VitalStim in Swallowing Rehabilitation

Transcription

1 VitalStim in Swallowing Rehabilitation Meghan McAvoy, MS,CCC-SLP Mary Free Bed at Sparrow Hospital Disclosures No financial or non-financial disclosures Control of the swallow Both voluntary and involuntary Pattern elicited response Cortex, brainstem, peripheral nerves Sensory and motor Feedback is important Michigan 1

2 What is VitalStim? Neuromuscular electrical stimulation (NMES), wherein a device sends an electrical impulse through the skin to selected muscles Specifically meant for treatment of dysphagia FDA approved Used to support gains in muscle strength development, reduce atrophy, and enhance muscle reeducation Supports cortical reorganization through repetition, sensory input, movement feedback, and successful outcome of movement How does it work? Electrodes are placed in different positions to stimulate muscles involved in swallowing, based on impairments Electrical stimulation passes between the electrodes to create a biphasic pulse to the motor point Increased intensity leads to current passing deeper and depolarizing more neurons Sensory > sensory and motor Increased content of muscle contractile proteins, amount of enzymes used in aerobic pathways, mitochondrial size, and capillary density Keep it functional Normal swallow compared to a stimulated swallow Normal Contraction Muscle fibers do not all contract at the same time, but relay to each other Smaller motor units innervated by slow-twitch fibers depolarize first Fast-twitch fibers with increased effort Evoked Contraction Muscle fibers within the path of the current contract at the same time Larger motor units innervated by fast-twitch fibers are depolarized first Slow-twitch fibers with greater intensity Michigan 2

3 Increased intensity, fatigue more quickly Repeated fatigue changes the muscle Increases capacity to meet the demands VitalStim fatigues muscles more quickly due to the increased intensity BUT need to continue to use the muscles Keep it functional How to decide if someone is appropriate for VitalStim History Bedside Swallow Evaluation Instrumental Evaluation Not necessary, but helpful to objectively determine what needs to be targeted Treatment plan Michigan 3

4 Who is not appropriate for VitalStim? Patients with active neoplasm or infection at electrode location Patients with significant lower motor neuron damage Patients with significantly impaired cognition Open wounds at site Patients with seizure disorders, significant reflux, experiencing drug toxicity, tracheostomy patients, or those who have implanted electrical devices can participate, but proceed with caution What do you need to use VitalStim? Is VitalStim effective? Outcome measures vary depending on the study Clark et al, 2009 Variable physiological changes Positive changes for functional swallowing outcomes for most Design flaws Design flaws throughout VitalStim research Issues noted by Burns and Miller, 2011, indicating insufficient evidence to determine effectiveness, overall, and for diagnoses and severities Shaw et al, 2007: helpful for mild to moderate, less likely to make gains in severe Bulk of research done on patients following strokes Michigan 4

