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1-S2.0-S0003999315014240-Neuromuskular Electrical Simulation
1-S2.0-S0003999315014240-Neuromuskular Electrical Simulation
ORIGINAL RESEARCH
Abstract
Objective: To evaluate and compare the effects of neuromuscular electrical stimulation (NMES) acting on the sensory input or motor muscle in
treating patients with dysphagia with medullary infarction.
Design: Prospective randomized controlled study.
Setting: Department of physical medicine and rehabilitation.
Participants: Patients with dysphagia with medullary infarction (NZ82).
Interventions: Participants were randomized over 3 intervention groups: traditional swallowing therapy, sensory approach combined with
traditional swallowing therapy, and motor approach combined with traditional swallowing therapy. Electrical stimulation sessions were for 20
minutes, twice a day, for 5d/wk, over a 4-week period.
Main Outcome Measures: Swallowing function was evaluated by the water swallow test and Standardized Swallowing Assessment, oral intake
was evaluated by the Functional Oral Intake Scale, quality of life was evaluated by the Swallowing-Related Quality of Life (SWAL-QOL) Scale,
and cognition was evaluated by the Mini-Mental State Examination (MMSE).
Results: There were no statistically significant differences between the groups in age, sex, duration, MMSE score, or severity of the swallowing
disorder (P>.05). All groups showed improved swallowing function (P.01); the sensory approach combined with traditional swallowing therapy
group showed significantly greater improvement than the other 2 groups, and the motor approach combined with traditional swallowing therapy
group showed greater improvement than the traditional swallowing therapy group (P<.05). SWAL-QOL Scale scores increased more significantly
in the sensory approach combined with traditional swallowing therapy and motor approach combined with traditional swallowing therapy groups
than in the traditional swallowing therapy group, and the sensory approach combined with traditional swallowing therapy and motor approach
combined with traditional swallowing therapy groups showed statistically significant differences (PZ.04).
Conclusions: NMES that targets either sensory input or motor muscle coupled with traditional therapy is conducive to recovery from dysphagia
and improves quality of life for patients with dysphagia with medullary infarction. A sensory approach appears to be better than a motor approach.
Archives of Physical Medicine and Rehabilitation 2016;97:355-62
ª 2016 by the American Congress of Rehabilitation Medicine
Dysphagia is common in patients with stroke and is an indepen- aspiration pneumonia).1-4 This may increase mortality and length
dent predictor of outcome.1,2 It typically refers to difficulty in of hospital stay.5,6 Dysphagia caused by brainstem stroke has a
eating as a result of disruption in the swallowing process and greater occurrence than that caused by hemispheric stroke and
shows an increased risk of complications (eg, malnutrition, shows signs of the most severe form.7
It has been well established that the sequential and rhythmic
patterns of swallowing are produced and organized by a central
Disclosures: none. pattern generator (CPG)8-10 located in the lower brainstem
0003-9993/15/$36 - see front matter ª 2016 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2015.10.104
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356 M. Zhang et al
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Treatment of dysphasia 357
5 excluded
Fig 1 Flow diagram of the study. Abbreviations: MAþTT, motor approach combined with traditional swallowing therapy; SAþTT, sensory
approach combined with traditional swallowing therapy; TT, traditional swallowing therapy.
Sensory approach
This approach used a vocaSTIM-Mastera and a pair of 2 surface
electrodes.
Parameter settings
Parameter settings included the following: T/R exponential cur-
rent; triangle wave (ascending: 750ms, descending: 250ms); pulse
width of 1 second, pulse time of 1 second, and release time of 3
seconds; and frequency of .25Hz. The cathode was placed on the
submental region (fig 2), and the anode was placed on the occipital
skin. The intensity of the electrode stimulation ranged from 0 to
15mA, increasing the intensity gradually up to a sensory input
level expected to lead to swallowing. Fig 2 Position of the electrodes. Abbreviations: MA, motor approach,
where the cathode and anode were placed in parallel on the skin of the
Motor approach anterior belly of the digastric muscle in the submental region above the
This approach used a multifunctional nerve rehabilitation and hyoid bone; SA, sensory approach, where the cathode was placed on
treatment systemb and a pair of 2 surface electrodes. the submental region and the anode was placed on the occipital skin.
