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NMES vitalstim in dysphagia in young infants effective??

I am a paediatric physio and currently teaching (deveioping) taping courses.,.and especially interested in everything related to using tape in children.. With a colleague we developed a course on using kinesiotape for speechlanguage therapist.

In discussions with various speechlanguage pathologists, we have come across the fact that NMES is being used a lot in dysphagia treatment..

When I look at how this is done my question is, if such electro placements being used are sufficiently precise.

When I look at the electrode placing (and the huge patch to keep the electrodes stuk on the skin especially in children) I wonder how precise this electrotherapy is....I also wonder if it is not the tape itself that is having an effect and I would not be surprised that using elastic therapeutic tape might be more precise. The background being that a number of studies comparing kinesiotaping and NMES have found the effects to be very similar.

The Vitalstim info tells us that they targetting the suprahyoids and the thyrohyoid. I am presuming you know the NMES Vitalstim examples... https://www.youtube.com/watch?v=V7nRtrKdLYM https://www.youtube.com/watch?v=2bac_YiJ5UE

Am I being too critical? So many muscles are being triggered at the same time? Should its use be carefully monitored in such young infants?

Please let me know if NMES on such young children is safe and meaningful. Can you guide me to articles on its safely and proper use in infants. The information here does not make me less worried. The electrodes they use on adults are not much larger than the ones they use on tiny children.... http://dysphagiacafe.com/2014/05/12/vitalstim/

Hoping you can give me some assistance :) kind regards Esther de Ru estherderu@gmail.com

esther de ru

10 months ago

Back to General Electrotherapy

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estherderu171
estherderu171

dear Dinesh>Dinesh Verma said:

Dear Esther

Interesting question and please let me answer best to my ability since I have been involved in ESTIM for Dysphagia for past 10 years and conducted several Workshops across Asia n Europe ... Let me share my views :

Firstly we do not have that many research publications - with ESTIM and Paeds population - however some case studies and limited references available do show very positive out comes in PAEDS - with NMES. ADULT Population is Several researches Published till date - I would over 30 publications worldwide....

As far as your point that Positive Effect could be due to adhesive Plaster - I do not personally agree for the reasons - In the Original Work developing this technique - that was done by Ms Marcy Freed during early 2000s - an Speech Language pathologist - The plaster based electrodes were not developed and she used Round electrodes with 3 M tape ... with extremely positive outcomes that made the technique to be approved for clinical use in USA. Also there is no force applied to muscle in this application - the role of Adhesive plaster is NO MORE then a ADHESIVE BAND AID for sticking purposes. Kinesio Taping principles do work on different Application techniques as you very well know.

The effect of ESTIM is certainly well proven over the years and I do have references of several International Research publications.... for Adult population - largely with Stroke.

One of very interesting Physiological and LAB study was done in Spain - and I am giving you reference below - Led by Prof Pere Clave - Who is Chairperson of European Society of Swallowing disorder ( ESSD ) - and with their Extensively developed lab - That I was fortunate to visit - They produced some excellent outcomes - that actually Evaluated the effects on Swallow at SENSORY level intensity - IMPROVED SAFELY OF SWALLOW AS WELL AS Motor level intensity - IMPROVED SAFETY AND EFFICACY OF SWALLOW . Below is the summary .

Neurogastroenterol Motil (2013) doi: 10.1111/nmo.12211 Effect of surface sensory and motor electrical stimulation on chronic poststroke oropharyngeal dysfunction L. ROFES, V. ARREOLA,† I. L _OPEZ,,† A. MARTIN,† M. SEBASTI _AN,‡ A. CIURANA‡ & P. CLAV_E,† Centro de Investigaci_on Biom_edica en Red de enfermedades hep_aticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain †Gastrointestinal Physiology Lab, Hospital de Matar_o, Matar_o, Spain ‡Neurology Unit, Hospital de Matar_o, Matar_o, Spain

SENSORY LEVEL STIM Unsafe swallows were reduced by 66.7 % Laryngeal vestibule closure time was reduced by 22.9 % Max Hyoid vertical extension time reduced by 18.6 %

MOTOR LEVEL STIM Unsafe swallows were reduced by 62.5 % Laryngeal vestibule closure time was reduced by 38.2 % Max Hyoid vertical extension time reduced by 24.8%. Pharyngeal residues were reduced by 66.7 % . UES Opening time reduced by 39.4 % Bolus Propulsion force increased by 211 % Improved Safety and EFFICACY of swallow .

PLEASE NOTE - The Key Muscles that we address in the ESTIM technique are Supra-Hyoid muscle - those responsible for Forward and upward movement of Hyoid bone - Facilitating Normal Safer positioning to swallow also to some extent . Infra - Hyoid muscles - BOTH together resulting in HYO-LARANGEAL EXCUSRION. Pharyngeal Constrictor muscles - resulting in Greater contraction forces ( as shown in study above by Physiological measurements ) ... Now important point is - One must perform good Clinical Evaluation and Select Target Muscles and Activities those need to be encouraged - Hence it should NOT be the case that - Supra / infra hyoid muscle ground HAVE TO BE stimulated at Same intensity Levels. One could select Motor level at Channel 1 and Sensory level at Channel 2.

