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Using Modalities in the

Treatment of Dysphagia

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As an AOTA and ASHA Approved Provider CIAO is required to inform you of the parameters of this course. Using Modalities in the Treatment of Dysphagia, is an introductory orientation to the Experia equipment only. Completion of this course will not grant competency to use the VitalStim or VMS portion of the Experia unit. In accordance with guidelines

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boards’ professional conduct, use of any triggered electrical stimulation or waveform, including the VitalStim or VMS portion of the Experia device, requires competency through successful completion of the VitalStim Certification Course by CIAO Seminars. CIAO is required to maintain records of competency for ASHA and AOTA. 1ASHA’s Principle of Ethics II-2 and II-5, and Principle of Ethics III-1 2AOTA’s Occupational Therapy Code of Ethics and Ethics Standards Beneficence Principle 1 E, F, G

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Setting up sEMG ** Be sure to put water on the electrodes for sEMG

Select sEMG from home screen Select Edit Select Bar Graph to go to the screen to set-up the parameters Push Target Max to scroll through options of either Target Max, Target Avg, or Target Manual Select Capture Target Push Begin Capture when you are ready for the patient to swallow. Have the patient swallow 3-5 times, and then select End Capture Using the arrows, you may adjust the target up or down. Push the crooked arrow when you have selected the target level you desire for treatment. You may now select Trace View if you prefer that screen. You may now set the number of Swallow Trials. At the end of the session, you may Save to Patient Data Card. This option is given at the completion of the number of swallow trials or by pushing STOP which is located by the dial.

Setting up 2 channels of sEMG ** Be sure to put water on the electrodes for sEMG

Select sEMG from home screen Select Edit Select Bar Graph to go to the screen to set-up the parameters The Experia defaults to Channel 1. Set up as described below. Push Target Max to scroll through options of either Target Max, Target Avg, or Target Manual Select Capture Target Push Begin Capture when you are ready for the patient to swallow. Have the patient swallow 3-5 times, and then select End Capture Using the arrows, you may adjust the intensity up or down. Push the crooked arrow when you have selected the intensity you desire for treatment. Press Channel 1 to scroll through options of either Channel 1, Channel 2, or Channel 1+2. Select Channel 2. The information you set up on channel 1 will not be lost when you switch to this screen. Set up channel 2 as described above. Press the Channel button to scroll to Channel 1+2. Both channels are now displayed. You may now select Trace View if you prefer that screen. Push STOP to end the session. If you Save to Patient Data Card, both channels will be saved together on that card.

Setting up sEMG + Stim ** Be sure to put water on the electrodes for sEMG

Select sEMG + Stim from home screen Select Edit Set up the stim level first. Select Stim VitalStim to select which NMES mode you will use. Press the crooked arrow when the stim you want is highlighted in green. Select Edit Stim. Using the dial, you may now increase the intensity to a therapeutic level. Push the back arrow on the control panel when you have the intensity of stim you want during your session. The stim will turn off at this point. Push Target Max to scroll through options of either Target Max, Target Avg, or Target Manual Select Capture Target Push Begin Capture when you are ready for the patient to swallow. Have the patient swallow 3-5 times, and then select End Capture Using the arrows, you may adjust the target up or down. Push the crooked arrow when you have selected the intensity you desire for treatment. Select Start sEMG+Stim. The stim will only come on when the patient meets or exceeds the target set. The stim is on when the screen says “Contract” Press Stop sEMG+Stim or the STOP button by the dial to end the session. If you press the STOP button you will have the option to save to a patient data card.

Changing the stim parameters on sEMG + Stim ** Be sure to put water on the electrodes for sEMG

Select sEMG + Stim from home screen Select Edit Set up the stim level first. Select Stim VitalStim. Change to VMS and press the crooked arrow to select. Select Edit Stim. You can now change the phase duration, the frequency, the ramp (how quickly the stim reaches the level set), or the cycle time (how long the stim is on). Now increase the intensity with the dial to a therapeutic level. Push Edit sEMG to go back. The stim will turn off at this point. Push Target Max to scroll through options of either Target Max, Target Avg, or Target Manual Select Capture Target Push Begin Capture when you are ready for the patient to swallow. Have the patient swallow 3-5 times and then select End Capture Using the arrows, you may adjust the target up or down. Push the crooked arrow when you have selected the intensity you desire for treatment. Select Start sEMG+Stim. The stim will only come on when the patient meets or exceeds the target set. The stim is on when the screen says “Contract”. Press Stop sEMG+Stim or the STOP button by the dial to end the session. If you press the STOP button you will have the option to save to a patient data card.