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358 M. Zhang et al
Parameter settings and summing all the ratings into an overall scale score that was
Parameter settings included the following: transcutaneous electrical then transformed into a scale of 0 to 100,43,44 with zero indicating
nerve stimulation mode; bipolar index wave, square wave; pulse extremely impaired quality of life and 100 indicating no impair-
width of 100ms; pulse time of 10 seconds and release time of 5 ment experienced by the individual.
seconds; and frequency of 120Hz. The cathode and anode were
placed in parallel on the skin of the anterior belly of the digastric Data and statistical analyses
muscle in the submental region above the hyoid bone (see fig 2).16
The intensity of electrode stimulation ranged from 0 to 60mA, SPSS software version 22.0 for Windowsc was used to analyze all
increasing the intensity gradually to a level expected to elicit a the collected data. All data were formally tested for normality prior
contraction of the target muscle. to further analysis, and nonparametric tests were used for data that
The current intensity was started at 2mA and increased by 1-mA were not normally distributed. Descriptive data were reported as
intervals. When the patient expressed slight discomfort, their reac- mean SD for normally distributed or median (interquartile range)
tion was observed for a few seconds to allow for possible adaptation for discrete variables for baseline characteristics. One-way analysis
by the patient; if the patient continued to indicate discomfort or pain, of variance and Kruskal-Wallis test were used to assess differences
we defined the current intensity used prior to the patient’s indica- between the 3 groups in age, sex, disease duration, MMSE score,
tion as the maximal tolerable intensity.35 The maximal tolerable and initial swallowing function. The WST, SSA, FOIS, and SWAL-
current was subsequently administered as the stimulation intensity. QOL Scale were administered before and after treatment, and the
differences between the post- and pretreatment scores were tested
for significance using the Wilcoxon signed-rank test. The Kruskal-
Outcome measures Wallis test (K independent samples) was used to assess differences
All baseline characteristics were evaluated by an experienced certi- between all 3 groups. Differences were considered to be statistically
fied physical therapist who was not involved in the design of the significant when P<.05.
study or the treatment of the patients. The MMSE was used to assess
cognition36; its score ranged from 0 to 30. The WST37,38 (table 1)
and Standardized Swallowing Assessment (SSA)39-41 were used to Results
evaluate swallowing function. In the WST, the subject drank 30mL of
warm water in a sitting position, and the frequency of swallow and Participant characteristics
choking cough when subjects were drinking water were observed,
with level 1 indicating a normative swallowing function and level 5 In total, 82 participants were randomized into 3 groups, as pre-
indicating the worst swallowing function. The SSA consisted of 3 viously described. The traditional swallowing therapy group was
sections. The first section included the level of responsiveness, trunk comprised of 17 men and 10 women, with a mean age of 62.68.7
and head control, lip closure, breathing, sound intensity, pharyngeal years and disease duration of 21.34.1 days. The sensory
reflex, and voluntary cough and was scored in the range 8 to 23 approach combined with traditional swallowing therapy group
points. The second section assessed salivary management, laryngeal was comprised of 16 men and 12 women, with a mean age of
movement, repetitive swallowing, choking, and stridor and vocal 61.37.1 years and disease duration of 22.14.0 days. The motor
quality, with subjects swallowing 5mL of water 3 times (score range, approach combined with traditional swallowing therapy group
5e11 points). If all items of the first 2 sections were achieved, the was comprised of 19 men and 8 women, with a mean age of
third section was undertaken, with the subject swallowing 60mL of 62.29.2 years and disease duration of 20.64.3 days. There were
water (score range, 5e12 points). The total score for the SSA is in no statistically significant differences between the 3 groups in age,
the range of 18 to 46 points, with higher scores indicating worse sex, duration, MMSE score, or severity of the swallowing disorder
swallowing function. The Functional Oral Intake Scale (FOIS)42 was in the baseline evaluation (P>.05) (table 2).
used to evaluate oral intake. It used an ordinal series of 7 swallowing
function levels that ranged from no oral intake (level 1) to total oral Treatment effects
intake with no restriction (level 7).
In addition, the Swallowing-Related Quality of Life (SWAL- Table 3 and figure 3 present the descriptive statistics for pre- and
QOL)43,44 Scale was used to assess the participants’ quality of life. posttreatment results of the WST, SSA, FOIS, and SWAL-QOL
This is a 44-item tool constructed for use in clinical research for Scale. The effect data (posttreatment data minus pretreatment
patients with oropharyngeal dysphagia that assesses 11 aspects of data) showed statistically significant positive treatment effects for
quality of life, including burden, eating duration, eating desire, all 3 groups (P.01).
symptom frequency, food selection, communication, fear, mental There were significant differences between the 3 groups in the
health, social, fatigue, and sleep. Each scale was constructed using size of treatment effect (P<.05). Table 4 shows the sensory
a Likert method of summated ratings, weighting each item equally approach combined with traditional swallowing therapy group had
a significantly greater improvement in swallowing function than
Table 1 Water swallow test the other 2 groups, and the motor approach combined with
traditional swallowing therapy group improved more significantly
Score Performance Deficit than the traditional swallowing therapy group (P<.05).
