Swallowing disorders are a common complication after stroke, resulting in complications such as aspiration pneumonia, impaired water and nutrient intake, asphyxia, and psychological disorders, which seriously affect the quality of life of patients and increase the disability and mortality rates. The most effective way to treat post-stroke swallowing disorders is to provide early and standardized comprehensive rehabilitation treatment, and the author reviews the comprehensive rehabilitation treatment for post-stroke swallowing disorders in recent years. Swallowing disorders and their associated aspiration are common complications of stroke. The incidence of post-stroke dysphagia is reported to be 37%-78% in foreign literature 1, and 62.5% in China 2. Swallowing disorders can cause aspiration pneumonia, malnutrition and dehydration, mainly due to medullary palsy caused by damage to the cranial nerve nuclei in the brainstem related to swallowing or pseudo medullary palsy caused by damage to bilateral cortical medullary tracts 3. 5. According to foreign scholars, misaspiration occurs in 9.9% of right hemisphere stroke patients, 12.1% of left hemisphere lesions, 24% of bilateral hemisphere lesions, and 39.5% of brainstem lesions. 6. The key to reduce these complications is to pay sufficient attention to post-stroke dysphagia and to provide early rehabilitation treatment. Theoretical basis for rehabilitation of dysphagia: neural network reorganization and collateral sprouting are the basis for restoration of swallowing function through training. The central nervous system is highly plastic, and after damage to central neurons and their synaptic connections, important anatomical and functional reorganization can occur very quickly. In this process of functional reorganization, the external environment, which is closely linked to the body, and various factors affecting the body’s behavior can affect this process, which provides the basis for rehabilitation treatment. The stimulation can lead to the enhancement of central synapses, the establishment of new synaptic chains, the generation of new motor reflex arcs, and the early restoration of swallowing function. The start of rehabilitation treatment for stroke swallowing disorder should be started as early as possible after the diagnosis of stroke is established and the patient is hospitalized in the acute phase. Patients with ischemic stroke can be rehabilitated after 48h as long as their consciousness is clear, their vital signs are stable and their condition is no longer developing. Hypertension and cerebral hemorrhage are generally appropriate after 10-14 d. The assessment and treatment of swallowing disorders in stroke often requires a multidisciplinary team of professionals working closely together to diagnose, treat, rehabilitate, and manage the patient’s swallowing disorder, including rehabilitation physicians, speech therapists, nurses, physical therapists, occupational therapists, neurologists, otolaryngologists, geriatricians, radiologists, and Gastroenterology, and other physicians. The communication method of the group is based on the speech therapist as the main contact hub, including: consultation system, regular case discussion, telephone communication, Internet communication, etc. Many foreign hospitals and related institutions have swallowing centers that use group work model and overall systematic treatment for such swallowing disorders, while few group work models and related studies have been carried out in China. Wan Guifang and Dou Zulin [10] explored the impact of group work model on the evaluation and rehabilitation treatment of swallowing disorders after stroke and concluded that the early evaluation of swallowing disorders is valued, and group The intervention of the working group model, including the treatment of language impairment and cognitive impairment, can significantly improve the overall rehabilitation effect and survival quality of patients. In a study by Chi-Lifen et al. in the stroke unit model for the treatment of post-stroke dysphagia, compared with the treatment of post-stroke dysphagia in a general ward, the results were significant, with a low rate of pulmonary infection and a good recent prognosis. The stroke unit is a new ward medical management model for hospitalized stroke patients with a collaborative medical, technical and nursing team, and studies at home and abroad have shown that the most effective treatment for stroke is the stroke unit. With the promotion and development of stroke unit model in China, the treatment of post-stroke swallowing disorder will be further improved and developed. The comprehensive rehabilitation treatment for stroke swallowing disorder is summarized as follows: direct training, indirect training, compensatory training, biofeedback training, acupuncture treatment, medication, surgery, psychotherapy, etc. Logemann summarized the rehabilitation treatment strategies into 3 categories: direct strategies, indirect strategies, compensatory strategies, China mostly take integrated treatment means, now the main methods are introduced as follows: direct training: