Surface Electrical Stimulation for Treating Swallowing Disorders after Stroke: A Review of the Stimulation Intensity Levels and the Electrode Placements

Poorjavad M, Talebian Moghadam S, Nakhostin Ansari N, Daemi M.

Stroke Res Treat. 2014;2014:918057. Epub 2014 Apr 2. Review.

Abstract

Neuromuscular electrical stimulation (NMES) for treating dysphagia is a relatively new therapeutic method. There is a paucity of evidence about the use of NMES in patients with dysphagia caused by stroke. The present review aimed to introduce and discuss studies that have evaluated the efficacy of this method amongst dysphagic patients following stroke with emphasis on the intensity of stimulation (sensory or motor level) and the method of electrode placement on the neck. The majority of the reviewed studies describe some positive effects of the NMES on the neck musculature in the swallowing performance of poststroke dysphagic patients, especially when the intensity of the stimulus is adjusted at the sensory level or when the motor electrical stimulation is applied on the infrahyoid muscles during swallowing.

 

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The Effect of Early Neuromuscular Electrical Stimulation Therapy in Acute/Subacute Ischemic Stroke Patients With Dysphagia

Kyeong Woo Lee, MD, PhD, Sang Beom Kim, MD, PhD, Jong Hwa Lee, MD, PhD, Sook Joung Lee, MD, PhD, Jae Won Ri, MD,corresponding author and Jin Gee Park, MD

Ann Rehabil Med. Apr 2014; 38(2): 153–159.
Published online Apr 29, 2014.

Abstract:

Objective

To compare the outcome of an early application of neuromuscular electrical stimulation (NMES) combined with traditional dysphagia therapy (TDT) versus traditional dysphagia therapy only in acute/subacute ischemic stroke patients with moderate to severe dysphagia by videofluoroscopic swallowing study (VFSS).

Methods

Fifty-seven dysphagic stroke patients were enrolled in a VFSS within 10 days after stroke onset. Patients were randomly assigned into two treatment groups. Thirty-one patients received NMES combined with TDT (NMES/TDT group) and 26 patients received TDT only (TDT group). Electrical stimulation with a maximal tolerable intensity was applied on both suprahyoid muscles for 30 minutes, 5 days per week during 3 weeks. The swallowing function was evaluated at baseline and 3, 6, and 12 weeks after baseline. Outcomes of the VFSS were assessed using the Functional Oral Intake Scale (FOIS).

Results

The mean ages were 63.5±11.4 years in the NMES/TDT group and 66.7±9.5 years in the TDT group. Both groups showed a significant improvement on the FOIS after treatment. The FOIS score was significantly more improved at 3 and 6 weeks after baseline in the NMES/TDT group than in the TDT group (p<0.05).

Conclusion

An early application of NMES combined with TDT showed a positive effect in acute/subacute ischemic stroke patients with dysphagia. These results indicated that the early application of NMES could be used as a supplementary treatment of TDT to help rehabilitate acute/subacute dysphagic stroke patients by improving their swallowing coordination.

Kinematic Effects of Hyolaryngeal Electrical Stimulation Therapy on Hyoid Excursion and Laryngeal Elevation

Nam HS, Beom J, Oh BM, Han TR.

Dysphagia. 2013 Apr 20.

Abstract

The purpose of this study was to assess the effect of repeated sessions of electrical stimulation therapy (EST) on the neck muscles with respect to the stimulation site by using quantitative kinematic analysis of videofluoroscopic swallowing studies (VFSS) in dysphagia patients with acquired brain injury. We analyzed 50 patients in a tertiary hospital who were randomly assigned into two different treatment groups. One group received EST on the suprahyoid muscle only (SM), and the other group received stimulation with one pair of electrodes on the suprahyoid muscle and the other pair on the infrahyoid muscle (SI). All patients received 10–15 sessions of EST over 2–3 weeks. The VFSS was carried out before and after the treatment. Temporal and spatial parameters of the hyoid excursion and laryngeal elevation during swallowing were analyzed by two-dimensional motion analysis. The SM group (n = 25) revealed a significant increase in maximal anterior hyoid excursion distance (mean ± SEM = 1.56 ± 0.52 mm, p = 0.008) and velocity (8.76 ± 3.42 mm/s, p = 0.017), but there was no significant increase laryngeal elevation. The SI group (n = 25), however, showed a significant increase in maximal superior excursion distance (2.09 ± 0.78 mm, p = 0.013) and maximal absolute excursion distance (2.20 ± 0.82 mm, p = 0.013) of laryngeal elevation, but no significant increase in hyoid excursion. There were no significant differences between the two groups with respect to changes in maximal anterior hyoid excursion distance (p = 0.130) and velocity (p = 0.254), and maximal distance of superior laryngeal elevation (p = 0.525). EST on the suprahyoid muscle induced an increase in anterior hyoid excursion, and infrahyoid stimulation caused an increase in superior laryngeal elevation. Hyolaryngeal structural movements were increased in different aspects according to the stimulation sites. Targeted electrical stimulation based on pathophysiology is necessary.