1 Can swallow the water smoothly, once in 5s Normative
2 Can swallow without cough, twice Minimal Quality of life
3 Can swallow once, but with cough Mild
4 Swallow more than twice, with cough Severe The SWAL-QOL Scale scores increased to a significantly greater
5 Cough frequently, cannot swallow Profound extent in the sensory approach combined with traditional swal-
lowing therapy and motor approach combined with traditional
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Treatment of dysphasia 359
swallowing therapy groups than those in the traditional swallow- thyrohyoid muscle. Freed et al22 considered the electrical stimu-
ing therapy group; simultaneously, the difference between the lation to be an effective and safe treatment for poststroke
sensory approach combined with traditional swallowing therapy dysphagia that improves swallowing function better than tradi-
and motor approach combined with traditional swallowing therapy tional thermal-tactile stimulation treatment. Kushner19 suggested
groups was also statistically significant (PZ.04). that supplementing traditional dysphagia therapy and progressive
resistance training with NMES during inpatient rehabilitation was
Safety significantly more effective than those 2 therapies alone in
reducing feeding tube-dependent dysphagia in patients who have
In this study, no significant side effects were observed, including had an acute stroke.19
skin burns, laryngeal muscle spasms, bradycardia, or sharp fluc- The present study suggests that NMES added to traditional
tuations in blood pressure. Only a few patients (3 in the sensory therapy is more effective than traditional therapy alone in treating
approach combined with traditional swallowing therapy group and patients with dysphagia with lower brainstem infarction. It also
4 in the motor approach combined with traditional swallowing indicates that it is more effective to target NMES at the sensory
therapy group) experienced local skin redness or allergic reaction input rather than at the motor muscles. Possible explanations for
in the electrode placement area; this disappeared soon after the the efficacy of NMES observed in this study may be as follows.
cessation of the electrical stimulation, and no one dropped out First, the sensory approach may increase the local sensory input to
because of the skin reaction. We observed that as their swallowing the central nervous system via the CPG to induce the action of
function recovered, the target stimulus current decreased gradually swallowing, therefore eliciting both sensory and motor effects, and
in some patients. the sensory stimulation may have a long-term effect in reorgani-
zation of the human cortex, resulting in the enhancement of brain
plasticity/recovery in swallowing control.29-31 Second, it is known
that even a few days without normative daily swallowing can
Discussion result in disuse atrophy of the oropharyngeal muscles; the motor
NMES is a noninvasive intervention technology for the manage- approach may elicit local muscle contractions, which may
ment of swallowing disorders. Recently, it has been widely improve and enhance laryngeal elevation22,27 and protect the
applied in the clinical setting and shown to be effective in treating muscles from atrophy.28
dysphagia in poststroke patients. A meta-analysis concluded that Swallowing is composed of highly complex sensorimotor
the electrical stimulation may improve swallowing function.45 neuronal components and is programmed by the CPG in the
Leelamanit et al24 reported that the electrical stimulation can brainstem.46-49 During swallowing, the sensory inputs arising
improve dysphagia by increasing synchronous contraction of the from the posterior oral, pharyngeal, and some laryngeal mucosae
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360 M. Zhang et al
Fig 3 Assessment of pre- and posttreatment. Abbreviations: MAþTT, motor approach combined with traditional swallowing therapy; SAþTT,
sensory approach combined with traditional swallowing therapy; TT, traditional swallowing therapy.
are transmitted to the medullary nucleus tractus solitarius and sensory approach, therefore, seems to be the most effective
nucleus ambiguus, with reticular formation linking synaptically to approach to adopt.
the cranial motor neuron pools bilaterally.46-48 However, many
researchers have found that a complex array of cortical repre-
Study limitations
sentations, including the frontal operculum, sensorimotor cortices,
cingulate, premotor cortex, parietal cortex, insular, basal ganglia, The absence of a sham group without any treatment could be
thalamus, and cerebellum, also play an important role in swal- considered a significant limitation of this study. Studies involving
lowing control.49-53 The sensory approach for dysphagia in stroke a larger number of participants are needed, and the long-term
targets the enhancement of sensory feedback from the oropharynx curative effects warrant further investigation.
to the CPG, and the motor approach targets the strengthening of
the oropharyngeal musculature. The efficacy of the sensory
approach observed in this study may also be explained by its ef- Conclusions
fects on stimulating brain plasticity/recovery in swallow-
ing control. NMES that targets either the sensory input or motor muscles,
This study also demonstrated that NMES could not only combined with traditional therapy, is conducive to recovery from
improve the swallowing function but also increase the quality of dysphagia and improves quality of life for patients with dysphagia
life in these patients. Dysphagia affects the most basic of human with medullary infarction. The sensory approach appears to be
functions, the ability to eat and drink. The SWAL-QOL Scale was more effective than the motor approach.
constructed for use in clinical research for patients with oropha-
ryngeal dysphagia.43 The quality of life improved to a signifi-
cantly greater extent in the sensory approach combined with Suppliers
traditional swallowing therapy group than in the motor approach
combined with traditional swallowing therapy and traditional a. vocaSTIM-Master; Physiomed Elektromedizin.
swallowing therapy groups. Traditional therapy combined with the b. WOND2000F; Guangzhou TopMedi Co. Ltd.
c. SPSS software version 22.0 for Windows; IBM.
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Treatment of dysphasia 361
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