817709 AIM Li and Deng

acupuncture
IN MEDICINE
Original paper

Acupuncture in Medicine
Acupuncture combined with swallowing 2019, Vol. 37(2) 81­–90
https://doi.
DOI: 10.1136/acupmed-2016-011305

training for poststroke dysphagia: a

org/10.1136/acupmed-2016-011305
© The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
meta-analysis of randomised journals.sagepub.com/home/aim

controlled trials

Ling Xin Li1 and Kai Deng2

Abstract
Objective: This meta-analysis aimed to assess the efficacy and safety of the combination of acupuncture with swallowing
training for poststroke dysphagia.
Method: Nine electronic databases (including PubMed and China National Knowledge Infrastructure) were searched
from their inception through June 2016. Seventeen studies were included in this meta-analysis. Data on 1479 eligible
patients were extracted, and the relative risk (RR) and standard mean difference (SMD) with 95% CI for the effective
rate (ER), swallowing function assessment (SFA), individual activity (IA), eg., modified Barthel Index (MBI) and quality of
life (QOL) were evaluated.
Results: The pooled ER (RR 1.26, 95% CI 1.19 to 1.34, P<0.001, 14 studies) and SFA (SMD 1.06, 95% CI 0.79 to 1.32,
P<0.001, five studies) suggested that combination therapy yielded a significantly higher ER and improved the SFA scores
to a greater degree than swallowing training alone in patients with poststroke dysphagia. The pooled QOL score (SMD
1.06; 95% CI −0.04 to 2.17, P=0.06, two studies) did not differ between groups. The MBI data (SMD 1.47, 95% CI 1.07 to
1.87, P<0.001, one study) showed significant improvement in IA. Some evidence of publication bias was observed for the
ER, although the trim-and-fill analysis and fail-safe number indicated no influence of publication bias on its pooled effect
size. There was no evidence of publication bias of any other outcome measures.
Conclusion: This study showed that acupuncture combined with swallowing training may improve the ER, swallowing func-
tion and activities of daily life of patients with poststroke dysphagia compared with conventional swallowing training alone.

Keywords
post-stroke dysphagia, acupuncture, swallowing training, effective rate, swallowing function assessment, individual activity,
quality of life

Accepted: 22 October 2017

Introduction difficulties in stroke patients. Many studies have suggested

Dysphagia is a common complication in stroke patients, with
a reported incidence of 34.7%–44%.1 It is characterised by
swallowing difficulty in the oropharyngeal phase, especially
for liquids,2 and can lead to aspiration pneumonia, nasogas-
tric tube placement and even death.3–5 Dysphagia has also
been associated with quality of life (QOL) issues, such as
social anxiety, withdrawal and depression.6,7 The currently
available management strategies for dysphagia, such as acu-
puncture or swallowing training, are temporary and have
relatively limited effectiveness.8,9 Consequently, multidisci-
plinary approaches are essential to address swallowing
that acupuncture10–16 and swallowing training9,17 may be
1Department of Rehabilitation Medicine, West China Hospital, Sichuan
University, Chengdu, China
2Department of Gastroenterology, West China Hospital, Sichuan
University, Chengdu, China
LXL and KD contributed equally.
Corresponding author:
Dr Ling Xin Li, Department of Rehabilitation Medicine, West China
Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
Email: lilingxinlsh@163.com

Acupuncture in Medicine, 37(2)

