Surface Electromyographic Biofeedback versus Neuromuscular Electrical Stimulation for Post-Stroke Dysphagia: A Systematic Review and Network Meta-Analysis

Na LiQianqian JinYi ZhangLi ZhangXiapei Peng^*

• The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

Background: Post-stroke dysphagia is a common complication with a high incidence rate, significantly impairing patients' quality of life and health status. Although traditional swallowing training is widely used, its efficacy exhibits considerable individual heterogeneity. Surface electromyographic biofeedback (sEMG-BF), as an emerging rehabilitation technology, shows promising potential. However, there is a lack of systematic and comprehensive evaluation as well as high-quality evidence to support its clinical application. Objective: This study aims to systematically evaluate and conduct a network meta-analysis to compare the efficacy of sEMG-BF, NMES, and conventional therapy in improving electrophysiological outcomes, swallowing function, and quality of life in patients with post-stroke dysphagia. Methods: A systematic review and network meta-analysis were conducted by searching databases including PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus for prospective randomized controlled trials on the application of sEMG-BF in patients with post-stroke dysphagia. We included randomized controlled trials that compared sEMG-BF, NMES, or conventional therapy in patients with post-stroke dysphagia. The study focused on the effects of sEMG-BF on electrophysiological outcomes in these patients. Results: Six studies were ultimately included in the analysis. sEMG-BF significantly increased mean amplitude (MD = 6.45, 95% CI: 3.53, 9.38) and reduced swallowing duration (MD = -0.22, 95% CI: -0.26, -0.18). Network meta-analysis revealed the following SUCRA ranking: sEMG-BF, neuromuscular electrical stimulation (NMES), and conventional therapy. sEMG-BF significantly improved the SSA score (MD = - 6.43, 95% CI: -9.74, -3.11). For SWAL-QOL, the pooled estimate was MD = 29.36 (95% CI: -14.96, 73.69), which did not reach statistical significance. The network meta-analysis demonstrated that sEMG-BF outperformed NMES and conventional therapy in improving swallowing function, consistent with direct comparison results. Conclusion: This study suggests that both sEMG-BF and NMES may provide benefits for post-stroke dysphagia, although sEMG-BF demonstrated superior effects in most outcomes, the evidence is limited by small sample sizes and heterogeneity. Further high-quality trials are needed to confirm its efficacy. By enhancing the amplitude of electromyographic signals in swallowing-related muscles and improving muscle contraction capacity, sEMG-BF improves swallowing function; however, the pooled SWAL-QOL estimate was not statistically significant.