Regarding Size of electrodes - As for PAEDS group - You may consider - 2 electro placements ... It is not Mandatory that always 4 electrodes have to be placed... !

ESTIM indeed has VERY positive outcomes on Dysphagia management - and perhaps at current time - I could say one of VERY WELL researched area of application in Electrotherapy - with a few RCT - OUTCOME studies done as well.. !

Some of the EMG activity recording done at labs - have shown increased CORTICAL Activity in the brain while the Stim is ON and remaining Post Stim - This is reinforcing Cortical reorganization and Stimulation at sensory levels DO also facilitate Motor return.

Hope above is helpful in making some clarifications .

Esther - May I know your country of location Please..??

Regards

Dinesh Verma SINGAPORE

Improved SAFETY of swallow

dear Dinesh, Thank you very much for the detailed reaction. I will have a good read and will come back with more questions when I have done so. Am based in the Netherlands, but have worked in Germany and Spain also. In my role as advocate of taping, I am particularly interested because a number of studies comparing both NMES to Kinesiotaping have shown very similar outcomes. kind regards Esther

Dinesh Verma
Dinesh Verma

Dear Esther

Interesting question and please let me answer best to my ability since I have been involved in ESTIM for Dysphagia for past 10 years and conducted several Workshops across Asia n Europe ... Let me share my views :

Firstly we do not have that many research publications - with ESTIM and Paeds population - however some case studies and limited references available do show very positive out comes in PAEDS - with NMES. ADULT Population is Several researches Published till date - I would over 30 publications worldwide....

As far as your point that Positive Effect could be due to adhesive Plaster - I do not personally agree for the reasons - In the Original Work developing this technique - that was done by Ms Marcy Freed during early 2000s - an Speech Language pathologist - The plaster based electrodes were not developed and she used Round electrodes with 3 M tape ... with extremely positive outcomes that made the technique to be approved for clinical use in USA. Also there is no force applied to muscle in this application - the role of Adhesive plaster is NO MORE then a ADHESIVE BAND AID for sticking purposes. Kinesio Taping principles do work on different Application techniques as you very well know.

The effect of ESTIM is certainly well proven over the years and I do have references of several International Research publications.... for Adult population - largely with Stroke.

One of very interesting Physiological and LAB study was done in Spain - and I am giving you reference below - Led by Prof Pere Clave - Who is Chairperson of European Society of Swallowing disorder ( ESSD ) - and with their Extensively developed lab - That I was fortunate to visit - They produced some excellent outcomes - that actually Evaluated the effects on Swallow at SENSORY level intensity - IMPROVED SAFELY OF SWALLOW AS WELL AS Motor level intensity - IMPROVED SAFETY AND EFFICACY OF SWALLOW . Below is the summary .

Neurogastroenterol Motil (2013) doi: 10.1111/nmo.12211 Effect of surface sensory and motor electrical stimulation on chronic poststroke oropharyngeal dysfunction L. ROFES, V. ARREOLA,† I. L _OPEZ,,† A. MARTIN,† M. SEBASTI _AN,‡ A. CIURANA‡ & P. CLAV_E,† Centro de Investigaci_on Biom_edica en Red de enfermedades hep_aticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain †Gastrointestinal Physiology Lab, Hospital de Matar_o, Matar_o, Spain ‡Neurology Unit, Hospital de Matar_o, Matar_o, Spain

SENSORY LEVEL STIM Unsafe swallows were reduced by 66.7 % Laryngeal vestibule closure time was reduced by 22.9 % Max Hyoid vertical extension time reduced by 18.6 %

MOTOR LEVEL STIM Unsafe swallows were reduced by 62.5 % Laryngeal vestibule closure time was reduced by 38.2 % Max Hyoid vertical extension time reduced by 24.8%. Pharyngeal residues were reduced by 66.7 % . UES Opening time reduced by 39.4 % Bolus Propulsion force increased by 211 % Improved Safety and EFFICACY of swallow .

PLEASE NOTE - The Key Muscles that we address in the ESTIM technique are Supra-Hyoid muscle - those responsible for Forward and upward movement of Hyoid bone - Facilitating Normal Safer positioning to swallow also to some extent . Infra - Hyoid muscles - BOTH together resulting in HYO-LARANGEAL EXCUSRION. Pharyngeal Constrictor muscles - resulting in Greater contraction forces ( as shown in study above by Physiological measurements ) ... Now important point is - One must perform good Clinical Evaluation and Select Target Muscles and Activities those need to be encouraged - Hence it should NOT be the case that - Supra / infra hyoid muscle ground HAVE TO BE stimulated at Same intensity Levels. One could select Motor level at Channel 1 and Sensory level at Channel 2.