feeding position generally take a sitting position, can not sit up the head of the bed elevated 30 °, take the supine position, head tilted forward, hemiplegic patients with the affected side of the shoulder pillow cushion, after the entrance of the spoon, in the front 1/3 of the tongue slightly force After the entrance of the spoon, the food should be pressed downward and backward, the food should be entered from the corner of the mouth on the healthy side, and the sitting position should be maintained for 15 min after eating to prevent food reflux. The eating speed of patients with swallowing disorder should be slower than normal people, and generally the eating time of each meal should be controlled at about 45 min. The amount of one bite suitable for swallowing each intake, including the amount of eating and speed control of one bite, normal adults are generally 20ML, if too much, food will spill or remain in the throat easy to cause accidental aspiration, too little is difficult to induce swallowing reflex. For patients with swallowing disorders, the tableware used for eating has special requirements. It is appropriate to use a small shallow spoon, which can be easily delivered into the mouth and limit the amount of bites, and some special utensils can be used, such as syringes and paper cups cut into curved openings. In the United States and Japan and other countries, there are a variety of commercialized, dedicated to the use of hand dysfunction patients eating tableware, but almost no production and use in developing countries. This aspect awaits further development of rehabilitation engineering and occupational therapy in China. The eating environment should be established with the same medical environment with emergency conditions as the trial feeding. At the same time, the eating environment should be neat and tidy, trying to avoid eating in a noisy, cluttered environment, and should make the patient focus on swallowing. Dietary modifications have been shown to reduce the incidence of aspiration pneumonia due to swallowing disorders when used alone. Systematic television radiographic swallowing studies have found that changes in the texture of the food mass can reduce food mass infiltration, and coupled with the low cost of dietary modification, the American Gastroenterological Association guidelines state that dietary modification should be routinely performed if there is a risk of aspiration pneumonia due to swallowing disorders during the oropharyngeal phase. Cai Wei et al [14] the Chinese Expert Consensus Group on Nutritional Management of Stroke Patients suggested that swallowing disorders are the main reason for the presence of malnutrition in stroke patients. The recommendations of the expert consensus on nutritional management of stroke affect the prognosis of stroke: 1. Nutritional management is part of the overall management of the stroke patient (acute and rehabilitation phase) and is included in the scope of routine work developed by the hospital for stroke and routinely recorded on the patient’s medical documentation. 2. A nutritional risk assessment and management plan for stroke patients should be developed within 48 h of admission and repeated at least once a week. The recommended method of nutritional risk assessment is the 2002 European Society of Nutrition standard, with an actionable plan developed by a professional dietitian in conjunction with a clinician according to individualized needs. 3. At the time of discharge, a diet plan should be developed for the patient and the life caregiver should be instructed to monitor the patient’s weight and dietary intake and included in the follow-up observation index. Indirect training: Swallowing muscle training includes passive and active training of lip, tongue, pharynx, cheek and other swallowing muscles, such as jaw movement, lip spreading, lip protrusion, lip smacking, cheek puffing, tongue anterior extension and retraction and up and down and various resistance exercises. The purpose of respiratory training is to increase lung capacity and improve the coordination of breathing and swallowing, such as controlled airflow exhalation, fast inhalation and slow exhalation training, coordinated breathing exercises, and therapist-assisted breathing training. Relaxation training increases the flexibility and softness of the head and neck muscles and can be performed before each swallowing session. The patient is seated, maintaining a neutral position of the body and head and neck, and performing forward flexion, backward extension, lateral extension and head turning movements. The patient was encouraged to do throat clearing exercises by inhaling deeply through the nose, holding the breath for 5 seconds with the lips closed, and then doing throat clearing exercises. Sensory facilitation training gives patients various sensory stimuli before they start swallowing so that they can trigger swallowing, called sensory facilitation method. The methods include: 1. Increase the force of the spoon down on the tongue when bringing the food into the mouth. 2. Giving food with strong sensory sensations, such as cold, tactile, or strong sweet, sour, bitter, and spicy tasting food masses. 3.Give food balls that need to be chewed to provide initial oral stimulation with the help of chewing motion. 4.Gently stimulate the soft palate, tongue root or posterior pharyngeal wall with a frozen cotton swab to make the swallowing reflex occur easily. Ice stimulation of the skin around the lips and cheeks can also reduce salivation. 5.Encouraging patients to eat by themselves can make them get more sensory stimulation. DPNS can enhance oral muscle function and pharyngeal reflex to enhance swallowing function. DPNS emphasizes three reflex areas: tongue root, soft palate, epiglottis and mesopharyngeal retractor. The patient’s tongue is then pulled out and stimulated with an ice-cold lemon stick in eight areas: bilateral soft palate smooth stimulation, trilateral soft palate smooth stimulation, posterior tongue smooth stimulation, lateral tongue stimulation, medial tongue stimulation, bilateral pharyngeal wall stimulation, posterior tongue root retraction reflex force stimulation and uvula stimulation. 6, soft palate functional training for the soft palate upward weakness of patients, can be used to guide the airflow method, “push support” therapy. 7, vocal cord training vocal cord closure is an important factor in preventing misaspiration. Patients inhale, hold back the breath, then swallow, and cough independently after the end of swallowing; you can do whistle blowing exercise, first deep breathing, then blow the whistle with force, repeat ten times to increase vocal fold closure. 8, special swallowing training forceful swallowing method, low head swallowing method, supraglottic swallowing, supraglottic swallowing, Mendelssohn method, etc. 9, electrical stimulation training at present, domestic clinical research has basically determined that electrical stimulation treatment of swallowing disorders is effective, and its efficacy is better than the efficacy of swallowing manipulative treatment. However, there is controversy about the effectiveness of electrical stimulation treatment compared with acupuncture treatment. This may be related to the relatively rough study group. In addition, the subjects of domestic studies are mostly acute or subacute patients, and there are few patients with chronic dysphagia, so the efficacy of the treatment for refractory dysphagia remains to be studied. Transcutaneous functional low-frequency electrical stimulation for swallowing disorders has been studied in some studies, and the results are mostly suggestive. The main form of electrical stimulation used by the investigators has not yet targeted the activation of specific muscle movements during the dynamics of swallowing. Jean et al. observed the efficacy of electrical stimulation of the bilateral pharyngeal-palatal arches in the treatment of swallowing disorders, where the stimulation information could enter the central swallowing pattern generator via the linguopharyngeal afferent pathway and improve the swallowing delay. The results showed a reduction in food delivery time, infiltration and aspiration in all patients. It has also been suggested that stimulation of the pharyngopalatine arch can affect the neurotransmission pathways that initiate swallowing, the benefits and drawbacks of which depend on the frequency of stimulation. Intramuscular electrical stimulation is rarely used to study the recovery of swallowing, and Burnett et al. developed an implantable functional electrical stimulation system to help patients with delayed swallowing or laryngeal supination impairment in the chronic phase of stroke. This study reported that stimulation of the mandibular hyoid muscle and/or metacarpophalangeal muscle on both sides resulted in laryngeal elevation of 50% of normal swallowing and 80% of normal swallowing speed. Complete implantation of a muscle stimulator may be a treatment for chronic dysphagia [24]. Medium-frequency electrical stimulation Zhang Guangwei et al [25] studied medium-frequency electrical stimulation compared with rehabilitation treatment with cold stimulation alone and showed that the cure rate and overall effective rate of swallowing disorders were significantly higher in the group treated with medium-frequency electrical stimulation compared with the cold stimulation group. The patient adopts a certain position or head posture to change the shape of the pharynx, to reduce the symptoms of swallowing disorder by changing the pathway or direction of food passage, to improve the efficiency of swallowing, and to reduce misaspiration during swallowing. Several compensatory swallowing methods are commonly used:repetitive swallowing, reciprocal swallowing, swallowing in lateral position, nod-like swallowing, lateral swallowing, and forceful swallowing. Other rehabilitation therapies Biofeedback training uses surface electromyographybiofeedback (SEMGBF) to help patients maintain and improve their swallowing ability while they receive immediate voice feedback through progressive swallowing. The use of SEMGBF in conjunction with a series of food group swallowing and respiratory protection training can significantly