NMES Helps Parkinson’s Patient with Swallowing, Speech, and Respiratory Coordination
A patient with advanced Parkinson’s disease finally made it to rehab. He arrived at my office with a wet towel that he was using to wipe saliva which was constantly being lost. We immediately began VitalStim along with 3 times a week of pharyngeal therapy. Within just an hour, a swallow of saliva was seen. In the first week, more and more swallowing of saliva was observed. By the end of the third week, saliva swallowing was almost at 100% (although swallowing was not perfect) and water-drinking and eating of soft foods were greatly and continuously improving. At the same time, his speech and respiratory coordination improved. At that time, he told me “you have added life to my days and days to my life”. -Deb Bastidas, SLP, Texas,
Deborah Bastidas & Associates website and Facebook page
Strong Progress Seen in Pediatric Patient Using NMES for Dysphagia Therapy
In Austin, Texas, Dell Children’s Hospital referred a 4-year 4-month-old female patient to RiverKids Pediatric Home Health. She presented with severe oropharyngeal dysphagia, NPO status, and with a gastrointestinal tube. She has had respiratory and pulmonary complications since birth. Her birth was premature, as she was a product of twin birth. She had a trach and is now off the vent but is still predominantly G-tube-fed. She showed increased oral-sensory aversion. The patient was diagnosed by an MBSS with significant swallowing disorder.
Within the first six months of treatment, she had 48 speech therapy sessions, including NMES (neuromuscular electrical stimulation).
Since therapy began, there has been an improvement in the timing of the swallow, better management of secretions, and a reduced need for suction. She is safely accepting pureed and dissolvable solids and soft mashed foods. With liquids, she has ranged from honey to nectar consistencies and now is safely accepting thin liquids via a straw and an open cup as shown with her latest MBSS. She is increasing her mastication skills with new soft solid foods.
It’s amazing to see how far she has come over the last two years from NPO and completely refusatory when touched in and around the oral area to now eating flavored cereal with milk and gumming/munching soft fruits, including blueberries, blackberries, and strawberries. She is also drinking a variety of thin liquids from an open and straw cup! Great success and strong progress!
RiverKids Pediatric Home Health, Allison Edwards, M.S., CCC-SLP, Austin Branch
Website: www.RiverKidsTexas.com Facebook: RiverKidsTexas
Success Using NMES with OHTAHARA SYNDROME
Ohtahara Syndrome is a rare form of epilepsy, often referred to as “early infantile encephalopathy”, which starts in infancy. A child diagnosed with Ohtahara Syndrome will experience seizures and may also have severe developmental problems, however, a child with the syndrome may appear to be healthy at birth through three months of age. The characteristic of Ohtahara Syndrome begins with sudden jerky movements at around three months of age and may include a variety of seizures, not necessarily all together but individually, and can be Generalized Tonic-Clonic Seizures, Focal Seizures, Infantile Spasms, and Myoclonic Seizures.
The Speech Pathologist from a local School District in the Seattle area approached me and has a possible individual willing to try some neuro re-education for swallowing. The student was 11 years old, had a floppy body, and could not hold herself up. She also had a trach and ventilator for breathing. She had an augmentative-assisted communication device that she used to communicate. The only control that the student had to activate the device was the lower right lip and she was able to localize and maintain eye contact with individuals.
Speaking with the mother, she would like to have her daughter eat. The child’s mother wanted her child to be able to eat rather than being fed by a peg tube using a Ketogenic diet. Instead of using the traditional supplement for nutrition for peg tube feeders, her mother had previously worked with a nutritionist to create a diet and make all her daughter’s meals utilizing food-balanced vitamins and minerals that were then fed through the peg tube for nourishment. The trach care and peg site had pristine care and were in optimal condition.
I was asked if I would use advanced techniques to improve the swallow and the parents agreed that VitalStim would be used once a week for an hour. We set up a time and day usually in the late afternoon.
Set up:
- VitalStim developed by Marcie Freed was used. However, instead of two channels, 4 channels with electrodes were placed on the face and neck in a strategic location. The positions used were:
- 4a for addressing the anterior spillage and leakage, premature spillage and residuals, pocketing holding food, stasis, and nasal regurgitation bilaterally. The rationale for using this position is to stimulate extrinsic, some intrinsic tongue muscles, and the suprahyoid muscle activating the laryngeal elevation (VitalStim training manual page 75).
- 3a for addressing penetration, aspiration, piecemeal deglutition, residuals, and decreased pharyngeal transit timing. The rationale for using the 3a position is to elicit contractions of the mylohyoid, digastric, and thyrohyoid muscles. With intensity, the deeper penetration reaches the hyoglossus and possibly some fibers of the upper and middle pharyngeal constrictors (page 72).
- On alternate weeks, the placements used were 4a and 3b. 3b focused on the delayed opening of the UES, decreased opening of the Upper Esophageal Sphincter (UES), CP bar, premature closure of the UES, penetration, aspiration, and pyriform pooling with residuals (page 74).
- No food or liquids were tried during treatment but active swallowing during the treatment was encouraged.
3. Length of treatment 60 minutes
4. Milliamps (mA) used: 7-16 mA. It started at the lower end of the mA intensity and worked up in intensity for an hour. The minimal amount of time at the lower intensity was up to 12 minutes and the higher intensity was longer for maximum benefit. As a result of this work, the young lady’s lower lip became strong, and adjustments had to be made for accessing the AAC device. She would often overshoot her desired word. No seizure activity was noted during treatment time. The young student tolerated the treatment without any adverse effects.
Results: This treatment lasted for 7 months and was treated once a week. The facial muscles improved and the muscles for swallowing improved as well. The young student was not able to do a Modified Barium Swallow Study (MBSS) due to her medical condition. Instead, the Fiberoptic Endoscopic Evaluation of Swallowing (FEES) technique was used to assess the young girl’s swallow. The outcome was she was able to protect her airway without difficulty. Given that when one does an MBS or a FEES, proceed with caution because each test is a moment in time. She was able to pass the FEES without any questions that she was protecting her airway well and no noted aspiration was present. The case was turned over to the school district for follow-up.
Sherrie Cooper, MS CCC-SLP, Sultan School District, Washington