Regarding Size of electrodes - As for PAEDS group - You may consider - 2 electro placements ... It is not Mandatory that always 4 electrodes have to be placed... !

ESTIM indeed has VERY positive outcomes on Dysphagia management - and perhaps at current time - I could say one of VERY WELL researched area of application in Electrotherapy - with a few RCT - OUTCOME studies done as well.. !

Some of the EMG activity recording done at labs - have shown increased CORTICAL Activity in the brain while the Stim is ON and remaining Post Stim - This is reinforcing Cortical reorganization and Stimulation at sensory levels DO also facilitate Motor return.

Hope above is helpful in making some clarifications .

Esther - May I know your country of location Please..??

Regards

Dinesh Verma SINGAPORE

Improved SAFETY of swallow

estherderu171
estherderu171

Prof Gad Alon said:

Before answering in more details, please get and read this publication :

Christiansen ME, Mabe B, Russell G, et al. Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. Pediatr Pulmonol 2011;46: 559-565. OBJECTIVE: Dysphagia can lead to chronic aspiration and pulmonary disease. The objective of this study was to compare change in swallowing function in pediatric patients with dysphagia who received neuromuscular electrical stimulation (NMES) to a control group who received usual oral motor training and dietary manipulations without NMES. STUDY DESIGN: Retrospective analysis of change in Functional Oral Intake Scale (FOIS) level derived from videofluoroscopic swallowing studies performed before and after NMES (treatment group: N = 46) compared to control group (control group: N = 47). Children were classified into two groups based on the etiology of their dysphagia (primary vs. acquired). NMES took place in a tertiary medical center for an average of 22 treatment sessions over 10 weeks. An independent t-test was used to test for differences in the change in FOIS level between groups. An analysis of covariance was run within groups to assess the relationship between diagnosis and change in FOIS level. RESULTS: Both groups improved in their FOIS level (P < 0.01) but the amount of change was not different (P = 0.11). Only the treatment group who had acquired dysphagia improved more than the similar subgroup of control children (P = 0.007). CONCLUSION: NMES treatment of anterior neck muscles in a heterogeneous group of pediatric patients with dysphagia did not improve the swallow function more than that seen in patients who did not receive NMES treatment. However, there may be subgroups of children that will improve with NMES treatment.

Dr. Alon

Thank you I will try to find and read first....

Prof Gad Alon
Prof Gad Alon

Before answering in more details, please get and read this publication :

Christiansen ME, Mabe B, Russell G, et al. Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. Pediatr Pulmonol 2011;46: 559-565. OBJECTIVE: Dysphagia can lead to chronic aspiration and pulmonary disease. The objective of this study was to compare change in swallowing function in pediatric patients with dysphagia who received neuromuscular electrical stimulation (NMES) to a control group who received usual oral motor training and dietary manipulations without NMES. STUDY DESIGN: Retrospective analysis of change in Functional Oral Intake Scale (FOIS) level derived from videofluoroscopic swallowing studies performed before and after NMES (treatment group: N = 46) compared to control group (control group: N = 47). Children were classified into two groups based on the etiology of their dysphagia (primary vs. acquired). NMES took place in a tertiary medical center for an average of 22 treatment sessions over 10 weeks. An independent t-test was used to test for differences in the change in FOIS level between groups. An analysis of covariance was run within groups to assess the relationship between diagnosis and change in FOIS level. RESULTS: Both groups improved in their FOIS level (P < 0.01) but the amount of change was not different (P = 0.11). Only the treatment group who had acquired dysphagia improved more than the similar subgroup of control children (P = 0.007). CONCLUSION: NMES treatment of anterior neck muscles in a heterogeneous group of pediatric patients with dysphagia did not improve the swallow function more than that seen in patients who did not receive NMES treatment. However, there may be subgroups of children that will improve with NMES treatment.

Dr. Alon

estherderu171
estherderu171

dear Sandy, Thank you for such a rapid response. Do look forward to hearing from the others. The process from opening mouth to the swallow (eating or drinking) needs many more muscles than the masseter only. It is one of the many you need for the whole eating or drinking process. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597750/table/T1/ this is a link to names of many of the muscles and their cranial nerves. That is one of the reasons I am asking. Can we assume that any stimulus to a muscle innervated by cranial nerves will react in the same way as a stimulus given to muscles innervated by motor nerves? What message are we giving the brain?? Is there a difference?

Dr Sandy Rennie
Dr Sandy Rennie

Hi Esther.

Regrettably I have no experience with muscle stimulation for patients with dysphagia. However in looking at these vitastim videos, it appears that the electrodes used for children are quite small, and thus would not be considered to be over-stimulating proximal muscles. I agree with you that the tape patch used may also be having some effect, however if this type of stimulator actually causes muscle contraction I can see how it would help with chewing and swallowing by stimulating the masseter muscles on the cheek.

Sorry I could not be more helpful. Perhaps one of my ElectroForum colleagues can assist.

Sincerely, Sandy Rennie

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