Setting up 4 channels of NMES From the home screen, press Select Channel to scroll through the channels. Channel 1 defaults to pair with channel 2; channel 3 pairs with channel 4. Select the NMES (VitalStim, VMS, or High Volt) that you wish to use. If you wish to set up the 2 channels differently, push Set Intensity Both Channels to scroll through options of setting the 1st channel, the 2nd channel, or both channels. Increase the intensity with the dial. Then push the home button. You can see at the bottom of the screen that the stim you just set up continues to run. Then scroll through Select Channel and choose another channel. If you already set up channel 1 and 2 together, scroll to channel 3. Select the NMES that you wish to use. Set up these channels as described above. Then push the home button. You may adjust the intensity level or stop the stim in any channel from the home screen by scrolling through and selecting the channel that you wish to control. Or you can use the remote controls to change/stop any channel.

1

Using modalities in the treatment of dysphagiay p g

Introduction to the Experia

Overview

• Explanation of different e-stim waveforms

• Demonstrate and practice set-up of VitalStim, VMS, and High Volt

• sEMG 101

• Demonstrate and practice set-up of sEMG and sEMG triggered stim

Let’s push some buttons

• Review of basic buttons– On/off– Home, back– Start, stop, pause

• Demonstrate patient education library– Select file folder– Select ‘MMC VitalStim Graphics’– Back or home to return to main screen

E-stim waveforms

Review of the basics…

• A muscle is made of bundles of muscle fibers.

• The fibers are innervated by the peripheral nerves which cause the muscle to contact.

Inside a muscle fiber

• Muscles have both fast twitch and slow twitch fibers.

Fast

Fast

Slow

slow

• Large = type II, fast twitch muscle fibers

• Small = type I, slow twitch

Fast

Fast

Fast

Fast

slow

slow

slow

slow

slow

2

Fast Twitch vs. Slow Twitch

Type ISlow twitch

Type II (a/b)Fast twitch

Contraction speed Slow Fast

Endurance High Medium/Low

Fatigue Slow Medium/Fast

Strength Low High

Function StaticPostural

DynamicExplosive

Type IIa fibers are abundant in the swallowing muscles.

Waveform key definitions

• Phase Duration - the length of time the current flows from one electrode to another (there are 2 phases in a pulse)

• Frequency- number of times the current pulses in a second

• Intensity- the amount of current that is delivered; the depth that the current penetrates is determined by the intensity

What’s the phase duration?• A pulse is the individual electrical event. During a pulse

the current flows back and forth between the two

electrodes.

• The phase duration is the amount time the current travels from one electrode to the other.

Red Black

Differences in phase durationThe larger the muscle fiber, the less

resistance to the current. • Think of a fireman’s hose vs. garden

hose. • The water can flow with less

resistance because it’s wider.

The longer the time the current flows (longer phase duration) the more time ( g p )the current has to impact both small and large fibers.

The shorter the phase duration, the less likely the current is to impact the small fibers.

Example: 300 μs →

100 μs →

+

Different phase durations for different muscle fibers

Neuron Diameter Min phase duration Touch, proprioception Large 100-200 μs Fast twitch motor neuron Large 100-200 μs Slow twitch motor neuron Small 200-300 μs Pin prick, sharp sensation (“ouch”)

Small 200-300 μs

Slow pain (throb, tooth ache, burning pain)

Very small 500 μs

Pop quizNeuron Diameter Min phase duration Touch, proprioception Large 100-200 μs Fast twitch motor neuron Large 100-200 μs Slow twitch motor neuron Small 200-300 μs Pin prick, sharp sensation (“ouch”)

Small 200-300 μs

Slow pain (throb tooth ache Very small 500 μsSlow pain (throb, tooth ache, burning pain)

Very small 500 μs

• If VitalStim is 300 μs, which neurons are responding to the current?

•Which neurons will respond if we change the phase duration to 100 μs? Which neurons won’t?

•How might that be beneficial in dysphagia treatment?

3

What is frequency?

• The number of pulses of current per second (pps) is expressed in Hertz (Hz).

• Different neurons each respond best to a different frequency.

80

80

30

30

q y

• This is their native frequency.

• Fast twitch neurons respond best at 80 Hz

• Slow twitch respond best at 30 Hz

80

80

80

80

30

30

30

30

30

You’re speaking my language!