improve the efficacy of swallowing training. craryM, A. et al. reported the results of training 45 patients with swallowing disorders and demonstrated that SEMGBF can improve the transoral feeding function of patients in a short period of time. Acupuncture treatment methods: Head acupuncture: stimulate the cerebral cortex and improve blood circulation Neck acupuncture: improve the blood supply of vertebral 2 basilar artery, thus improving the blood supply to the brainstem. Local acupuncture points: stimulate the linguopharyngeal nerve and vagus nerve, so that excitation is uploaded to the upper motor neurons and the regulation of the cortical brainstem bundle by the cerebral cortex is restored. The combination of the three therapies as a whole and locally has the characteristics of adjusting human functions and treating both the symptoms and the root cause. In addition, there are reports of better results of post-stroke swallowing disorder treated with acupuncture combined with functional training. Hyperbaric oxygen combined with acupuncture treatment has the effect of increasing the partial pressure of oxygen in the lesion, rapidly increasing the oxygen content, increasing the diffusion radius of capillaries, promoting the formation of collateral circulation in brain tissue, and stimulating collateral sprouting. Studies have shown that hyperbaric oxygen combined with acupuncture treatment not only improves the swallowing function of stroke patients, but also reduces the occurrence of complications and significantly improves the quality of survival of patients. Manual massage is performed by a massage therapist who gives the patient temporomandibular joint area and soft tissue massage of the neck and joint loosening manipulation. Up and down massage of the thyroid cartilage to the skin below the jaw with fingers can cause up and down movement of the jaw and back and forth movement of the tongue, which then triggers swallowing. This method can be used for patients who have food in their mouth but are unable to produce swallowing motions. Pharmacologic treatment For patients with excessive oropharyngeal secretions, anticholinergic drugs are used to inhibit oropharyngeal secretion and reduce aspiration and coughing, but excessive salivary reduction can make saliva sticky and thick, filiform and difficult to clear. MasieroS et al. demonstrated a role for renin angiotensin-converting enzyme inhibitors in preventing secondary aspiration pneumonia in patients with post-stroke dysphagia. morrisH conducted a study of two cases of patients with severe dysphagia treated successfully with botulinum toxin injections into the cricopharyngeal muscle. However, the efficacy of the drug treatment is not definite at present and further observation and evaluation is needed. Stellate ganglion block therapy Wei used hydromyelia injection combined with SGB to treat 32 cases of post-stroke dysphagia. After two courses of treatment, the difference in swallowing ability scores between the treatment group and the control group was significant. However, it should be operated with caution to prevent complications. It is believed that the possible mechanism for SGB to improve swallowing function is that SGB relieves the excitation of sympathetic nerves, causing vasodilation in the innervated area, improving blood circulation, and promoting the recovery of neurological function. Surgical treatment can be used for patients who also have misaspiration on a tube fed diet. The purpose of surgery is to reduce the communication between the trachea and esophagus, thus reducing and eliminating misaspiration and facilitating the removal of food from the pharynx. Tracheotomy is sometimes used in patients with swallowing disorders to facilitate ventilation and airway clearance, but the use of transoral feeding with tracheal intubation with a balloon is not advocated because it does not prevent misaspiration, but rather promotes it. Relatively conservative methods to preserve articulatory function include: cricopharyngeal myotomy, epiglottis remodeling, partial or total cricoid cartilage resection, laryngeal suspension, and laryngostomy. Methods to facilitate the passage of the esophageal mass include: insertion of a bypass tube, upper esophageal sphincterotomy, mechanical fenestration in the esophagus, compensatory laryngeal-glottis-chin fixation, etc. Gastrointestinal nutrition therapy Adequate nutritional support can reduce the complications and improve the prognosis of patients with swallowing disorders. Current gastrointestinal nutrition includes percutaneous endoscopic gastrostomy and nasal feeding. The most commonly used clinical method is placement of a nasogastric tube, which, although effective, has many disadvantages, such as blockage of the tube lumen, tube replacement, tube displacement, patient discomfort, esophagitis, impact on the patient’s cosmetic appearance, gastroesophageal reflux, frequent reflux, parotitis, and destruction of nasal cartilage. The disadvantages of the traditional use of surgical gastrostomy are the need for anesthesia and open placement of a gastrostomy tube, which increases both patient pain and surgical risk, and the high cost. Since 1980, when non-surgical percutaneous endoscopic gastrostomy was introduced for clinical use, it has been widely used in China and abroad. The advantages are ease of operation and few complications. More than 200,000 cases of PEG are performed each year in the United States, and the American Gastrointestinal Association has made it the method of choice for patients who cannot eat through the mouth but need a long-term supply of nutrition. In the past 30 years, the scope of clinical application of PEG has been expanding and has received more and more attention. 