The Bridge Neurological Centre, part of Elysium Neurological, has begun a trial of neuromuscular electrical stimulation for a resident with dysphagia following a family request and numerous investigations on its suitability. The innovative treatment has previously been trialled in UK hospitals with promising results but this is one of the first uses in a residential setting as part of a comprehensive speech and language rehabilitation programme.
In this EveryExpert article we speak with Mira Bou Akar, Lead Speech and Language Therapist at The Bridge Neurological Care Centre, in Middlesbrough, who has been leading the introduction of this ground breaking treatment. Mira talks us through how neuromuscular electrical stimulation is being used with Ampcare ESP, what initial progress has been seen and what this may mean for dysphagia treatment in the future.
Traditional dysphagia treatment
Dysphagia, the difficulty moving material from the mouth to the stomach, also known as swallowing difficulties, can occur post-stroke, cancer, dementia or progressive neurological disease due to anatomical, physiological and neurological impairments. This is a painful condition, and in some complex cases swallowing is impossible, so there is significant negative impact on physical and mental wellbeing, both for the individuals suffering from dysphagia and their families.
Therapeutic care for dysphagia has previously focused on management of symptoms, and rehabilitation of swallow function, with very few alternative treatment innovations yielding positive outcomes for patients. However, in response to the call from NICE 2014 for more robust research in this area, and the issue of the NICE 2018 guidelines, the use of neuromuscular electrical stimulation (NMES) in the treatment of dysphagia is growing in research interest, clinical trials and clinical practice. Within the UK, clinicians from Sheffield Teaching Hospitals NHS Foundation Trust (2019) led a clinical study testing the efficacy of NMES using the Ampcare Effective Swallowing Programme (Ampcare ESP).
In the study, (Martindale N, Stephenson J, Pownall S. (2019)) patients who experienced dysphagia with reduced laryngeal elevation completed a therapy program using NMES. Although further research is needed, the findings suggested that NMES was successful in reducing impairment in a subset of patients with dysphagia resulting from stroke and non-stroke aetiology.
NMES at The Bridge
Although the growing interest into the use of NMES means that it has become more common place within acute setting clinical practice, it is still not yet widely used within residential rehabilitation settings. There are varied reasons for this, such as lack of awareness, training and/or resources. Mira Bou Akar explains the remarkable way that NMES came to be trialled in a rehabilitation programme for the first time at The Bridge Neurological Care Centre.
Mira explains: “Ampcare ESP was initially suggested by the family of one of our residents who has a complex aetiology and has had dysphagia for at least five years. When this individual arrived at The Bridge he began a comprehensive dysphagia programme with regular sessions, trialling different approaches and we worked closely with the family to understand his history and what might work best for him.
“It was very important for us to work with the family, and gather extensive medical history from previous placements because there were many different factors to consider with this particular individual. For example, he has a history of cancer and radiation treatment, he also experienced a stroke and didn’t use his muscles for swallowing for certain periods so functionality was lost. Plus, he has been on limited rehabilitation programmes at other services with no functional improvement for his swallow. We needed a bespoke solution for him and regularly explored other therapeutic approaches, as part of those discussions, the family suggested the possibility of Ampcare.
“There’s still a lot of research and audits needed on NMES to see how beneficial it is for different aetiology and patients especially in complex rehabilitation settings, and we, of course, must follow the national guidelines, but it is a therapy that shows great promise so I wanted to trial it.”
Ampcare Effective Swallowing Programme
Ampcare ESP was developed in the United States by a team of expert physiotherapists and speech and language therapists. It’s non-invasive and combines electrical stimulation parameters with resistive exercises. The programme uses a dual-channel electrotherapy system with a pair of electrodes, placed submentally in order to stimulate the supralaryngeal muscles and/or with a facial placement to address oral deficits. Electrical stimulation is used in combination with simultaneous oral and/or laryngeal exercises, with the intended outcome of improved quality of muscle contraction and swallowing function. Mira Bou Akar undertook specialist training to be able to use Ampcare ESP as part of a rehabilitation programme and explains what that process was like.
Mira says: “We wanted to trial the treatment as soon as possible so we chose the training that would enable that to happening – an online course with different modules, each one concludes with an exam and then certification, followed by a virtual meeting with Ampcare ESP US team. It’s a comprehensive course, you of course need to understand the product and how it works, you need to know your anatomy and where to place the electrodes.