82
beneficial for dysphagia in stroke patients, but whether the
combination of acupuncture and swallowing training leads to
greater improvements in swallowing function than swallow-
ing training alone remains unclear. Thus, we aimed to per-
form a meta-analysis to investigate the effectiveness of
combination therapy for treating dysphagia in patients with
stroke versus conventional care alone.
Methods
Search strategy
Comprehensive electronic and manual searches were con-
ducted in nine databases (PubMed, OVID (MEDLINE,
EMBASE), ISI (Science Citation Index Expanded), EBSCO
(Academic Source Premier), the Cochrane Library, China
National Knowledge Infrastructure, China Biology Medicine,
Wanfang and VIP) from their inception through 16 June 2016.
The references cited in the searched articles were also
reviewed. The search strategy was designed and performed
independently by two authors (LXL and KD) and is detailed in
online supplemental appendix 5; if discrepancies occurred,
consensus was reached through consultation. If multiple stud-
ies were identified by the same research group, we included
the paper that had the most complete information. Searches
were limited to studies published in English and Chinese.
Study selection
Decisions regarding study eligibility were independently
made by the two authors (LXL and KD). The inclusion crite-
ria were as follows: (1) patients: all of the participants had
been diagnosed with ischaemic or haemorrhagic stroke by
CT or MRI and were clinically confirmed to have dysphagia;
(2) study design: the trials had to be randomised controlled
trials (RCTs, not including quasi-RCTs) that aimed to com-
pare combination therapy with swallowing training alone;
(3) outcomes: the primary outcomes were the clinical effec-
tive rate (ER), swallowing function assessment (SFA), indi-
vidual activity (IA; eg, the modified Barthel index (MBI))
and QOL (eg, swallowing-related QOL (S-QOL)); adverse
events (AEs) were considered secondary outcomes. The
exclusion criteria were as follows: (1) non-original research
articles; (2) studies that were not published in English or
Chinese; and (3) studies in which the required data were una-
vailable. Any disagreements were resolved by the two review
authors through discussion and consultation when necessary.
Figure 1 shows the flowchart of the study selection proce-
dure, which was presented in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
2009 guideline.18
Data extraction
The retrieved studies were carefully assessed, and the data
were independently extracted by the two researchers (LXL
Acupuncture in Medicine, 37(2)
Acupuncture in Medicine
and KD). Information on the following items was collected
for each trial: first author, publication year, study period,
number of eligible cases, age, gender, duration, the acu-
puncture and swallowing training regimen, and data related
to ER, SFA, IA, QOL and AE. Disagreements were settled
by discussion and consensus between the two authors.
Quality assessment
The quality of the methodology of the extracted studies was
independently assessed by the two reviewers (LXL and
KD) using the Cochrane risk of bias tool.19 Any disagree-
ments regarding study selection or discrepancies in the rat-
ings were resolved through discussion.
Statistical analyses
The effect sizes were the relative risk (RR) and 95% CI
for dichotomous data and the standard mean difference
(SMD) with 95% CI for continuous data. Statistical het-
erogeneity among the included studies was assessed
using the I2 statistic, for which P<0.10 and I2 >50% rep-
resented substantial heterogeneity.20 The following pro-
cedure was applied to explain any type of heterogeneity
that existed: (1) sensitivity analysis; (2) subgroup analy-
sis and meta-regression; and (3) a random-effects model
using the DerSimonian-Laird method.21 Publication bias
was assessed with: (1) funnel plots and Begg’s test/
Egger’s test22; (2) a trim-and-fill adjusted analysis; and
