Neuromuscular electrical stimulation as a treatment dysphagia in stroke patients
Date First Published:
February 1, 2012
Last Updated:
August 7, 2012
Report by:
Rachel Beesley and Claire Mitchell, Speech and Language Therapists (Central Manchester University Hospitals NHS Foundation Trust)
Search checked by:
Rachel Beesley, Central Manchester University Hospitals NHS Foundation Trust
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*)
Search Details:
NMES= 14 articles
e-stim= 1
transcutaneous electrical stimulation= 10
vitalstim= 6
TES= 3
electrical stimulation= 65
e-stim= 1
transcutaneous electrical stimulation= 10
vitalstim= 6
TES= 3
electrical stimulation= 65
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Electrical stimulation for swallowing disorders caused by stroke Freed M, Freed L, Chatburn R, Christian M May-01 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 |
| Neuromuscular electrical stimulation and hermal tactile stimulation for dysphagia caused by stroke: an RCT 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 |
| Comparing the effects of rehabiliation swallowing therapy vs neuromuscular elctrical stimulation therapy among stoke patients with persistent laryngeal dysphagia: an RCT 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, |
| Treatment of post stroke dysphagia by VitalStim therapy coupled with conventional swallowing training. 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 |
| Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction 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 |
Author Commentary:
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.
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:
- Freed M, Freed L, Chatburn R, Christian M. Electrical stimulation for swallowing disorders caused by stroke
- Lim K, Lee H, Lim S, Choi Y. Neuromuscular electrical stimulation and hermal tactile stimulation for dysphagia caused by stroke: an RCT
- 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
- 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.
- Bulow M, Speyer R, Baijens L, Woisard V, Ekberg O. Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction