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Point/Counterpoint: Electrical Stimulation for Dysphagia:

The Argument Against Electrical Stimulation for Dysphagia
Ianessa A. Humbert
Department of Physical Medicine and Rehabilitation, Johns Hopkins University
Baltimore, MD

Abstract
Surface electrical stimulation for dysphagia is still a controversial subject. Some studies
tout the benefits of using electrical stimulation (e-stim) for improving a disordered
swallow. It is important to ensure that the discussion about e-stim is balanced. In this
article, I discuss selected counterpoints, including e-stims intended use, the objective
findings of scientific findings, and whether speech-language pathology training in the
area of swallowing anatomy and physiology adequately prepares clinicians to use e-stim
for dysphagia. Overall, clinicians are urged to take into account all sides of this debate
and make educated decisions about whether it should be a part of their clinical practice.
In this article, I will discuss three points that support the argument against the use of
electrical stimulation (e-stim) for dysphagia:

Point 1: The intended clinical use of e-stim for swallowing is not clear.

Point 2: Objective, scientific findings do not support e-stims marketed outcomes.

Point 3: Speech-language pathologists (SLP) training in swallowing is insufficient for

most physiologically based treatments for dysphagia.

Unclear Clinical Use of E-Stim

What is the intended use of e-stim for dysphagia? Can anyone clearly summarize it?
There are many vague hypotheses, such as to improve swallowing, or to increase oral intake
of food, or because nothing else worked, and we were desperate.
The problem is that e-stim for swallowing (like compensatory strategies) should serve a
specific purpose. For example, many patients aspirate on thin liquids because of delayed onset
of the pharyngeal swallow response. When a clinician recommends replacing thin liquids with
thickened liquids for such a patient, the expected outcome (reduced aspiration) and rationale
(thickened liquids move more slowly, thereby minimizing the negative effects of a delayed
response to the bolus) are fairly well known and logical.
Now, lets consider this same patient diagnosis (delayed onset of the pharyngeal swallow
resulting in aspiration on thin liquids) with respect to e-stim. Under what circumstances would
you decide that e-stim is appropriate? What stimulation intensity would be appropriate? What
electrode array would be most likely to succeed? Should the patient actively swallow during
this time or engage in non-swallowing, if any, activities? What about patient selection; is e-stim
likely to be more useful for individuals with particular diagnoses? To answer any of these
questions, one first has to determine the physiological cause of the diagnosis. In other words,