(3) the fail-safe number (Nfs).23 The statistical analysis
was performed using Statistics Data Analysis Special
Edition software (Stata SE, V.12.0; Stata Corp LP,
College Station, Texas, USA).
Results
Study inclusion and characteristics
A total of 1142 relevant references were initially retrieved.
Ultimately, 17 studies24–40 were included in the meta-analy-
sis. The search results are shown in the flowchart in Figure
1. The eligible cases totalled 1479 patients: 745 in the
experimental groups and 734 in the control groups. All 17
of the included RCTs were conducted in China; 16 were
published in Chinese and 1 was published in English. These
included trials were reported from January 2004 to
November 2016. Among the acupuncture regimens, the
nine most commonly used acupuncture points were GB20
(Fengchi), GB12 (Wangu) and TE17 (Yifeng) in the nape,
CV23 (Lianquan) and Pang Lianquan (0.8–1 cun from
CV23) in the neck, and Jinjin, Yuye and Yanhoubi (on the
posterior pharyngeal wall) in the mouth. The swallowing
training protocol primarily consisted of functional training
and feeding-swallowing training. The training consisted of
12–90 sessions (5–45 min per session) and lasted from 2
weeks to 2 months. The outcome measurements included:
Li and Deng
Figure 1. Flowchart of the search procedure for the meta-analysis. CBM, China Biology Medicine; CNKI, China National
Knowledge Infrastructure; RCT, randomised controlled trial.
(1) ER (in 15 studies); (2) SFA (in nine studies), including
five scales: the water swallowing test41,42 (WST, three stud-
ies); videofluoroscopic swallowing study43 (VFSS, one
study); standardised swallowing assessment44 (SSA, two
studies); dysphagia outcome and severity scale45 (DOSS,
one study); and Fujishima Ichiro’s dysphagia scale46 (FDS,
two studies); (3) IA (MBI, one study); and (4) QOL
(S-QOL,47 two studies). Measurements of AEs, including
ecchymosis, haematoma, pain, mild vomiting, aspiration
pneumonia and malnutrition, were reviewed but not
included in the meta-analysis. The characteristics of the
included studies are shown in Table 1. Based on the
Cochrane risk of bias tool and previous evaluation criteria,
three studies were considered to be grade A. The quality
assessment is summarised in Table 2.
Synthesis of results
Effect size of ER. The ER data (15 studies, 1295 patients)
were first analysed using a random-effects model. The
pooled RR and 95% CI values showed significant heteroge-
neity (I2=64.4%, n=15, P<0.001), which disappeared
(I2=0.0%, n=14, P=0.857) after excluding one study.25 The
83
results of the remaining 14 studies (RR 1.26, 95% CI 1.19
to 1.34, n=14, P<0.001, fixed-effects model, details in
online supplemntary appendix 1) and the forest plot of ER
(Figure 2A) suggested that, for patients with poststroke
dysphagia, a combination of acupuncture and swallowing
training yielded a higher ER than treatment with swallow-
ing training only. In the following subgroup and meta-
regression analyses, no evidence of an influence of any
subgroup on the pooled ER was observed (all P>0.05,
details in online supplemental appendix 2). In the analysis
of publication bias, visual inspection of the funnel plot
(Figure 3A) and the use of metabias analysis (Begg’s and
Egger’s tests) revealed significant publication bias (all
P=0.001). Thus, a further trim-and-fill analysis and Nfs cal-
culation were performed. The results showed that the
pooled estimated effect sizes after five iterations and the
addition of six missing studies were not significantly differ-
ent before and after the trim-and-fill analysis (RR 1.27,
95% CI 1.21 to 1.33, Q=13.6, P=0.405; RR 1.22, 95% CI
1.17 to 1.28, Q=29.5, P=0.059), and the filled funnel plot
was approximately symmetrical (Figure 3B). Furthermore,
the fail-safe number (Nfs0.05=328.98; Nfs0.01=155.92) also
indicated that there was no significant influence of
Acupuncture in Medicine, 37(2)
 84