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Surface electrical stimulation in dysphagic parkinson patients: A randomized clinical trial

Baijens LW, Speyer R, Passos VL, Pilz W, van der Kruis J, Haarmans S, Desjardins-Rombouts C.

Laryngoscope. 2013 Apr 17.

Abstract

OBJECTIVES/HYPOTHESIS:

A new treatment for oropharyngeal dysphagia in Parkinson’s disease was evaluated in the present study.

STUDY DESIGN:

Prospective randomized controlled trial.

METHODS:

The study describes the effects of surface electrical stimulation (SES) of the neck (submental region) in dysphagic Parkinson patients using different intensities of electrical current. Quasi-random allocation was performed when assigning patients to treatment groups. Three groups consisting of dysphagic patients with idiopathic Parkinson’s disease (N = 90) received daily treatment for 15 days with periods of no treatment during the weekend. All three received traditional logopedic dysphagia treatment. In addition, two groups received SES, either motor-level or sensory-level stimulation. A standardized measurement protocol, including fiber optic endoscopic evaluation of swallowing (FEES) and videofluoroscopy of swallowing (VFS), was performed before and after therapy. A team of experienced raters was blinded to the treatment group and to the moment of measurement. Intrarater and interrater reliability were calculated.

RESULTS:

Using proportional odds models (POMs), some of the visuoperceptual ordinal outcome variables showed significant improvement in all groups following treatment. Following 15 days of SES of the submental region, few significant effects were found, suggesting a therapy effect of traditional logopedic dysphagia treatment without any additional influence of SES.

CONCLUSIONS:

On the grounds of this study, it is concluded that further research is needed on the exact mechanism of SES and its effects on the neural pathways involved in swallowing.

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Transcutaneous neuromuscular electrical stimulation can improve swallowing function in patients with dysphagia caused by non-stroke diseases: a meta-analysis

Tan C, Liu Y, Li W, Liu J, Chen L.

J Oral Rehabil. 2013 Apr 23.

Abstract

There is still debate over whether the effect of transcutaneous neuromuscular electrical stimulation (NMES) in dysphagia rehabilitation is superior to traditional therapy (TT). The purpose of this meta-analysis was to assess the overall efficacy by comparing the two treatment protocols. Published medical studies in the English language were obtained by comprehensive searches of the Medline, Cochrane and EMBASE databases from January 1966 to December 2011. Studies that compared the efficacy of treatment and clinical outcomes of NMES versus TT in dysphagia rehabilitation were assessed. Two reviewers independently performed data extraction. Data assessing swallowing function improvement were extracted as scores on the Swallowing Function Scale as the change from baseline (change scores). Seven studies were eligible for inclusion, including 291 patients, 175 of whom received NMES and 116 of whom received TT. Of the seven studies, there were two randomised controlled trials, one multicentre randomised controlled trial and four clinical controlled trials. The change scores on the Swallowing Function Scale of patients with dysphagia treated with NMES were significantly higher compared with patients treated with TT [standardised mean difference (SMD) = 0·77, 95% confidence interval (CI): 0·13 to 1·41, P = 0·02]. However, subgroup analysis according to aetiology showed that there were no differences between NMES and TT in dysphagia post-stroke (SMD = 0·78, 95% CI: -0·22 to 1·78, P = 0·13, 4 studies, 175 patients). No studies reported complications of NMES. NMES is more effective for treatment of adult dysphagia patients of variable aetiologies than TT. However, in patients with dysphagia post-stroke, the effectiveness was comparable.

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Neuromuscular Electrical Stimulation Efficacy in Acute Stroke Feeding Tube-Dependent Dysphagia During Inpatient Rehabilitation

Kushner DS, Peters K, Eroglu ST, Perless-Carroll M, Johnson-Greene D.

Am J Phys Med Rehabil. 2013 Mar 8.

