J Huazhong Univ Sci Technol［Med Sci］

DOI 10.1007/s11596-011-0153-5 31(1):73-76,2011 73

J Huazhong Univ Sci Technol［Med Sci］ 31(1):2011

Treatment of Post-stroke Dysphagia by VitalStim Therapy Coupled

with Conventional Swallowing Training*
Wenguang XIA (夏文广)1, 2, Chanjuan ZHENG (郑婵娟)2, Qingtao LEI (雷清桃)3, Zhouping TANG (唐洲平)1,
Qiang HUA (华 强)2, Yangpu ZHANG (张阳普)2, Suiqiang ZHU (朱遂强)1#
1
Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
430030, China
2
Department of Rehabilitation Medicine, Center of Brain Department, Hubei Xinhua Hospital, Wuhan 430015, China
3
Department of Neurofunctional Diseases, Center of Brain Department, Hubei Xinhua Hospital, Wuhan 430015, China

© Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2011

Summary: To investigate the effects of VitalStim therapy coupled with conventional swallowing
training on recovery of post-stroke dysphagia, a total of 120 patients with post-stroke dysphagia were
randomly and evenly divided into three groups: conventional swallowing therapy group, VitalStim
therapy group, and VitalStim therapy plus conventional swallowing therapy group. Prior to and after
the treatment, signals of surface electromyography (sEMG) of swallowing muscles were detected,
swallowing function was evaluated by using the Standardized Swallowing Assessment (SSA) and
Videofluoroscopic Swallowing Study (VFSS) tests, and swallowing-related quality of life
(SWAL-QOL) was evaluated using the SWAL-QOL questionnaire. There were significant differences
in sEMG value, SSA, VFSS, and SWAL-QOL scores in each group between prior to and after treat-
ment. After 4-week treatment, sEMG value, SSA, VFSS and SWAL-QOL scores were significantly
greater in the VitalStim therapy plus conventional swallowing training group than in the conventional
swallowing training group and VitalStim therapy group, but no significant difference existed between
conventional swallowing therapy group and VitalStim therapy group. It was concluded that VitalStim
therapy coupled with conventional swallowing training was conducive to recovery of post-stroke
dysphagia.
Key words: dysphagia; VitalStim therapy; swallowing therapy; stroke

Post-stroke dysphagia represents one of common tal between December 2007 and June 2010 were in-
complications in stroke patients[1–2]. It predisposes pa- cluded in this study. Inclusion criteria of post-stroke
tients to pulmonary infection and malnutrition, which dysphagia included: (1) fulfilling the diagnostic criteria
substantially affects patient’s quality of life and raises for various cerebrovascular diseases formulated by the
social burdens[3]. Neuromuscular electrical stimulation, Fourth Academic Conference of National Cerebrovascu-
serving as a supplementary training technique of lar Diseases in 1995; (2) being finally diagnosed as hav-
dysphagia therapies, has been extensively used in the ing cerebral infarction or cerebral hemorrhage by CT or
clinical practice in China, but its curative effects remain MRI; (3) having swallowing disorder as confirmed by
controversial[4–5]. The present study investigated the ef- water drinking test; (4) no pulmonary diseases; (5) being
fects of VitalStim therapy coupled with conventional 40–80 years old; (6) possessing clear consciousness and
swallowing training on recovery of post-stroke dys- being able to cooperate; (7) being willing to provide
phagia in patients. written informed consent.
The patients were randomly and evenly divided into
three groups: conventional swallowing training, Vital-
1 SUBJECTS AND METHODS
Stim therapy, and VitalStim therapy plus conventional
swallowing training. All patients were assessed and
1.1 General Data of Subjects given treatments accordingly 48 hours after presence of
A total of 120 post-stroke dysphagia patients who stable vital signs and absence of neurological signs.
had received treatment at the Department of Neurology There were no statistically significant differences in age,
and Department of Rehabilitation, Hubei Xinhua Hospi- gender, cause of dysphagia, duration and severity of the
condition among the three groups (table 1).
1.2 Assessment Techniques
Wenguang XIA, E-mail: [email protected]
#
1.2.1 Bedside Swallowing Assessment The standardized
Corresponding author, E-mail: sqzhu@tjh. tjmu. edu. cn swallowing assessment (SSA) was used for the evalua-
*
This project was supported by a grant from the Health Bu- tion of swallowing function[6, 7].
reau of Hubei Province, China (No. JX5B36). 1.2.2 Surface Electromyography (sEMG) sEMG sig-
 74 J Huazhong Univ Sci Technol［Med Sci］ 31(1):2011

nals of swallowing muscles were collected through the swallowed 2 mL of water, the maximum amplitude of
use of Flexcomp Biomonitoring System (Thought Tech- sEMG signals was measured, and the average of three
nology, Canada) and analyzed by using Flexcomp Infin- measurements was calculated[8–10].
iti software that goes with the system. After patient

Table 1 Comparison of general data of patients

Gender Age (years, Stroke type (n) Dysphagia SSA
Groups Male Female ±s) Cerebral Cerebral Others duration ( ±s)
hemorrhage infarction (days)
Conventional swal- 25 15 65.32±14.29 17 18 5 8.94±3.62 37.9±6.4
lowing therapy
VitalStim therapy 23 17 66.40±15.63 14 22 4 9.22±3.88 38.7±6.9
VitalStim ther- 28 12 65.85±14.63 13 25 2 8.37±3.12 39.5±7.1
apy+conventional
swallowing therapy
SSA: Standardized swallowing assessment