• The native frequency of neurons is much like a native language.

• A bilingual person will respond to directions in both languages

80

80

30

30

but more easily respond to her native language of English.

• The neurons will respond to the current at both frequencies but more easily respond to their native frequency of either 80 or 30 Hz.

80

80

80

80

30

30

30

30

30

Different frequencies for different fibers

Neuron Diameter Native frequency Touch, proprioception Large 80 Hz and higher Fast twitch motor neuron Large 80 Hz and higher Slow twitch motor neuron Small 30 Hz Pin prick, sharp sensation (“ouch”)

Small 30 Hz ( ouch ) Slow pain (throb, tooth ache, burning pain)

Very small Below 30 Hz

As a rule of thumb, use 80 Hz when targeting swallowing.

Intensity

• Associated with depth of penetration

• Measured in mA

• VitalStim has a maximum intensity of 25 mA

Increasing intensity

Less mA= less depth, fewer fibers contract

Greater mA= more depth, more fibers contract

Now let’s look at the Experia….p

3 NMES Waveforms

4

Good Ol’ VitalStim

• Phase duration = 300 μs• Frequency = 80 Hz• Intensity = 25 mA maximum

• This is the waveform that has been found to be most ff ti d i th li i l t i l b itt d t th FDAeffective during the clinical trials submitted to the FDA.

VitalStim Demonstration/Lab

Make sure that you can do the following:

1. Set up a session of VitalStim

2. Set the intensity on channel 1 higher than on channel 2

3. Set up 4 channels of VitalStim

4. Use the remote controls to change the intensity

Variable Muscle Stim (VMS)

• Same waveform as VitalStim, but the parameters are adjustable

• Phase duration = 100-300 μs

• Frequency = 5-80 Hz (Remember: Set at 80 Hz)

I t it 25 A i• Intensity = 25 mA maximum

100- 300 μs

100- 300 μs

Test yourself

• Which parameter of the waveform would you change for a patient that is experiencing tolerance issues?

• What should the phase duration and frequency be set at to make the stim better tolerated?to make the stim better tolerated?

• What neurons are targeted at 300 μs and 80 Hz?– 100 μs and 80 Hz?

– 300 μs and 30 Hz?

– 100 μs and 30 Hz? (why would you not use this setting?)

VMS Demonstration/Lab

Make sure you can do the following:

1. Set up a session that would be more comfortable to a patient

2. Change the length of the timer

3. Record the session on the patient data card

High Volt

• A very different waveform from VitalStim

• A double spike, monophasic waveform

• Phase duration= 100 μs• Frequency= 5- 80 Hz• Intensity= 500 volts maximum

5

Volts?• Volts are the push behind the current. By increasing the

volts, we may push the current deeper into the body.

• 500v~25mA; Experia unit does not exceed 25mA

• Think of a garden hose… g– If you put your thumb over the nozzle, you generate

more push for cleaning off the sidewalk without turning the water up higher.

Why would I use High Volt?

• The increased push may help penetrate through fibrotic tissue or reach deeper through excessive adipose tissue.

• This may be beneficial for• This may be beneficial for patients after radiation treatment for head and neck cancer.

• This may also be beneficial for bariatric patients.

How is the set up different from VitalStim?

• Choose what intensity to use based on therapeutic signs of a sub-max contraction, not the number displayed on the unit.

• Only 1 channel of High Volt should be used on a patient• Only 1 channel of High Volt should be used on a patient at a time. Limit the time to 20 minutes.

• VMS can be set up on an additional channel to have 2 channels of stim during the session.

High Volt Demonstration/Lab

Make sure that you can do the following:

1. Set up a High Volt session

2. Set up a session with High Volt on channel 1 and VMS on channel 3

Using surface EMG in the treatment of dysphagia

What is surface EMG (sEMG)

• Biofeedback

• Measures muscle activity non-invasively

• Uses surface electrodes placed on the skin overlying a muscle or muscle group

6

Muscle Skin

• Electrodes pick up the electrical activity from muscles (in μV) that is a result of the contraction– Stronger contraction= more

electrical activity– Less of a contraction= less

l t i l ti it

What is it measuring?

