Vitalstim Therapy in Dysphagia Management:
Notes from a Clinician’s Diary
Dysphagia management has been evolving over the years and one of the emerging techniques with evidence building over the past few years is the technique called VITALSTIM therapy.
What is VITALSTIM ?
VITALSTIM therapy based on Neuromuscular Electrical Stimulation (NMES) principles, helps to restore muscle function. In this treatment method small (upto 25 mA) electric currents are used to strengthen the muscles responsible for swallowing.
During therapy, the clinician attaches electrodes externally to the neck in the suprahyoid and infrahyoid region as per specific placements and trains the patient to swallow using strategies such as ‘swallow-cough-swallow’. The progression of treatment sessions is guided by information obtained via objective assessments such as Videofluoroscopy (VFS) and / or FEES.
How does one use this method?
As a practitioner using this treatment method, guided by literature, my general methodology would be to assess the patient clinically followed by an objective evaluation of swallowing using either VFS or FEES. Treatment sessions are then started and progress is monitored clinically each session.
Sessions are conducted on a daily basis with each session spanning 45-60 minutes. It is evidence based practice to use tools such as the MASA, FOIS, SWAL-QOL, NZIMES, 8-point aspiration-penetration scale to document and share findings in any public domain. I have found it useful to reevaluate patients via objective means after 10-15 sessions. This enables tailoring the subsequent treatment sessions as per findings and also explain to patient and family the change seen post treatment.
Should one use other treatment options along with VITALSTIM therapy?
As a researching therapist, it would be good to document everything that we use upfront as this enables us to relate better to the outcomes that we get eventually. I do use all that works for a patient, which may include oro-motor exercises, swallow exercises and or diet modification along with this treatment.
What’s new in the realm of research on VITALSTIM therapy?
Research is underway in several parts of the world to study the use of this therapy method with various client groups and the results are encouraging.
Shaw et al (2007) in their most recent study published in Annals of Otology, Rhinology and laryngology found that Vitalstim therapy helps mild to moderate dysphagic patients gain independence from feeding tubes.
Belafsky et al (2006) in their non concurrent cohort study to evaluate the efficacy of ES with dysphagic patients found that dysphagia therapy with transcutaneous electrical stimulation is superior to traditional dysphagia therapy alone in individuals in a long-term care facility.
Blumenfeld et al (2005) in a case control study compared 40 ES and 40n traditional therapy patients and found that swallow severity improved with the ES group.
Mc Duffie et al ( 2006) in their retrospective case series on H/N ca and post op XRT patients report that 100% patients studied identified positive change post treatment.
Christiaanse et al (2004) in the wake forest group study with paediatric clients reported 57% clients improving in their swallow score and 17% resuming normal oral diet.
How have patients here responded to this treatment method?
My clinical and teaching experience has found a new boost with VITALSTIM therapy. It is a tremendously useful tool in dysphagia management, which facilitates improvement for most patients. Let me share the outcomes of two of my patients here with you.
Case study 1
- Mdm NAG 70 years, Chinese
- History of old CVAs, Brain Stem stroke leading to dysphagia and NG tube insertion
- Dysphagia and on NG feeds alone for > 6 months
- Mild Dysarthria, weak voice
- Functional Communication skills
- Home bound, attends physiotherapy twice a week at a community setting
- Maids are the main care givers
Initial ST – Clinical assessment and pre therapy Fiberoptic Endoscopic Examination of Swallowing (FEES) revealed the following:
- Aspiration of own secretions
- Mod-severe delayed swallows (latency of > 15 secs)
- Poor ‘white out’
- Aspiration on all consistencies given during FEES
- Pen-Asp scale rating: 7
- Diffuse pharyngeal residue post weak swallow attempts
- Recommended to continue with NG feeds only.
Patient started on Dysphagia management involving VS therapy following this. Therapy also focused on oro-motor therapy, caregiver education for follow up of exercises and specific strategies at home. Objective assessments were periodically done to track change.
Patient was started on small oral trials of semisolids following 18 sessions of therapy and an objective examination of swallowing.
Therapy continued and oral intake was gradually increased. It was noted that she would vomit and was unable to manage more than 15-20 tsp of food at any one time. VFS done post 28 sessions of therapy revealed the following:
- Significantly improved swallow function
- Improved swallow triggers (latency 3-6 secs)
- Silent aspiration on thin and eventually on thick fluids
- Pen-Asp scale rating: 6 for fluids, 0 for other consistencies
- Nil penetration and aspiration on semisolids and solids
- Nil abnormalities with UES and LES.
- Possible gastric emptying issues
Patient has been continuing with therapy and has been referred to the specialists for further evaluations. She continues small oral feeds 2-4 times a day and receives the fluids via Ng tube.
Case study 2
- Mdm KKL , 62 yrs, Chinese
- Intracranial bleed, craniectomy done
- On Ng feeds since surgery ( > 6 months)
- Dysphasic, utters few words occasionally
- Non-verbal, nods head to indicate ‘yes’
- Severe dyspraxia
Initial ST – Clinical assessment and pre therapy Video fluoroscopy (VFS) revealed the following:
- Mild consistent silent penetration on all consistencies
- Risk of aspiration with increased intake
- Very delayed swallow triggers (latency > 15 secs) with bolus filling
- valleculae and sinuses to capacity prior to trigger
- Reduced laryngeal elevation
- Pen-Asp scale rating: 3
Patient started on Dysphagia management involving VS therapy following this. Treatment sessions were also tailored to facilitate and consolidate non-verbal communication, address the issue of dyspraxia and caregiver education to enable carry over from therapy sessions to day-to-day activities.
VFS done post 16 sessions of therapy revealed the following:
- Trace transient penetration with thin fluids
- Nil aspiration on any of the consistencies
- Improved swallows ( latency of 3 secs)
- Improved pharyngeal contraction, able to clear minimal residue in sinuses
- Pen-Asp scale rating: 2
Both the dietitian and speech therapist saw the patient regularly to ensure her intake was building up to meet the nutritional and hydrational needs. With continued team effort involving nurses, caregivers and allied professionals, she was weaned off the NG tube and she continues to eat orally. She has gained 6 kgs in the last 1.5 months.
Reflections in conclusion…..
Given the emerging evidence from literature as well as the clinical outcomes VS therapy is an important aspect of dysphagia management.
