A stimulus for eating. The use of neuromuscular transcutaneous electrical stimulation in patients affected by severe dysphagia after subacute stroke: A pilot randomized controlled trial

Abstract

BACKGROUND:

Oropharyngeal dysphagia is a common problem in subacute stroke patients leading to aspiration pneumonia and malnutrition. Non-invasive neuromuscular electrical stimulation (NMES) coupled with traditional therapy could be best treatment option for patients with post-stroke dysphagia, however results are still inconclusive and more studies are requested.

OBJECTIVE:

The aim of the study was to investigate the effect of laryngopharyngeal neuromuscular electrical stimulation on dysphagia caused by stroke.

METHODS:

Thirty-three patients affected by subacute stroke and dysphagia participated in this study. The subjects were divided into NMES plus traditional dysphagia training (n = 17) and traditional dysphagia training alone in a time matched condition (n = 16). Both groups were treated 5 days/week for 8 weeks. All patients were evaluated before and after the treatment. The study was designed as a single blind randomized controlled trial. Primary outcomes were considered the status of swallowing function according to the Functional Oral Intake Scale (FOIS), the instrumental Fiberoptic Endoscopic Examination of Swallowing examination, the Penetration Aspiration Scale and the Pooling score and the presence of oropharyngeal secretion. Secondary outcomes were the type of diet taken by mouth; the need for postural compensations and the duration of the dysphagia training.

RESULTS:

A functional improvement was observed in both groups but treatment group showed a significant improvement for primary outcome with the exception of the pooling Score (p = 0.015, p = 0.203; p = 0.003; p = 0.048 respectively) and for secondary outcome p <0.005. The results confirm that laryngopharyngeal neuromuscular electrical stimulation in post-stroke patients with dysphonia improve outcome of the training.

CONCLUSIONS:

Laryngopharyngeal neuromuscular electrical stimulation may be considered as an additional and effective treatment option for dysphagia after stroke.

Keywords

Stroke dysphagia neuromuscular electrical stimulation rehabilitation fiberoptic endoscopic evaluation of swallowing deglutition

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References

Blumfeld,

, Hahn,

, LePage,

, Leonard,

, & Belafsky,

(2006). Transcutaneous electrical stimulation versus traditional dysphagia therapy: a a nonconcurrent cohort study. Otolaryngology Head and neck surgery, 135, 754–757.

Bülow,

, Speyer,

, Baijens,

, Woisard,

, & Ekberg,

(2008). Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction. Dysphagia, 23, 302–309.

Burkhead

L.M.

, Sapienza

C.M.

, & Rosenbek

JC.

(2007). Strength-training exercises in dysphagia rehabilitation: Principles, procedures and directions for future research. Dysphagia, 22, 25.

Carnaby-Mann

G.D.

, & Crary,

M.A.

(2007). Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg, 133, 564–571.

Chen,

Y.W.

, Chang,

K.H.

, Chen,

H.C.

, Liang,

W.M.

, Wang,

Y.H.

, & Lin,

Y.N.

(2016). The effect s of surface NMES on post-stroke dysphagia: a systematic review and meta-analysis patients with post-stroke dysphagia. Clinical Rehabilitation, 30, 24–35.

Crary,

M.A.

, Mann,

G.D.

, & Groher,

M.E.

(2005). Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil, 86, 1516–1520.

Farneti,

, Fattori,

, Nacci,

, et al. (2014). The Pooling-score (P-score): inter- and intra-rater reliability in endoscopic assessment of the severity of dysphagia. Acta Otorhinolaryngol Ital, 34, 105–110.

Fraser,

, Rothwell,

, Power,

, Hobson,

, Thompson,

, & Hamdy,

(2003). Differential changes in human pharyngoesophageal motor excitability induced by swallowing, pharyngeal stimulation, and anesthesia. Am J Physiol Gastrointest Liver Physiol, 285, 137–144.

Freed,

M.L.

, Freed,

, Chatburn,

R.L.

, & Christian,

(2001). Electrical stimulation for swallowing disorders caused by stroke. Respir Care, 46, 466–474.

10.

Fujiu,

, & Logemann,

J.A.

(1996). Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol, 5, 25–30.

11.

Geeganage

, Beavan.

, Ellender

, & Bath

P.M.