Abstract

OBJECTIVE:

The aim of this study was to compare the efficacy of neuromuscular electrical stimulation (NMES) in addition to traditional dysphagia therapy (TDT) including progressive resistance training (PRT) with that of TDT/PRT alone during inpatient rehabilitation for treatment of feeding tube-dependent dysphagia in patients who have had an acute stroke.

DESIGN:

This study is an inpatient rehabilitation case-control study involving 92 patients who have had an acute stroke with initial Functional Oral Intake Scale (FOIS) scores of 3 or lower and profound to severe feeding tube-dependent dysphagia. Sixty-five patients, the NMES group, received NMES with TDT/PRT, and 27 patients, the case-control group, received only TDT/PRT. Treatment occurred in hourly sessions daily for a mean ± SD of 18 ± 3 days. χ Analyses/t tests revealed no significant statistical differences between the groups for age (t = -0.85; P = 0.40), sex (χ = 0.05; P = 0.94), and stroke location (χ = 4.2; P = 0.24). A Mann-Whitney U test revealed a statistically significant difference between the groups for the initial FOIS score (z = -2.4; P = 0.015), with the NMES group having worse initial scores with a mean rank of 42.64 and the case-control TDT/PRT group having a mean rank of 55.8. The main outcome measure was the comparison of the FOIS scores after treatment.

RESULTS:

The mean ± SD FOIS score after NMES with TDT/PRT treatment was 5.1 ± 1.8 compared with 3.3 ± 2.2 in the case-control TDT/PRT group. The mean gain for the NMES group was 4.4 points; and for the case-control group, 2.4 points. Significant improvement in swallowing performance was found for the NMES group compared with the TDT/PRT group (z = 3.64; P < 0.001). Within the NMES group, 46% (30 of 65) of the patients had minimal or no swallowing restrictions (FOIS score of 5-7) after treatment, whereas 26% (7 of 27) of those in the case-control group improved to FOIS scores of 5-7, a statistically significant difference (χ = 6.0; P = 0.01).

CONCLUSIONS:

This study suggests that NMES with TDT/PRT is significantly more effective than TDT/PRT alone during inpatient rehabilitation in reducing feeding tube-dependent dysphagia in patients who have had an acute stroke.

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Neuromuscular electrical stimulation versus traditional therapy in patients with Parkinson’s disease and oropharyngeal Dysphagia: effects on quality of life

Heijnen BJ; Speyer R; Baijens LW; Bogaardt HC

Dysphagia; 27(3): 336-45, 2012 Sep

ABSTRACT:

This study compares the effects of traditional logopedic dysphagia treatment with those of neuromuscular electrical stimulation (NMES) as adjunct to therapy on the quality of life in patients with Parkinson’s disease and oropharyngeal dysphagia. Eighty-eight patients were randomized over three treatment groups. Traditional logopedic dysphagia treatment and traditional logopedic dysphagia treatment combined with NMES at sensor or motor level stimulation were compared. At three times (pretreatment, post-treatment, and 3 months following treatment), two quality-of-life questionnaires (SWAL-QOL and MD Anderson Dysphagia Inventory) and a single-item Dysphagia Severity Scale were scored. The Functional Oral Intake Scale was used to assess the dietary intake. After therapy, all groups showed significant improvement on the Dysphagia Severity Scale and restricted positive effects on quality of life. Minimal group differences were found. These effects remained unchanged 3 months following treatment. No significant correlations were found between dietary intake and quality of life. Logopedic dysphagia treatment results in a restricted increased quality of life in patients with Parkinson’s disease. In this randomized controlled trial, all groups showed significant therapy effects on the Dysphagia Severity Scale and restricted improvements on the SWAL-QOL and the MDADI. However, only slight nonsignificant differences between groups were found.

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Avaliação da estimulação elétrica no tratamento da disfagia secundário ao acidente vascular encefálico

