Comparative Effectiveness of Combined and Single Neurostimulation and Traditional Dysphagia Therapies for Post-Stroke Dysphagia: A Network Meta-Analysis.

BACKGROUND: Comparative therapeutic benefits of combined and single neurostimulation therapies including neuromuscular electrical stimulation (NMES), pharyngeal electrical stimulation (PES), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and traditional dysphagia therapy (TDT) remain unknown in post-stroke dysphagia (PSD) rehabilitation. Therefore, we performed the first network meta-analysis (NMA) to determine comparative effectiveness of combined and single neurostimulation and traditional dysphagia therapies for PSD. METHODS: A frequentist NMA model was performed with therapy effect sizes presented as standardized mean differences (SMD) and corresponding 95% confidence interval (95% CI) for therapy comparisons while netrank function ranked the therapies in R-Software. Meta-regression models for study characteristics were analyzed using Bayesian NMA Model. RESULTS: Overall, 50 randomized controlled studies with 2250 participants were included. NMES + TDT 3.82 (95% CI, 1.62-6.01), tDCS + TDT 3.34 (95% CI, 1.09-5.59), rTMS + TDT 3.32 (95% CI, 1.18-5.47), NMES 2.69 (95% CI, 0.44-4.93), and TDT 2.27 (95% CI, 0.12-4.41) demonstrated very large effect in improving swallowing function. NMES + TDT -0.50 (95% CI, -0.68 to -0.32, rTMS + TDT -0.44 (95% CI, -0.67 to -0.21), TDT -0.28 (95% CI, -0.46 to -0.10), and NMES -0.19 (95% CI, -0.34 to -0.04) demonstrated medium to small effect in reducing pharyngeal transit time (PTT). rTMS -0.51 (95% CI, -0.93 to -0.08) demonstrated medium effect in reducing oral transit time (OTT). No significant therapy comparison differences were found for reducing aspiration/penetration. The highest ranked therapy was NMES + TDT for better swallowing function and reduction of PTT, rTMS for reduction of OTT, and tDCS + TDT for reduction of aspiration/penetration. Therapeutic effects of the therapies were moderated by frequency, sessions, and duration. CONCLUSION: Combined therapies including NMES + TDT, tDCS + TDT, and rTMS + TDT demonstrate better therapeutic effect for improved swallowing function and reduction of PTT, OTT, and aspiration/penetration for PSD.

A case for inclusive design: Analyzing the needs of those who frequent Taiwan's urban parks.

Taiwan's declining birthrate has resulted in an aging population, and the needs addressed by public facilities are changing along with the shifting population structure. Visitors to urban parks filled out 869 questionnaires on the topic of inclusive design. Structural equation modeling revealed that park patrons could be categorized as those with special needs, and the general public. The biggest difference between these two groups manifests in their disparate needs concerning outdoor primary service facilities, followed by facilities related to accessibility, automation and the functions performed in open areas. Difficulty with autonomous access was identified as the leading cause of exclusion. Based on the autonomous access principle, three inclusive needs levels were identified: safety (high priority), accessibility (moderately-high), and regular maintenance (average). Inclusive design in public parks aims to equalize usage by all sectors of society.