(2012). Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev 10:CD000323.

12.

Guillén-Solà

, Messaggi Sartor

, Bofill Soler

, Esther,

Duarte

, Barrera,

M.C.

, & Marco

(2017). Respiratory muscle strength training and neuromuscular electrical stimulation in subacute dysphagia stroke patients: a randomized controlled trial. Clinical Rehabilitation, 31, 761–771.

13.

Hamdy,

, Rothwell,

J.C.

, Aziz,

, & Thompson,

D.G.

(2000). Organization and reorganization of human swallowing motor cortex: implications for recovery after stroke. Clin Sci (Lond), 99, 151–157.

14.

Heck,

F.M.

, Doeltgen,

S.H.

, & Huckabee,

M.L.

(2012). Effects of submental neuromuscular electrical stimulation on pharyngeal pressuregeneration. Arch Phys Med Rehabil, 93, 2000–2007.

15.

Huang,

K.L.

, Liu,

T.Y.

, Huang,

Y.C.

, Leong,

C.P.

, Lin,

W.C.

, & Pong,

Y.P.

(2014). Functional outcome in acute stroke patients with oropharyngeal Dysphagia after swallowing therapy. J Stroke Cerebrovasc Dis, 23, 2547–2553.

16.

Ickenstein

G.W.

, Stein,

, Ambrosi

, et al. (2005). Predictors of survival after severe dysphagia stroke. J Neurol, 252, 1510–1516.

17.

Jungheim,

, Schubert,

, Miller,

, & Ptok,

(2017). Swallowing Function After Continuous Neuromuscular Electrical Stimulation of the Submandibular Region Evaluated by High-Resolution Manometry. Dysphagia, 32, 501–508.

18.

Kang,

J.H.

, Park,

R.Y.

, Lee,

S.J.

, Kim,

J.Y.

, Yoon,

S.R.

, & Jung,

K.I.

(2012). The effect of bedside exercise program on stroke patients with Dysphagia. Ann Rehabil Med, 36, 512–520.

19.

Kushner,

D.S.

, Peters,

, Eroglu,

S.T.

, Perless-Carroll,

, & Johnson-Greene,

(2013). Neuromuscular electrical stimulation efficacy in acute stroke feeding tube-dependent dysphagia during inpatient rehabilitation. Am J Phys Med Rehabil, 92, 486–495.

20.

Langmore,

S.E.

, Schatz,

, & Olsen,

(1988). Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia, 2, 216–219.

21.

Lee,

K.W.

, Kim,

S.B.

, Lee,

J.H.

, Lee,

S.J.

, Ri,

J.W.

, & Park,

J.G.

(2014). The effect of early neuromuscular electrical stimulation therapy in acute/subacute ischemic stroke patients with Dysphagia. Ann Rehabil Med, 38, 153–159.

22.

Leelamanit,

, Limsakul,

, & Geater,

(2002). Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope, 112, 2204–2210.

23.

Lim,

K.B.

, Lee,

H.J.

, Lim,

S.S.

, & Choi,

Y.I.

(2009). Neuromuscular electrical and thermal-tactile stimulation for dysphagia caused by stroke: a randomized controlled trial. J Rehabil Med, 41, 174–178.

24.

Logemann

J.A.

(2005). The role of exercise programs for dysphagia patients. Dysphagia, 20, 139.

25.

Ludlow,

C.L.

, Humbert,

, Saxon,

, Poletto,

, Sonies,

, & Crujido,

(2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal Dysphagia. Dysphagia, 22, 1–10.

26.

Mann, , Hankey,

G.J.

, & Cameron,

(1999). Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke, 30, 744–748.

27.

Martino,

, Foley,

, Bhogal,

, Diamant,

, Speechley,

, & Teasell,

(2005). Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke, 36, 2756–2763.

28.

Martino,

, Pron,

, & Diamant,

N.E.

(2000). Screening for oropharyngeal dysphagia in stroke: Insufficient evidence for guidelines. Dysphagia, 15, 19–30.

29.

Mendelsohn,

M.S.

, & McConnel,

F.M.

(1987). Function in the pharyngoesophageal segment. Laryngoscope, 97, 483–489.

30.

Oh,

B.M.

, Dy,

Kim

, & Paik,

N.J.