Soares, Thaís Miranda Curvelo; Conceição, Tatiana Maíta Alves; Cardoso, Fabrício; Beresford, Heron
Acta fisiátrica; 16(4)dez. 2009
ARTIGO DE REVISÃO
A disfagia neurogênica compreende as alterações da deglutição que ocorrem em virtude de uma doença neurológica, com os sintomas e complicações decorrentes do comprometimento sensório-motor dos músculos envolvidos no processo da deglutição. Este tipo de disfagia é particularmente debilitante, podendo levar a morte ou aumento do custo de saúde decorrentes da aspiração traqueal. Esta patologia é comum e consiste numa complicação potencialmente fatal para AVE agudo, ocorrendo em aproximadamente 50% desses pacientes. Dentre os possíveis tratamentos, a estimulação tátil-térmica e biofeedback têm um sucesso freqüente, variando de 0% a 83%. Estudos registram alto sucesso deste tratamento com pacientes que sofreram AVE, o que geralmente não incluem a mais severa forma de disfagia. Já o uso da estimulação elétrica no tratamento da disfagia foi primeiro descrito em 1996 por Freed et al e, posteriormente, por Park et al. O objetivo dessa estimulação elétrica era alcançar um ramo aferente do reflexo da deglutição em pacientes com atraso do início da deglutição. Sendo esta uma alternativa de tratamento ainda pouco explorada, o objetivo desse estudo foi realizar uma revisão bibliográfica sobre a utilização da estimulação elétrica no tratamento da disfagia em pacientes que sofreram acidente vascular encefálico. Conclusão: A disfagia neurogência, por estar diretamente associada ao aumento da morbi-mortalidade, necessita da atenção especial dos profissionais da Saúde. Sendo a eletroestimulação uma terapêutica importante a ser explorada já que possui uma eficácia significativa nesta patologia.

Assessment of electrical stimulation in the treatment of the dysphagia caused by stroke

Soares, Thaís Miranda Curvelo; Conceição, Tatiana Maíta Alves; Cardoso, Fabrício; Beresford, Heron
Acta fisiátrica; 16(4)dez. 2009.
Neurogenic dysphagia encompasses the disturbances in swallowing that occur because of a neurological disease, with the symptoms and complications stemming from the sensorial-motor impairment of the muscles involved in the swallowing process. This type of dysphagia is particularly debilitating. It can cause death or increased health care costs due to tracheal aspiration. This pathology is common and it presents a potentially fatal complication for stroke, happening in approximately 50% of these patients. Among the possible treatments, tactile-thermal stimulation and biofeedback are frequently successful, varying from 0% to 83%. Studies register a high success rate for this treatment with patients that have suffered strokes, which doesn’t usually include the most severe dysphagia. The use of the electrical stimulation in treating dysphagia was first reported in 1996 by Freed et al and, later, by Park et al. The objective of the electrical stimulation was to find an afferent branch for the swallowing reflex in stroke patients with dysphagia associated with delayed initiation of swallowing. Since this was a little-explored alternative treatment, the objective of that study was to perform a bibliographical review concerning the use of electrical stimulation in the treatment of dysphagia in patients that had suffered strokes. Conclusion: Dysphagia caused by stroke is directly associated with an increase in life-threatening medical complications and requires the attention of health professionals. Electrical stimulation is an important therapy for dysphagia and its effectiveness in this pathology must be explored.

Differential effects of neuromuscular electrical stimulation parameters on submental motor-evoked potentials

Doeltgen SH, Dalrymple-Alford J, Ridding MC, Huckabee ML.

Neurorehabil Neural Repair. 2010 Jul-Aug;24(6):519-27. Epub 2010 Mar 12.

Abstract

BACKGROUND:

Neuromuscular electrical stimulation (NMES) of the muscles underlying the pharynx and faucial pillars affects the excitability of corticobulbar projections in a frequency- and duration-specific manner. The anterior hyomandibular (submental) muscles are primary targets for the clinical application of NMES to improve disordered swallowing, but the optimal NMES parameters for this application are unknown.

OBJECTIVE:

To determine the influence of NMES parameters on the excitability of corticobulbar projections to the submental musculature.

METHODS:

Transcranial magnetic stimulation (TMS) was used in event-related protocols, triggered by either volitional contraction of the submental muscles or pharyngeal swallowing, to assess corticobulbar excitability prior to, immediately following, and 30, 60, and 90 minutes post-NMES in 25 healthy volunteers. In the first 2 experiments, 4 stimulus frequencies (5, 20, 40, and 80 Hz) and 3 NMES dosages, manipulated through stimulus train durations or number of repetitions, were evaluated. The optimal excitatory NMES triggered by volitional swallowing (event-related NMES) was then replicated in a new sample and contrasted with non-event-related NMES (either discrete events or continuously for 1 hour).

RESULTS:

It was found that 80Hz NMES increased motor-evoked potential (MEP) amplitude at 30 minutes and 60 minutes poststimulation only after 60 repetitions of 4-s event-related NMES trains. Non-event-related and continuous NMES did not affect MEP amplitudes. No changes in MEP onset latencies were observed.

CONCLUSIONS:

Changes in corticobulbar excitability induced by NMES of the submental muscle group are frequency and dose dependent and only occur after NMES triggered by volitional swallowing. Underlying neural mechanisms are discussed.

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