5 Efficacy with brain injured population Terre and Mearin, 2015 Randomized, controlled, blinded to patients and assessors analyzing data, subjective and objective measures evaluated over 3 month period Functional Oral Intake Score (FOIS), Likert scale Oral transit time, palatoglossal closure, and piecemeal swallowing (Oral); Pharyngeal residuals after the swallow, laryngeal elevation, cricopharyngeal dysfunction, pharyngeal delay time, pharyngeal transit time, and penetration/aspiration (Pharyngeal) Pharyngeal manometry to address UES relaxation, pharyngo-esophageal coordination, and pharyngeal contraction Results Larger gains in FOIS in VitalStim group after 1 mo (P= 0.005) Higher level of perceived improvement with VitalStim after 1 mo (P=0.001) Improvements in ability to handle thinner consistencies at 1 mo with VitalStim (P=0.015) No significant change in post-treatment analyses between groups for temporal measures, but greater changes in VitalStim group Oral transit time within the normal range for the VitalStim group Improved, but still abnormal pharyngeal delay (PDT) and pharyngeal transit time (PTT) with VitalStim At 3 mo, more VitalStim subjects rated to have normal PDT and PTT vs persistent abnormal in control subjects Pharyngo-esophageal manometry showed significant increase in pharyngeal contraction pressure at 1 mo after VitalStim with no significant change in sham group (P=0.04) No change for either group at 3 mo Sources Burns, M. I., & Miller, R. M. (2011). The Effectiveness of Neuromuscular Electrical Stimulation (NMES) in the Treatment of Pharyngeal Dysphagia: A Systematic Review. Journal of Medical Speech-Language Pathology, 19(1), Clark, H., Lazarus, C., Arvedson, J., Schooling, T., & Frymark, T. (2009). Evidence-Based Systematic Review: Effects of Neuromuscular Electrical Stimulation on Swallowing and Neural Activation. American Journal of Speech-Language Pathology, 18(4), doi: / (2009/ ) Cole, S., & Head, P. (2015, March 21-22). Training Manual for the use of Neuromuscular Electrical Stimulation in the treatment of Dysphagia. Lecture presented at VitalStim Certification Program, Chicago. Gallas, S., Marie, J. P., Leroi, A. M., & Verin, E. (2009). Sensory Transcutaneous Electrical Stimulation Improves Post-Stroke Dysphagic Patients. Dysphagia, 25(4), doi: /s Handa, Y., Yagi, R., & Hoshimiya, N. (1998). Application of Functional Electrical Stimulation to the Paralyzed Extremities. Neurologia medio-chirurgica, 38(11), doi: /nmc Humbert, I., Michou, E., Macrae, P., & Crujido, L. (2012). Electrical Stimulation and Swallowing: How Much Do We Know? Seminars in Speech and Language, 33(03), doi: /s Korfage, J., Schueler, Y., Brugman, P., & Eijden, T. V. (2001). Differences in myosin heavy-chain composition between human jaw-closing muscles and supra- and infrahyoid muscles. Archives of Oral Biology, 46(9), Doi: /s (01) Ludlow, C. L., Humbert, I. Saxon, K., Poletto, C., Sonies, B., & Crujido, L. (2007). Effects of Surface Electrical Stimulation Both at Rest and During Swallowing in Chronic Pharyngeal Dysphagia. Dysphagia, 22(1), doi: /s Milner-Brown, H. S., & Miller, R. G. (1988). Muscle strengthening through electric stimulation combined with low-resistance weights in patients with neuromuscular disorders. Arch Phys Med Rehabil, 69(20), 4. Ortega, O., Rofes, L., Martin, A., Arreola, V., Lopez, I. & Clave, P. (2016). A Comparative Study Between Two Sensory Stimulation Strategies After Two Weeks Treatment on Older Patients with Oropharyngeal Dysphagia. Dysphagia, 31(5), Doi: /s Safety Issues regarding the use of VitalStim Therapy. (2008, September 14). Retrieved Shaw, G. Y., Sechtem, P. R., Searl, J., Keller, K., Rawi, T. A., & Dowdy, E. (2007). Transcutaneous Neuromuscular Electrical Stimulation (VitalStim) Curative Therapy for Severe Dysphagia: Myth or Reality? Annals of Otology, Rhinology & Laryngology, 116(1), Doi: / Stal, P. (1994). Characterization of human oro-facial and masticatory muscles with respect to fibre types, myosins and capillaries. Morphological, enzyme-histochemical, immunehistochemical and biochemical investigations. Swed Dent J Suppl, 98. Steele, C. M., & Miller, A. J. (2010). Sensory Input Pathways and Mechanisms in Swallowing: A Review. Dysphagia, 25(4), Doi: /s Terre, R., & Mearin, F. (2015). A randomized controlled study of neuromuscular electrical stimulation in oropharyngeal dysphagia secondary to acquired brain injury. European Journal of Neurology, 22(4), doi:10.111/ene Toyama, K., Matsumoto, S., Kurasawa, M., Setoguchi, H., Noma, T., Takenaka, K., Kawahira, K. (2014). Novel Neuromscular Electrical Stimlation System for Treatment of Dysphagia after Brain Injury. Neurologia medico-chirugica, 54(7), doi: /nmc.oa Michigan 5