“Most importantly you need to know the reasoning behind what you’re doing so you can know how to amend the exercises and adjust it. It doesn’t suit all patients so you need to be able to personal the process and understand possible contraindications and how to best use it for the individuals you are treating.”
Individually tailored sessions
At the time of talking with EveryExpert, Mira had successfully completed five therapy sessions with Ampcare ESP. She explains how each session is a combination of NMES and traditional speech and language exercises according to the individual’s ability.
Mira explains: “Ampcare ESP are 30 minute sessions of stimulation, and within that there are on and off times. During the ‘on’ times we use the machine to electrically target and stimulate the muscles. We started with submental placement of the electrodes initially and then introduced the facial placement as Ampcare ESP was well tolerated by the patient. Electrode placements and wiring were decided based upon our speech therapy assessments, with careful consideration of which side or muscles were weaker/stronger, and our therapy goals.
“During the ‘off’ times, the muscles have a break from the electrical stimulation, but I still try to stimulate the patient’s swallow. This is tailored to the individual and their swallowing abilities and safety levels. Sometimes we use tasters to help with the swallows, to increase saliva production.
“So the sessions are a combination between the stimulation of the device and speech and language exercises according to the patient’s needs – and we adjust this according to the individual’s responses, tolerance and results obtained. The sessions were also scheduled around the patient’s needs, preferences, any visits/outings that he had planned and took into consideration his fatigue levels, other care or therapeutic interventions and the best times for optimal engagement.
“A well-tailored exercise program was also formulated to complement the Ampcare therapy that the patient completes on his own, or with his family or other team members.”
Collecting therapy data
Mira and the Speech and Language service at The Bridge are one of the first services in the UK to be trialling Ampcare ESP and are collecting data from their therapy sessions. Mira has liaised with Sue Pownall and members of her team at Sheffield Teaching Hospitals NHS Foundation Trust who led their clinical trials and has been at the forefront of NMES research in the UK. Mira explains why it is important to collect data from her work.
Mira says: “Research about Ampcare ESP and NMES is still being conducted, especially within a complex residential setting so all data from therapy is useful so that we can understand which patients respond well to treatment and why. I am implementing the adapted NICE clinical audit tool to Ampcare ESP within my therapeutic work. I collect baseline data for the patient, then after the treatment, plus I assess whether there were any risks using it.
“I record the Ampcare parameters each session and outcome measures are gathered using varied instrumental and bedside dysphagia assessments, patient questionnaires plus qualitative and quantitative scales. I also review the patient’s and his family’s views on therapy progression as this feeds onto their quality of life. In addition, the patient’s tolerance, compliance and motivation is also recorded. During the Ampcare session, the patient’s vital signs including their oxygen levels are closely monitored along with any signs of discomfort, skin irritation, etc.”
Future plans for NMES
With initial positive results from the use of Ampcare, Mira is optimistic about its future use at the service.
Mira says: “Well of course we need to see how it goes with this patient in particular, and we must take everything on a case by case basis, but I’m very optimistic about future use. The individuals we support at The Bridge have complex needs, complex aetiologies and a lot of comorbidities, so we need to know more about NMES and its impact longer term with complex patients before we can say anything more definitive. But in general I do have high hopes for NMES, because we’re triggering varied muscles needed during a swallow function combined with rehabilitation exercises and program. It’s very targeted.
“What is also good about Ampcare is that if you stimulate a muscle, because of the anatomical structure and swallow kinematics, it could pull other structures with it. The hyoid range of movement during Ampcare stimulation, for example, could impact tongue position.
“I’m very excited to try it with other residents, where appropriate, to see how we can help them. Other speech and language therapists can also participate in the training and the therapy can be rolled out more widely, which I’m hopefully with benefit more individuals with dysphagia and their families. My hope for the future is to be able, with the audits and data collected at The Bridge, to contribute to the ongoing research for NMES.”
Get the latest insights, blogs and news from Elysium Neurological over on their EveryExpert thought leadership hub: elysiumhealthcare.co.uk/neurological/every-expert/
Martindale N, Stephenson J, Pownall S. (2019) Neuromuscular Electrical Stimulation Plus Rehabilitative Exercise as a Treatment for Dysphagia in Stroke and Non-Stroke Patients in an NHS Setting: Feasibility and Outcomes. Geriatrics (Basel). 2019 Sep 24;4(4):53. doi: 10.3390/geriatrics4040053. PMID: 31554267; PMCID: PMC6960664.
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