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Three Part Question

In [stroke patients with new onset dysphagia], is [neuromuscular electrical stimulation (NMES) better than compensatory strategies or thermo-tactile stimulation] in the [recovery of swallow function]

Clinical Scenario

There is new emerging technology designed to electrically stimulate key muscles involved in swallowing for treating people with dysphagia. This is more commonly used in the United States but it is now being provided in the UK by independent practitioners. The Royal College of speech and language therapists do not endorse this treatment due to lack of a robust evidence base so we do not know if this type of therapy is effective and for which client group it is most effective for. Patients are beginning to ask therapists about this kind of treatment so a search of the available evidence is useful to inform patients of the most up to date evidence.

Search Strategy

Medline was used as the search engine. The title and abstract were searched and criteria was set to human subjects and English language only. The search was: (neuromuscular electrical stimulation OR NMES OR e-stim OR transcutaneous electrical stimulation OR vitalstim OR TES OR electrical stimulation) AND (dysphagia OR swallow*)
NMES= 14 articles
e-stim= 1
transcutaneous electrical stimulation= 10
vitalstim= 6
TES= 3
electrical stimulation= 65

Search Outcome

After the removal of duplicates 74 articles were found. Out of these only 5 were accepted for the BET. Articles were excluded for reasons such as low grade evidence, mixed client groups, reviews and studies on normal subjects.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Freed M, Freed L, Chatburn R, Christian M May 2001 USA	stroke	Trial	swallow function score	Both groups showed improvement but ES had higher final swallow scores	No sample size calculations,swallow function score is a subjective measure and does not include solids, only liquids. Outcome measure is aspiration only, not control of bolus/residue etc. The final score was determined by functional improvement (subjective), not by repeat objective barium swallow, subjects and SLTs were unblinded. The TS group were longer post stroke than the ES group
Lim K, Lee H, Lim S, Choi Y 2009 Korea	stoke	Randomised control trial	swallow function score, Rosenbek penetration/aspiration scale, pharyngeal transit time	improved outcomes for electrical stimulation group	small sample size (28), various types of CVA and post onset time, short follow up period
Permsirivanich W, Tipchatyotin S, Wongchai M, Leeamanit V et al 2009 Thailand	stroke	Randomised control trial	functional oral intake scale	electrical stimulation appeared to have better outcomes	very early on in recovery (2 weeks post CVA), no account for spontaneous recovery, unclear how blinded, small sample size (28), subjective and vague outcome measures,
Xia W, Zheng C, Lei Q, Tang Z, Hua Q, Zhang Y, Zhu S 2011 China	Stroke	Randomised control trial	bedside swallow assessment, videofluoscopy, swallow related quality of life	No significance difference found between vitalstim vs conventional swallow therapy but significant result in both combined	not made clear what conventional swallow training is, no mention of spontaneous recovery or definition of 'acute' dysphagia, small sample size, no long term impact included, some outcome measures are subjective or fully explained what was measured. More info on stroke severity and functional severity of dysphagia pre and post treatment would be useful, all results are statistically significant
Bulow M, Speyer R, Baijens L, Woisard V, Ekberg O 2008 Sweden	stroke	Randomised trial	videofluroscopy, nutritional status, oromotor function, visual analogue scale	no statistically significant difference between electrical stimulation and traditional therapy. Patients subjective views had little corrolation with objective measures	small sample size

Comment(s)

From the original search there is little high grade evidence available at present. Althought some studies show an improvement in swallow function, the outcome measures are often subjective or not fully explained.

Clinical Bottom Line

More robust studies need to be conducted before the use of electrical stimulation can proved to be an effective and safe option for dysphagia therapy

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Freed M, Freed L, Chatburn R, Christian M Electrical stimulation for swallowing disorders caused by stroke Respiratory Care May 2001, vol 46, no 5
2. Lim K, Lee H, Lim S, Choi Y Neuromuscular electrical stimulation and hermal tactile stimulation for dysphagia caused by stroke: an RCT Journal of rehabilitation medicine 2009 41: 174-178
3. Permsirivanich W, Tipchatyotin S, Wongchai M, Leeamanit V et al Comparing the effects of rehabiliation swallowing therapy vs neuromuscular elctrical stimulation therapy among stoke patients with persistent laryngeal dysphagia: an RCT Journal of the medical association of Thailand 2009 92 (2) 259-65
4. Xia W, Zheng C, Lei Q, Tang Z, Hua Q, Zhang Y, Zhu S Treatment of post stroke dysphagia by VitalStim therapy coupled with conventional swallowing training. Journal Huazhong University of Science and Technology 31 (1):73-76 2011
5. Bulow M, Speyer R, Baijens L, Woisard V, Ekberg O Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction Dysphagia 23:302-309