2009, the Working Group on Nutritional Support for Neurological Diseases of the Chinese Journal of Neurology issued the Consensus on Nutritional Support for Neurological Diseases, which proposed that patients with stroke with dysphagia, after 4 wk of onset, do not improve the use of PEG feeding when available. In 2001, a prospective multicenter cohort study of 122 patients with neurological persistent dysphagia showed that PEG feeding had better survival rates, aspiration rates, and extubation rates than the nasogastric tube feeding group. Balloon dilation includes one-time balloon catheter dilation and graded multiple balloon catheter dilation, with the latter mostly used in clinical practice. Dou Zulin [37] was the first in China to use the balloon in a common catheter and use water injection to fill the balloon, pull it out from the bottom up, and gradually dilate the cricopharyngeal muscle by changing the diameter of the balloon through the change of water injection. Meng [38] et al. used a modified double-lumen balloon catheter for cricopharyngeal muscle dilation treatment and showed that the application of a modified double-lumen balloon catheter could significantly reduce the occurrence of complications compared to the previous plain catheter. Psychotherapy Good psychotherapy is the basis and guarantee of successful training. A survey [39] found that most patients with swallowing disorders are accompanied by different degrees of psychological disorders, causing anxiety, fear, anorexia, and low self-esteem. Treatment should focus on their psychological problems at the same time. Psychological guidance is also targeted to patients’ personality characteristics, education level and life experiences. Family members are encouraged to accompany the patient so that the patient can perform swallowing function training in the best psychological condition. There are many clinical treatment methods for post-stroke swallowing disorder, but there is no systematic and standardized best treatment plan. According to statistics, up to 1/3 of awake stroke patients with swallowing disorder die within 6 months after stroke, while less than 10% of awake stroke patients without swallowing disorder die within 6 months. For example, VFSS is the “gold standard” for diagnosis of swallowing disorder, but it is not carried out in many hospitals or even in some provincial hospitals, and there is no international standard for swallowing disorder diagnosis. The diagnosis of swallowing disorders is still at a descriptive qualitative level. The diagnosis of dysphagia is still at the descriptive qualitative level. There is also a lack of unified efficacy assessment criteria with good reliability and validity for outcome measurement. 4. The domestic literature reports a very high positive rate of treatment for swallowing disorders with many methods, but a considerable number of clinical studies still have clinical research methodological flaws that greatly affect the reliability of the study findings. For example, lack of rigorous scientific research design, inadequate randomization, lack of high-quality multicenter, large sample, randomized controlled clinical trial studies, lack of standardized diagnostic criteria, neglect of inclusion and exclusion criteria, etc. 5. Many foreign hospitals and related institutions have swallowing centers, which adopt a holistic system of treatment for such swallowing disorders, while those engaged in this work in China are mainly clinical nurses and rehabilitation therapists, and the training of professional speech and swallowing therapists is an urgent problem. 6. There are various diagnostic and efficacy assessment criteria for post-stroke swallowing disorders, and there is no unified standard yet. 7. Post-stroke swallowing disorder involves several disciplines and fields. Rehabilitation physicians, speech therapists, nurses, physiotherapists, occupational therapists, nutritionists, neurologists, otorhinolaryngologists, geriatricians, radiologists, gastroenterologists, etc. should work closely together to achieve satisfactory results. The rehabilitation of swallowing disorder is one of the hot spots in stroke rehabilitation. It is our future work to carry out high-quality clinical research, improve diagnosis and treatment, and develop a set of unified and specific evaluation and comprehensive treatment plan and promote it, so that patients with swallowing difficulties after stroke can achieve the maximum recovery. This is the focus of our future work.