(2007). Recovery of swallowing function is accompanied by the expansion of the cortical ma. Int J Neurosci, 117, 1215–1227.

31.

Park,

J.S.

, Oh,

D.H.

, Hwang,

N.K.

, & Lee,

J.H.

(2016). Effects of neuromuscular electrical stimulation combined with effortful swallowing on post-stroke oropharyngeal dysphagia: a randomised controlled trial. J Oral Rehabil, 43, 426–434.

32.

Park,

J.W.

, Oh,

J.C.

, Lee,

H.J.

, Park,

S.J.

, Yoon,

T.S.

, & Kwon,

B.S.

(2009). Effortful swallowing training coupled with electrical stimulation leads to an increase in hyoid elevation during swallowing. Dysphagia, 24, 296–301.

33.

Permsirivanich,

, Tipchatyotin,

, Wongchai,

, et al. (2009). Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study. J Med Assoc Thai, 92, 259–265.

34.

Quinn,

T.J.

, Paolucci,

, Sivenius,

, Walker,

M.F.

, Toni,

, & Lees,

K.R.

(2009). Evidence-based stroke rehabilitation: an expanded guidance document from the european stroke organisation (ESO) guidelines for management of ischaemic stroke and transient ischaemic attack, European Stroke Organisation Executive Committee, European Stroke Organisation Writing Committee. J Rehabil Med, 41, 99–111.

35.

Robbins

J.A.

, Kays

S.A.

, Gangnon

R.E.

, et al. (2007). The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil, 88, 150–158.

36.

Rosenbek,

J.C.

, Robbins,

J.A.

, Roecker,

E.B.

, Coyle,

J.L.

, & Wood,

J.L.

(1996). A penetration-aspiration scale. Dysphagia, 11, 93–98.

37.

Ryu,

J.S.

, Kang,

J.Y.

, Park,

J.Y.

, et al. (2009). The effect of electrical stimulation therapy on dysphagia following treatment for head and neck cancer. Oral Oncol, 45, 665–668.

38.

Scarponi,

, Mozzanica,

, De Cristofaro,

, et al. (2015). Neuromuscular Electrical Stimulation for Treatment-Refractory Chronic Dysphagia in Tube-Fed Patients: A Prospective Case Series. Folia Phoniatr Logop, 67, 308–314.

39.

Schindler,

, Vincon,

, Grosso,

, Miletto,

A.M.

, Di Rosa,

, & Schindler,

(2008). Rehabilitative management of oropharyngeal dysphagia in acute care settings: data from a large Italian teaching hospital. Dysphagia, 23, 230–236.

40.

Sciortino,

, Liss,

J.M.

, Case,

J.L.

, Gerritsen,

K.G.

, & Katz,

R.C.

(2003). Effects of mechanical, cold, gustatory, and combined stimulation to the human anterior faucial pillars. Dysphagia, 18, 16–26.

41.

Shaker

, Kern

, Bardan

, et al. (1997). Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. Am J Physiol, 272, G1518–G1522.

42.

Shaw

G.Y.

, Sechtem

P.R.

, Searl.

, Keller

, Rawi

T.A.

, & Dowdy

(2007). Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol, 116, 36–44.

43.

Singh,

, & Hamdy,

(2006). Dysphagia in stroke patients. Postgrad Med J, 82, 383–391.

44.

Suiter,

D.M.

, Leder,

S.B.

, & Ruark,

J.L.

(2006). Effects of neuromuscular electrical stimulation on submental muscle activity. Dysphagia, 21, 56–60.

45.

Sun,

S.F.

, Hsu,

C.W.

, Lin,

H.S.

et al. (2013). Combined Neuromuscular Electrical Stimulation (NMES) with Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and traditional swallowing rehabilitation in the treatment of stroke-related. Dysphagia, 28, 557–566.

46.

Tan,

, Liu

, Li

, Liu.

, & Chen

(2013). Transcutaneous neuromuscular electrical stimulation can improve swallowing function in patients with dysphagia caused by non-stroke diseases: a meta-analysis. J Oral Rehabil, 40, 472–480.

47.

Teasell,

R.W.

, Bach,

, & McRae,

(1994). Prevalence and recovery of aspiration poststroke: a retrospective analysis. Dysphagia, 9, 35–39.