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why is the patients pharyngeal phase so delayed? This is a question that is not completely
understood by swallowing experts. So, when there is uncertainty about the cause of the
diagnosis, why should a clinician apply electrical stimulation (an additional unknown entity) to
the equation without first pursuing some logical thought process about its intended use and
identifying a clear rationale for why it should be successful?
What is the marketed intended use of e-stim by VitalStim? Currently, the most
commonly used device for delivering e-stim in a clinical setting is VitalStim. The
manufacturers website includes a description of e-stims intended use:
The VitalStim Therapy System is an adjunctive modality to traditional exercise that
unites the power of electrical stimulation with the benefits of swallowing exercises.
Combining VitalStim and traditional therapy allows clinicians to accelerate
strengthening, restore function, and help the brain remap the swallow. Research has
demonstrated that combining these therapies results in better outcomes than using
either one alone. (VitalStim Dysphagia, 2011)
These strong claims give rise to many questions. What exactly is the power of e-stim?
How does the brain remap a swallow? Though some studies have reported that e-stim is
beneficial, others show that it is either not beneficial or produces outcomes no different from
those produced by traditional swallowing treatment alone (discussed further below). Also,
studies that report cortical mapping after e-stim involve highly technical methodologies (neural
stimulation and imaging) after direct stimulation of the pharyngeal mucosa in patients
(Jayasekeran et al., 2010). On the other hand, Gallas, Marie, Leroi, and Verin (2010) found no
differences in cortical mapping in patients after submental electrical stimulation.
What is the intended use of electrical stimulation (e-stim) in other fields? E-stim is
widely used and accepted in the field of physical therapy. In fact, the Federation of State
Boards of Physical Therapy (FSBPT), which develops and administers the National Physical
Therapy Examination, includes content on the use of e-stim for physical therapy as part of the
exams Therapeutic Modalities section (FSBPT, 2007, 2010). Its intended use in physical
therapy is broadly defined and includes pain management (Fuentes, Armijo Olivo, Magee, &
Gross, 2010), improving function after spinal injury (Gater, Dolbow, Tsui, & Gorgey, 2011),
avoiding atrophy after paralysis (Gater et al., 2011; Needham, Truong, & Fan, 2009), and
improving strength (Monaghan, Caulfield, & OMathuna, 2010). Despite extensive published
research on e-stim for these purposes, meta-analyses and systematic reviews (that combine the
results of several studies to draw one larger conclusion about a treatment) report inconsistent
evidence of the benefits of e-stim for pain, strengthening, or post-stroke hemiparesis (Ada,
Dorsch, & Canning, 2006; Bax, Staes, & Verhagen, 2005; Fuentes et al., 2010; Glanz,
Klawansky, Stason, Berkey, & Chalmers, 1996; Mello, Nobrega, & Lemos, 2011; Scianni,
Butler, Ada, & Teixeira-Salmela, 2009). Of course, e-stim is not the only widely used treatment
in any particular field that does not have strong scientific evidence to support its use. This
treatment conundrum probably exists in all clinical fields. However, the difference between a
PTs use of e-stim and an SLPs use of e-stim, at this time, appears to be reflected in the
professionals time, clinical experience, educational preparation, and clear goals for its
intended use based on a thorough understanding of the complex system being treated (more
about SLP preparation in Point 3 below).
It is critical that the clinician establish the goals of applying e-stim before using it. One
requires a clear dysphagia diagnosis, an understanding of the cause for the pathology, and a
working knowledge of e-stims ability to reduce the pathology, along with the expected clinical
outcomes. Actually, this should be the case when the clinician considers any dysphagia
treatment. At this time, e-stim is being marketed to clinicians and patients with strong claims
of its benefits. In another rehabilitation discipline, physical therapy, e-stim is considered to be
a standard treatment modality; numerous scientific studies have been carried out on the topic,
yet conflicting evidence of its outcomes remains. The fields of both speech-language pathology
and physical therapy will continue to advance their scientific and clinical pursuits for answers

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about e-stim as a treatment. Though published evidence related to e-stim use has not been
conclusive, clinicians will continue to use e-stim for dysphagia; therefore, they are cautioned to
do so thoughtfully.