Electrodes

Motor Units

electrical activity

• Fibers closest to the skin contribute most to the sEMGsignal

• The farther the signal, the more resistance it encounters

• Adipose tissue and fibrotic tissue dampen the signal

sEMG terms

• Resting level is the baseline electrical activity (microvolts μV) generated when the patient is inactive

• Average output is the average electrical activity generated during a typical swallow

• Exercise target is the level at or above the average output that the patient aims to achieve during the session

For example…

• Resting level= 1μV

• Average output=10 μV

Why would I use sEMG?

• To measure the patient’s muscle activity when swallowing

– Permits objective documentation of effort to reinforce “swallow hard” for strength training

– Objectively measures when patient fatigues for endurance training

– Engages patients with tangible feedback about swallow performance

– Facilitates patient education• SLP can utilize dual channels to give the patient a model to

facilitate feedback

What are the sEMG Limitations?

• Not a reliable measure of strength– Only measures effort of the swallow

– Use a swallow evaluation to assess strength

• Not well suited to specific, individual muscle activity– Measuring effort of the whole swallow system, not

individual muscles

– Use 1 channel of sEMG on a patient (either the suprahyoids or the infrahyoids)

Remember…

• sEMG readings can only be compared within a treatment session but not between treatments – Readings will fluctuate with even slight change in electrode

placement and skin resistance

• Clinician must interpret signal to ensure it is reflective of desired swallowing activity– Example: Not just tongue pumping

– Electrodes are stupid- they don’t know what is a swallow and what is not!

7

How do I set up a sEMG session?

• Clean and moisten skin

• Apply a small drop of water to the electrodes before placingelectrodes before placing

• Apply 1 channel of electrodes over target muscle group; use lead wire with green grounding electrode– Most research has used the suprahyoids

Set up

• Once the electrodes are in place, the resting level should settle around 50 μV or below– If the resting level is too high, check the contact of the

electrodes

• Swallow ~ 3-5 times to establish average output level– Best to use the same bolus trial with these swallows as

what will be used in the tx trials

• Note: the resting level of sEMG activity might decrease in the first 5-10 minutes of treatment; if so, adjust the exercise target so that the average output is the same

Strength vs. Endurance Training

• Endurance training: Time or # of swallows before onset of fatigue. Target set at 100% of average swallow.

• Strength training: Number of swallows that hit the exercise target Target set at 105- 110%+ of averageexercise target. Target set at 105 110%+ of average swallow.

• Like VitalStim, the goal in treatment is NOT the modality– sEMG is part of treatment plan but is not the treatment goal

– Goal should be related to PO intake or saliva management

sEMG Demonstration/Lab

Make sure you can do the following:

1. Set up sEMG session

2 Set up a swallow trials session2. Set up a swallow trials session

3. Set up sEMG on 2 different patients

4. Change target of sEMG mid-session

5. Save to patient data card

What’s sEMG + stim?

• E-stim is delivered to the muscles for 2 seconds when the patient’s swallow reaches the sEMG exercise target set

• The e-stim provides a “boost” to complete the swallow when sufficient effort is produced to reach the target

• Very effective to

– Stimulate initiation of movement

– Improve quality of movement where weakness is key dysfunction

How do I set up sEMG+Stim?

• First set the desired level of e-stim to be delivered

Th th ll d t th• Then measure the swallow and set the exercise target

• Then press ‘start’ to put the 2 together

8

Which patients are best for sEMG?

sEMG Patients

• Neurogenic dysphagia

sEMG+Stim Patients

• Brainstem CVA or anoxic TBI (helps to “b t” ll )– Impairment of

endurance, weakness, or coordination

• Most patients can use sEMG in treatment

“boost” swallow)

• When every swallow counts

sEMG + stim Lab

1. Set up sEMG triggered stim

2. Change amount of time stim is ON for sEMG triggered stim

3. Make the stim more comfortable during sEMG triggered stim

You’re now ready to use your Experia!y p

Questions??

Empi, as the manufacturer of medical devices, does not practice medicine and does not recommend these or any other e-stim techniques for use on a particular patient. The clinician who performs any e-stim procedure is responsible for determining and utilizingprocedure is responsible for determining and utilizing the appropriate techniques for each individual patient. Empi is not responsible for selection of the appropriate technique to be utilized for an individual patient.

Published data

Crary, 1995

• 6 pts with chronic brainstem CVA (5-54 months)

– 61-72 y/o

– All with gastrostomy

– None could manage saliva easily

– All went through rehabilitation

– 2 with myotomy

– All with incomplete, and post-swallow residue

Crary MA. A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia. Winter 1995;10(1):6-18.