Table 1. Characteristics of the included studies.

Study Patients Interventions Designs Outcome

Duration (days,
ID First author Year Cases Age (years) weeks or months) MA (sessions) ST (sessions) E vs C Measures Conclusion

Acupuncture in Medicine, 37(2)

Ref. 24 Luo 2004 60 E, 60.50±6.21 E, 3.28±1.49m 28 28 in 4w MA+ST vs ST FDS Positive
C, 60.63±5.98 C, 3.22±1.41m

Ref. 25 Zhang 2007 220 E, 53.16±6.84 NR 30 30 in 1m MA+ST vs ST WST Positive

C, 51.37±8.63

Ref. 26 Zhang 2011 60 NR NR 30 24 in 4w MA+ST vs ST WST Positive

Ref. 27 Yu 2012 78 E, 63±10 E, 13.78±2.62d 20 20 MA+ST vs ST FDS Positive

C, 64±11 C, 14.56±2.48d

Ref. 28 Yi 2013 120 E, 61.0±6.5 E, 12.5±8.3d 30 90 in 1m MA+ST vs ST WST Positive

C, 59.2±7.3 C, 13.8±5.5d

Ref. 29 Yin 2013 113 E, 62.5±5.5 E, 11.5±2.2d 30 30 MA+ST vs ST SSA, S-QOL Positive
C, 60.8±7.4 C, 10.3±1.3d

Ref. 30 Li 2013 60 E, 56.9±4.6 NR 14 14 MA+ST vs ST WST Positive

C, 51.7±3.7

Ref. 31 Zhang 2014 60 E, 54.2±4.3 E, 3.9±0.5m 12 in 2w 12 in 2w MA+ST vs ST WST Positive

C, 53.7±2.9 C, 3.5±0.9m

Ref. 32 Tang 2014 96 E, 55.8±2.1 NR NR NR MA+ST vs ST WST Positive

C, 57.2±1.9

Ref. 33 Jia 2014 60 E, 58.30±7.87 <6m 24 in 4w 24 in 4w MA+ST vs ST WST Positive

C, 56.47±8.43
Acupuncture in Medicine
 Li and Deng

Table 1. (Continued)
Study Patients Interventions Designs Outcome

Duration (days,
ID First author Year Cases Age (years) weeks or months) MA (sessions) ST (sessions) E vs C Measures Conclusion

Ref. 34 Liu 2014 87 E, 53.6±8.5 E, 2w−12m 14 14 MA+ST vs ST WST Positive

C C, 1w−11m

Ref. 35 Tong 2014 60 E, 63 E, 35 30 in 6w 30 in 6w MA+ST vs ST WST Positive

C, 62 C, 36 (D)

Ref. 36 Zhu FH 2015 60 E, 54.1±16.6 NR 14 14 MA+ST vs ST WST Positive

C, 49.5±22.7

Ref. 37 Zhu BB 2015 60 E, 53.60±12.96 E, 6.83±1.60m 28 28 in 4w MA+ST vs ST WST Positive

C, 56.10±10.81 C, 7.05±1.33m

Ref. 38 Fu 2016 101 E, 52.8±10.4 E, 6.8±2.3w 2m 2m MA+ST vs ST SSA Positive

C, 55.4±13.8 C, 8.5±3.1w

Ref. 39 Feng 2016 60 E, 60±12 E, 38±18d 18 in 3w 18 in 3w MA+ST vs ST VFSS Positive

C, 58±12 C, 39±18d

Ref. 40 Xia 2016 124 E, 65.3±14.2 E, 9.3±2.3d 24 in 4w 24 in 4w MA+ST vs ST DOSS, MBI, Positive
C, 66.1±14.3 C, 8.7±2.5d S-QOL

BP, bulbar palsy; C, control group; CH, cerebral haemorrhage; CI, cerebral ischaemia; d, day; DOSS, dysphagia outcome and severity scale; E, experimental group; FDS, Fujishima Ichiro’s dysphagia
scale (a 10-point scale for assessing dysphagia developed by Japanese scholar Fujishima Ichiro); ID, identity; m, month; MA; manual acupuncture; MBI, modified Barthel index; NR, not reported; PBP,
pseudobulbar palsy; SFA, swallowing function assessment; SH, subarachnoid haemorrhage; SSA, standardised swallowing assessment; ST, swallowing training; S-QOL, swallowing-related quality of life;
VFSS, videofluoroscopic swallowing study; w, week; WST, water swallow test (a five-grade scale for assessing dysphagia developed by Kubota Toshio, a Japanese scholar).

Acupuncture in Medicine, 37(2)

85
86 Acupuncture in Medicine

Table 2. Methodological quality of the included studies.