Lack of Evidence-Based Support

The second point I want to make is that objective, scientific findings do not support estims marketed outcomes.
The VitalStim company reports that e-stim will accelerate strengthening, restore
function, and help the brain remap the swallow (VitalStim Dysphagia, 2011). E-stim for
dysphagia has been an intriguing and controversial subject ever since it was first advertised for
dysphagia treatment. However, the excitement surrounding the potential of a new treatment
should not overshadow the importance of learning about both sides of the argument, which
includes benefits as well as risks.
To date, the studies that have been published on the effects of e-stim on swallowing
have been conducted in healthy individuals and individuals with dysphagia over both shortand long-term periods. Short-term studies in healthy individuals and adults with dysphagia
typically examine the immediate physiological effects of e-stim on the neck and/or the
submental region. In summary, short-term physiological studies in healthy individuals and
patients report hyo-laryngeal descent when stimulation induces muscle contractions in the
anterior neck. Also, when swallowing with concurrent stimulation that causes a muscle
contraction, healthy adults and patients had significantly reduced hyo-laryngeal elevation
(Humbert et al., 2006; Ludlow et al., 2007). The clinician who does not understand why hyolaryngeal descent occurs needs to seek out more information about the principles of surface estim and about swallowing anatomy and physiology. This finding directly contradicts the
information in the VitalStim training manual, which states that significant laryngeal elevation
is expected within the first e-stim session in patients (Wijting & Freed, 2003).
The online, marketed information also lists benefits reported in long-term studies,
including that e-stim is safe and effective for patients (Carnaby-Mann & Crary, 2007);
accelerates the recovery time from a restricted diet (Blumenfeld, Hahn, Lepage, Leonard, &
Belafsky, 2006); and helps patients achieve sustained improvement and long-term results,
even when traditional therapy alone has not been effective. However, other studies do not
report the same benefits (Bulow, Speyer, Baijens, Woisard, & Ekberg, 2008; Freed, Freed,
Chatburn, & Christian, 2001; Kiger, Brown, & Watkins, 2006). Many studies are limited by a
small sample size (< 40 patients) and/or the presence of heterogeneous etiologies of dysphagia,
lack of a control or comparison group, and a focus on functional measures as the primary
outcome. Functional measures (oral intake, weight gain) are important indicators of success.
However, they cannot be directly tied to e-stim as the cause for such changes, unless
physiological measures (i.e., timing and range of motion of the structures involved in
swallowing) are considered alongside functional gains. After all, physiology is responsible for
bolus flow.
For instance, a study that compares two treatments (Treatment A and Treatment B) at
two time points (1 week and 8 weeks post-stroke) might show that, at 1 week, all patients are
on a restricted diet or nil per os (NPO). This outcome is functional (diet). If, after 8 weeks of
treatment, one patient group has a diet that is significantly improved and the others has not
changed much, then one might conclude that the treatment with the most significant
improvement in oral intake is superior. But, suppose the physiological changes between the
two groups are identical, meaning that neither treatment affected the disordered physiology
(i.e., laryngeal movement, delayed swallow)? What explains this change in oral intake? Because
rehabilitative swallowing treatments, such as e-stim, are expected to improve swallowing
physiology and, thus, improve bolus flow, the physiological effects must be measured before
one can claim strong benefits have been achieved. In addition, diet changes are subjective

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measures and, therefore, difficult to standardize. Therefore, researchers should be cautious in

drawing conclusions of improvement based on their e-stim studies, unless those studies
include (a) an appropriate control group, (b) an objective physiological measure that can
explain the more subjective outcome measures such as oral intake, and (c) explicitly stated
means for minimizing investigator biases by ensuring that subjective decisions (recommending
a less restrictive diet) are reached without the researchers knowledge of the patients treatment
groups. In an evidence-based systematic review of e-stim for swallowing, Clark, Lazarus,
Arvedson, Schooling, and Frymark concluded that 10 of the 14 studies on this topic were
exploratory, with significant methodological flaws, and that more high-quality studies are
needed before firm conclusions can be made (Clark et al., 2009).
New dysphagia treatments offer clinicians and clients hope that the complexities of the
pharyngeal phase of swallowing can be addressed and impairments remedied. Because
improving a patients swallowing ability is an urgent goal, clinicians usually recommend
compensatory techniques (bolus change, postural adjustments) or rehabilitation options that
have emerged into clinical practice ahead of supportive, empirical evidence. This is because the
scientific process often moves more slowly than the influx of patients with conditions that lead
to dysphagia with immediate needs. So, it is not surprising that treatments are applied though
scientific evidence is unsupportive or conflicting. As mentioned before, speech-language
pathology is not the only field with such a dilemma. Nonetheless, the onus is upon each
clinician who uses e-stim to determine both the benefits and risks before administering it to
patients.