9

Crary, 1995

Swallow instructions

– Hold bolus in mouth (motoric rest)

– Swallow bolus while maintaining mouth closure and sustain pharyngeal squeeze

F ll i ll i h l tl th h– Following swallow, inhale gently through nose

– Hum (airway check)

– If wet voice, inhale gently through nose and clear throat while keeping mouth closed

– Reswallow following the exact same sequence

– Repeat cycle until material is completely swallowed or until patient can no longer suppress expectoration

Crary MA. A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia. Winter 1995;10(1):6-18.

• 5 of 6 returned to full PO (modified), and maintained PO 18-22 months post

• # 6 had partial PO– Most complicated medical history

Crary, 1995

p y– Bilateral pharyngeal weakness– Esophago-gastric complaints

• Improvement in the coordination and timing of the swallow response

Crary MA. A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia. Winter 1995;10(1):6-18.

Huckabee, 1999

• 10 pts with chronic brainstem dysphagia (8-84 months)

– 3/10 with prior therapy, all with gastrostomy

– 6/10 with aspiration pneumonia

O t h MBS d di t l• Outcome measures: change on MBS and dietary scale changes

• Twice daily treatment + home use of effortful swallow and Mendelsohn

Huckabee ML, Cannito MP. Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia. Spring 1999;14(2):93-109.

Huckabee, 1999

• Treatment intensity was 10 hours in the clinic and home practice, 15 minutes x3

• Physiologic and dietary changes after 1 week, continued improvement at 6-12 monthsimprovement at 6 12 months

• 8/10 with tube removal by 5 months and normal diet

• None with aspiration pneumonia

Huckabee ML, Cannito MP. Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia. Spring 1999;14(2):93-109.

Leelamanit, 2002

• 23 patients with moderate or severe dysphagia

• sEMG triggered ES to thyrohyoid muscle (High Volt at 60Hz)

• Stim triggered when patient swallowed

• 4 hours daily until improvement noted

• Duration of treatment from 2-4 days or 3-30 days (depending on severity)

Leelamanit V, Limsakul C, Geater A. (2002). Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope. Dec 2002; 112(12), 2204-2210.

Leelamanit, 2002

• Results:– 20/23 patients improved– 6/20 relapsed and improved

with subsequent treatment– No adverse reactions reportedNo adverse reactions reported

Leelamanit V, Limsakul C, Geater A. (2002). Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope. Dec 2002; 112(12), 2204-2210.

10

Crary, 2004

• Retrospective analysis of functional outcome, time in therapy, and cost per unit of functional change in 45 patients– 25 with dysphagia following stroke– 20 with dysphagia following treatment for head/neck y p g g

cancer– All received systematic therapy program

supplemented with surface electromyographic (sEMG) biofeedback

Crary MA, Carnaby Mann GD, Groher ME, Helseth E. Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia. Summer 2004;19(3):160-164.

Crary, 2004

• 87% (39/45) increased functional oral intake of food/liquid– 92% of stroke patients– 80% of head/neck cancer patients

• Stroke group completed more therapy sessions but made more functional progress resulting in lower costs per unit of functional change

Crary MA, Carnaby Mann GD, Groher ME, Helseth E. Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia. Summer 2004;19(3):160-164.

         

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To update your address or phone number, or to obtainyour ASHA Account Number call ACTION CENTERat 1-800-498-2071 between 8:30am and 5:00pm. E.T.

You must provide your ASHA Account Number.ASHA Account Number

Provider Use OnlyComplete only for those participants receiving less

than the maximum number of ASHA CEUs (i.e.,partial credit). Please fill in leading zeros followed by

the number of ASHA CEUs. For example, to indicate aparticipant earned .55 ASHA CEU's (that is, 5 1/2

hours) write 0055.

Revised 8/2011

Completion Date

Submit this form to the Provider at the end of the course if you wish to earn and maintainASHA CEUs through the ASHA CE Registry (annual fee required).

If not an ASHA member or CCC holder, you must be licensed or credentialed to practicespeech-language pathology (SLP) or audiology or preparing to practice to earn ASHA CEUs.

Licensed: _______________________________________________________

Certified: _______________________________________________________

Clinical Fellow: __________________________________________________

Enrolled in a graduateprogram in SLP or audiology: _______________________________________

(University name and expected graduation date)

(Supervisor name and her/his ASHA account number)

(State/Organization and #)

(State and License #)

62046