Items

Blinding of Incomplete Grade of

Random sequence Allocation performance outcome Selective Other risk of
Study generation concealment and detection data reporting bias bias

Luo et al.24 L U U L L U B

Zhang et al.25 L U U L L U B

Zhang et al.26 L U L L L U A

Yu and Hu27 L U U L L U B

Yi28 L U U L L U B

Yin29 L U U L L U B

Li et al.30 L U U L L U B

Zhang31 L U U L L U B

Tang and Han32 L U U L L U B

Jia et al.33 L L U L L U A

Liu34 L U U L L U B

Tong et al.35 L U U L L U B

Zhu et al.36 L U U L L U B

Zhu and Zhao37 L U U L L U B

Fu38 L U U L L U B

Feng et al.39 L U U L L U B

Xia et al.40 L U L L L U A

L, low (risk of bias); H, high (risk of bias); U, unclear (risk of bias). A, four or more items meeting the ‘L’ level; B, two or three items meeting the ‘L’
level; C, one or no items meeting the ‘L’ level or one or more items meeting the ‘H’ level.

publication bias on the pooled effect size of ER (details in
online supplemental appendix 3).
Effect size of SFA. The SFA data (nine studies, 776 eligible
patients) yielded positive results but with significant het-
erogeneity (SMD 1.17, 95% CI 0.76 to 1.58, P<0.001;
I2=85.5%, n=9, P<0.001, online supplemental appendix
1). The sensitivity analysis showed that four of the included
studies28,31,33,38 were the primary contributors to the hetero-
geneity; no substantial heterogeneity existed when these
studies were excluded (SMD 1.40, 95% CI 1.18 to 1.61,
P<0.001; I2=53.8%, n=5, P=0.070, Figure 2B). Further-
more, the positive results were verified by the pooled
effect sizes of the excluded four studies but with heteroge-
neity (SMD 0.83, 95% CI 0.60 to 1.05, P<0.001; I2=91.1%,
n=4, P<0.001, online supplemental appendix 1). Further
subgroup analysis was performed, and no study character-
istics were identified as potential influences of the hetero-
geneity of the estimated effect size (all P>0.05, online
supplemental appendix 2), although the number of treat-
ment sessions (<28 sessions vs ⩾28 sessions) yielded
different SMDs for SFA (<28 sessions: n=3; ⩾28 ses-
sions: n=2) with a significant difference between groups
(P=0.004). By contrast, the meta-regression analyses
showed that the number of treatment sessions might not
influence the pooled effects of SFA (P=0.063). In the
following publication bias analysis, Begg’s funnel plot
was visually symmetrical (Figure 3C), and no publica-
tion bias was observed in Begg’s and Egger’s tests
(P=1.000 and P=0.869, respectively, online supplemen-
tal appendix 3).
Effect size of IA. MBI data were extracted from one study40
(with 124 eligible patients). The results showed that, com-
pared with conventional swallowing training, combination
therapy might improve the activities of daily life in patients
with poststroke dysphagia (SMD 1.47, 1.07 to 1.87,
P<0.001; online supplemental appendix 1).

Acupuncture in Medicine, 37(2)

Li and Deng 87

Figure 2. Forest plots of effective rate, swallowing function assessment and swallowing-related quality of life. RR, relative risk;
SMD, standardised mean difference.

Effect size of QOL. S-QOL data were extracted from two
studies,29,40 including 237 eligible patients, and negative
results were obtained in the meta-analysis (SMD 1.06,
95% CI −0.04 to 2.17, P=0.06; Figure 2C, supplemental
appendices 1, 3).
Adverse events
Data on AEs were collected from six studies.28,29,34,37–39 The
original results from the literature without statistics showed
that the number of cases of aspiration pneumonia (32 in the

Acupuncture in Medicine, 37(2)