Insufficient Training in Physiology

The third point I will discuss is that SLP training in swallowing is insufficient for most
physiologically based treatments for dysphagia.
The training and education for SLPs who want to focus on swallowing and swallowing
disorders as part of a medical model is limited, even though it is within the scope of the SLPs
practice. The curriculum for speech-language pathology requires high linguistic content to
prepare graduates to practice in educational settings (articulation and phonology, aural
rehabilitation, child language and development, literacy, language and learning). There is some
content on the sensory-motor based systems (fluency and fluency disorders, voice and voice
disorders, swallowing and swallowing disorders), although these might not be taught strictly
from a medical perspective. Taken together, these required topics are broad, and many do not
directly facilitate learning about swallowing. Furthermore, the required neurophysiology and
anatomy and physiology courses, some at the undergraduate level, focus on speech, language,
and hearing systems and rarely delve into swallowing physiology.
Recently, the American Speech-Language-Hearing Association (ASHA) outlined
requirements for dysphagia content for the graduate curriculum (2007). However, this does not
affect SLPs who have been practicing for many yearsour most seasoned clinicians. The 2005
Omnibus survey reported that approximately 87% of respondents self-identified as primary
care providers of dysphagia services (ASHA, 2005).
The anatomy in the neck is complex and the swallowing sensorimotor system
(particularly its neurophysiology) is not thoroughly understood. Muscles in the neck and face
are small, interdigitated, in close proximity to one another or superimposed upon one another,
and may serve different functions depending upon the task. Surface e-stim activates all tissues
that can be stimulated in its electrical current and, thus, lacks specificity. This is particularly
challenging for stimulating muscles of the anterior neck and submental regions, because a
nonspecific electrical field can activate so many diversely functioning muscles (although
research, to date, points to one primary outcome: hyo-laryngeal descent). In other words, when
stimulating muscles on the neck, clinicians should be aware that they could be stimulating
many different muscles, because the electrical current is likely larger than any single

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superficial muscle in the neck. Before any clinical use of e-stim is initiated, it is imperative that
clinicians have a solid understanding of normal swallowing anatomy and physiology.
The limited training in swallowing can be a potential constraint for even the accepted
swallowing treatments or compensatory mechanisms. For instance, the clinician must
understand the structural changes in the upper-aerodigestive tract caused by a head turn to
the right or to the left before he/she chooses this technique. Studies show that a sour bolus
and biofeedback can change swallowing kinematics (Ding, Logemann, Larson, & Rademaker,
2003) and are also associated with different cortical patterns of activity during swallowing
(Humbert & Joel, 2011). There are abundant continuing education opportunities for clinicians
who are interested in increasing their knowledge of swallowing physiology, neurophysiology,
and electrical stimulation. However, much of what has been published, even if read and
thoroughly understood, does not answer many of the critical questions (discussed in Point 1,
above) about e-stim for swallowing. Therefore, given the limited professional training on
swallowing, clinicians limited understanding of the principles of e-stim, and limited scientific
evidence about e-stims physiological outcomes in patients, widespread, liberal use of e-stim in
a clinical setting is contraindicated. One would not recommend a chin tuck to every dysphagia
patient without considering whether it is appropriate. The choice of e-stim should be made
with even greater caution because it is more complex than many compensatory strategies;
because e-stim has the potential to alter function (for better or for worse), the clinician should
possess substantial knowledge about swallowing physiology to avoid potential negative
outcomes (i.e., hyo-laryngeal descent).

Summary
E-stim for swallowing is a controversial topic. Studies show that it has the potential to
immediately alter swallowing physiology, although the outcomes were not positive. Many longterm, therapeutic studies in patients have not been carried out in a scientifically rigorous
manner, thereby limiting researchers ability to draw conclusions of beneficial outcomes for
swallowing. Although e-stim for swallowing has many studies dedicated to it, its intended use
is largely undefined in the clinical and scientific realms. Some continue to make general claims
about its ability to improve swallowing. All of these circumstances likely exist because of
limited understanding about swallowing in both the scientific literature and clinical practice.
Swallowing is a complex function, is more challenging to study compared to the limbs, and has
been steadily gaining attention only in recent decades. The principles of e-stim are to be
reconsidered when applying it to the neck versus the quadriceps because swallowing muscles
are small and multifunctional. Therefore, clinicians are cautioned about the marketing of estims benefits in isolation. Take into account all sides of this debate and make an educated
decision about whether it should be a part of your clinical practice.

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