristics, or baseline dysphagia severity. Patients treated with tDCS showed greater improvement in FEDSS than the sham group (1.3 versus 0.4 points, mean difference [MD] = 0.9, 95% CI: 0.4 to 1.4, p < 0.0005). Functional recovery was accompanied by a significant increase in activation (p < 0.05) in the contralesional swallowing network after real but not sham tDCS. Regarding predictors of treatment success, for every hour earlier that treatment was initiated, there was greater improvement on the FEDSS (adjusted OR = 0.99, 95% CI: 0.98 to 1.00, p < 0.05) in multivariate analysis. Stroke location in the right insula and operculum was indicative of a worse response to tDCS (p < 0.05). The authors concluded that the application of tDCS over the contralesional swallowing motor cortex supported swallowing network reorganization, thereby leading to faster rehabilitation of acute post-stroke dysphagia. Moreover, they noted that early treatment initiation appeared beneficial; tDCS may be less effective in right-hemispheric insulo-opercular stroke.

In a systematic review and network meta-analysis, Li et al. (2021) examined the effect of non-invasive brain stimulation (NIBS) on dysphagia after stroke and compared the effects of 2 different types of NIBS. These researchers retrieved RCTs on the effect of NIBS on dysphagia after stroke 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 performed using RevMan 5.3 and ADDIS 1.16.8. The effect size was evaluated by using the standardized mean difference (SMD) and a 95% CI. A total of 18 studies involving 738 patients were included. Meta-analysis showed that NIBS could improve the dysphagia outcome and severity scale (DOSS) score (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 2 different NIBS on the DOSS score was rTMS (p = 0.52) > tDCS (p = 0.48), the best probabilistic ranking of the SSA score was rTMS (p = 0.72) > tDCS (p = 0.28), and the best probabilistic ranking of the PAS score was rTMS (p = 0.68) > tDCS (p = 0.32). The authors concluded that existing evidence showed that NIBS could improve swallowing dysfunction and reduce the occurrence of aspiration following stroke, and that rTMS was better than tDCS. Moreover, these researchers stated that, limited by the number of included studies, more large-sample, multi-center, double-blind, high-quality RCTs are still needed to confirm the findings of this research.

These researchers stated that there are relatively few studies on the mechanism of NIBS improving dysphagia after stroke, and there is no clear conclusion at present. Moreover, they noted that although this study followed the criteria of systematic review and network meta-analysis report (PRISMA statement), there were certain potential biases. Currently, there are relatively few RCTs regarding NIBS to improve dysphagia after stroke. The included studies were published in both Chinese and English, and the lack of relevant gray studies may lead to bias in study selection. Some studies did not describe specific random methods, allocation concealment, or blind methods. Only 7 studies reported follow-up; the follow-up time was short, and there was no long-term effect of NIBS on swallowing function in stroke patients. The intervention time was 1 to 8 weeks, and the stimulation sites were unaffected, affected, or bilateral. Furthermore, the frequency and current of stimulation were also different. This study could not determine the relationship between the length of the intervention period, the stimulation site, the intensity of stimulation, and the improvement of swallowing function.

Cenci et al. (2024) noted that swallowing is a complex function that can be disrupted following stroke; tDCS is a non-invasive brain stimulation therapy that has recently been tested for the treatment of stroke-related dysphagia. These investigators carried out a search in the literature to examine the described evidence of the use of tDCS in dysphagia after stroke; 3 electronic databases were searched. The risk of bias evaluation was performed using the RoB-2 tool. The GRADE framework was also implemented. Of 265 studies, only 9 were included in this review. The most common location of the tDCS stimulation was the unaffected hemisphere (44%). Regarding the outcome measure, the DOSS was the most commonly used (55%). However, due to the high heterogeneity of the protocols, and considering the differences between the types of stroke, these researchers opted not to conduct a meta-analysis. Instead, a systematic review with a thorough analysis of each individual study and the impact of the differences on the outcomes was preferred. The authors concluded that the final considerations were that even though the majority of studies described benefits from tDCS in post-stroke dysphagia, as they presented too many methodological differences, it was not possible to compare them. Furthermore, many studies included patients with less than 6 months after stroke, which is an important bias as the swallowing function can recover spontaneously within this period, turning the certainty of the evidence really low.

Transoral Holmium YAG Laser Resection for the Treatment of Dysphagia

In a single-case report, Teasdale et al. (2025) described a pioneering approach to the treatment of superior thyroid cornu syndrome (STCS), a condition characterized by dysphagia and globus sensation due to anatomical variations in the thyroid cartilage, often resulting in significant patient discomfort and mis-diagnosis. This case entailed a man in his 50s, presenting with a persistent sensation of a lump in his throat and difficulty swallowing without associated pain or systemic symptoms, underwent a comprehensive diagnostic work-up that included flexible naso-endoscopy, MRI, contrast swallow, and CT scans, showing a medially displaced superior cornu of the thyroid cartilage. Traditional surgical interventions offered limited precision and potential for soft tissue trauma. This report introduced the use of the holmium:yttrium-aluminum-garnet (Ho:YAG) laser for transoral resection of the affected cartilage, a technique more commonly associated with urological and salivary stone treatments. This innovative application resulted in successful symptom resolution without significant complications, highlighting the Ho:YAG laser's safety and effectiveness for STCS treatment and encouraging further investigations of its use in otolaryngology.

Furthermore, an UpToDate review on “Oropharyngeal dysphagia: Clinical features, diagnosis, and management” (Lembo, 2025) does not mention laser as a therapeutic option.

References

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