88
Figure 3. Funnel plots of effective rate and swallowing
function assessment as a marker of publication bias analysis.
RR, relative risk; SMD, standardised mean difference.
experimental group and 39 in the control group), malnutri-
tion (two cases in the control group) and dehydration (four
cases in the experimental group and five cases in the con-
trol group) were higher in the control group than in the
experimental group (online supplemental appendix 4).
Additionally, AEs related to acupuncture, such as pain,
mild vomiting, ecchymosis and haematoma, occurred
rarely and were not severe. No AEs related to swallowing
training were reported in the included studies.
Acupuncture in Medicine, 37(2)
Acupuncture in Medicine
Preferred acupuncture points
We pooled the data related to the acupuncture points selected
from the included studies and found that nine acupuncture
points were most commonly used to treat dysphagia after
stroke: GB20, GB12 and TE17 in the nape; CV23 and Pang
Lianquan (0.8–1 cun from CV23) in the neck; and Jinjin,
Yuye and Yanhoubi (on the posterior pharyngeal wall) in the
mouth (online supplemental appendix 4). The findings were
similar to those of other published reviews.48,49
Discussion
Acupuncture and swallowing training are commonly used to
treat swallowing disorders in stroke patients as routine thera-
pies based on traditional Chinese medicine or modern
Western medicine. Furthermore, these therapies have been
used to treat other diseases, such as Parkinson’s disease.50
Whether the combination therapy has a more positive impact
on poststroke dysphagia than conventional swallowing train-
ing remains unclear. To our knowledge, this is the first meta-
analysis to evaluate the effectiveness and safety of the
combination of acupuncture and swallowing training versus
conventional care for treating poststroke dysphagia. Previous
studies have provided limited evidence due to small sample
sizes and poor methodological quality. Therefore, in the pre-
sent study, a meta-analysis with rigorous inclusion criteria
for RCTs (only RCTs that clearly stated use of random
sequence generation were included) were defined to provide
a reliable quantitative evaluation of existing evidence on the
effectiveness and safety of acupuncture and swallowing
training for the treatment of poststroke dysphagia. To com-
prehensively assess the value of acupuncture combined with
swallowing training, data on SFA, IA and QOL were chosen
to evaluate for improvements in multiple dimensions among
patients with poststroke dysphagia. Moreover, the ER was
taken as a global measure of clinical effectiveness. In the
meta-analysis, the estimated effect sizes of ER, SFA, MBI
and QOL suggested that the combined application of acu-
puncture and swallowing training improved swallowing
function and activities of daily life to a significantly greater
degree, than swallowing training alone. The negative result
regarding QOL might be due to the small number of included
studies and the small number of eligible patients. Overall,
the effectiveness and safety of acupuncture and swallowing
training for patients with poststroke dysphagia were con-
firmed by this meta-analysis. Regarding acupuncture points,
we summarised nine preferred points based on the included
studies and thereby provide recommendations for clinical
and research settings.
Limitations
There were some limitations in the present study. First, sub-
stantial heterogeneity and publication bias were observed
Li and Deng
in the included studies for the pooled estimation of the ER.
Although we reduced the influence of heterogeneity by per-
forming a sensitivity analysis, a subgroup analysis, a trim-
and-fill analysis and a fail-safe number calculation, we
could not exclude the possibility of residual confounding
by uncontrolled factors. Second, the long-term curative
effects of acupuncture combined with swallowing training
for poststroke dysphagia could not be evaluated because all
of the studies included in this meta-analysis reported only
short-term effects; outcomes at long-term follow-up were
not assessed. Third, there was diversity of and variation in
the acupuncture and swallowing training protocols.
Conclusions
This meta-analysis of currently available studies provides
evidence confirming that acupuncture combined with swal-
lowing training can improve the ER, SFA and IAs of daily
life in patients with poststroke dysphagia compared with
swallowing training alone. However, further clinical trials
with large sample sizes and standardised methodology are
required to verify these results.
Acknowledgements
We would like to thank Professor Jing He and Professor
Chengqi He of West China Hospital, Sichuan University, for
providing valuable suggestions and comments.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This research was supported by the Science and Technology
Department of Sichuan Province (ref. 2016SZ0039) and the
Medical Association of Sichuan Province (ref. S15063),
Chengdu, China.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Patient consent
Obtained.
Provenance and peer review
Not commissioned; externally peer reviewed.
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