1.2.3 Videofluoroscopic Swallowing Study (VFSS) ditions of patients. Treatment was administered twice a
Test While the patients were asked to swallow foods of day, lasting 30 min each time, 5 days a week, for 4 suc-
varying consistencies (pasty, liquid, solid) and amounts cessive weeks[15]. The above-mentioned assessments,
(2 mL, 5 mL, 10 mL), the therapists watched the screen conventional swallowing training, and VitalStim therapy
of an X-ray equipment to observe the food intake condi- were performed by experienced speech therapists blinded
tion in the anterior-posterior and lateral positions[11–12]. to the experimental design.
1.2.4 Swallowing-related Quality of Life 1.4 Statistical Analysis
(SWAL-QOL) Questionnaire The SWAL-QOL ques- The data were expressed as ±s and statistically
tionnaire consisted of 44 items. The quality of life was processed by using SPSS 12.0 software. t test and analy-
scored by patients and a higher score indicated a higher sis of variance were used for comparison of measure-
life quality[13, 14]. ment data. Correlation analysis was performed using
1.3 Treatments Perason test. A level of P<0.05 was considered to be
1.3.1 Conventional Swallowing Training The conven- statistically significant.
tional swallowing therapy included basic training and
direct food intake training. The basic training, i.e., func- 2 RESULTS
tional recovery training, referred to indirect training of
organs related to food intake and swallowing. Direct 2.1 Changes in Maximum Amplitude of sEMG Signal
food intake training involved several aspects including of Hyoid Bone Muscles prior to and after Treatment
food intake environment, body posture for swallowing, After treatment, the maximum amplitude of sEMG
and removal of pharyngeal food residue. Direct food signal in each group was significantly increased com-
intake training was used primarily for mild dysphagia. pared with that prior to treatment (P<0.01). After treat-
1.3.2 VitalStim Therapy The parameters of VitalStim ment, the maximum amplitude of sEMG signal in the
surface electrical stimulation system (Chattanooga Group, VitalStim therapy plus conventional swallowing traing-
USA) contained two direction square waves, with wave ing group was significantly increased in comparison with
width being 700 μs, frequency 80 Hz, and wave ampli- the conventional swallowing training group and Vital-
tude 0–25 mA. The system has two channels, each being Stim therapy group (P<0.01), but no significant differ-
equipped with 2 discharge electrodes. The surface elec- ence was found between conventional swallowing train-
trodes were placed on the surface of swallowing muscles. ing group and VitalStim therapy group (P >0.05) (table
Electrode position and treatment mode were selected 2).
according to VFSS scores, patient’s tolerance, and con-

Table 2 Comparison of the maximum amplitude of surface electromyography value between prior to and after treatment
Groups n Prior to treatment (μV) After treatment (μV)
Conventional swallowing training 40 378.8±56.2 702.2±87.4a
VitalStim therapy 40 396.3±62.4 733.5±88.3a
VitalStim therapy+conventional swallowing training 40 382.4±58.6 987.1±91.2a, b, c
a
P<0.01 vs prior to treatment in the same group;
b
P<0.01 conventional swallowing training group vs VitalStim therapy plus conventional swallowing training group;
c
P<0.01 VitalStim therapy group vs VitalStim therapy plus conventional swallowing therapy group.

2.2 Changes in Swallowing Function and increased compared with those prior to treatment. After
SWAL-QOL prior to and after Treatment treatment, SSA, VFSS, and SWAL-QOL scores were
Prior to treatment, there were no significant differ- significantly increased in the VitalStim therapy plus
ences in SSA, VFSS, and SWAL-QOL scores among conventional swallowing training group than in the con-
three groups (P>0.05). After treatment, SSA, VFSS, and ventional swallowing training group and VitalStim ther-
SWAL-QOL scores in each group were significantly apy group (P<0.01), but there existed no significant dif-
J Huazhong Univ Sci Technol［Med Sci］ 31(1):2011 75

ferences in these scores between conventional swallow- (table 3).

ing training group and VitalStim therapy group (P>0.05)

Table 3 SSA, VFSS and SWAL-QOL scores prior to and after treatment
n SSA VFSS SWAL-QOL
Groups Prior to After treatment Prior to After treatment Prior to After treatment
treatment treatment treatment
Conventional swal- 40 40.9±6.4 30.1±3.8a 2.74±1.63 5.32±1.43a 863±83 624±45a
lowing training
VitalStim therapy 40 38.7±6.9 29.6±4.2a 2.65±1.56 5.63±1.57a 850±75 645±58a
a, b, c a, b, c
VitalStim ther- 40 39.5±7.1 21.4±3.5 2.53±1.58 6.88±1.58 885±60 458±35a, b, c
apy+conventional
swallowing training
a
P< 0.01 vs prior to treatment in the same group; bP<0.01 vs conventional swallowing training group; cP<0.01 vs VitalStim therapy
group
SSA: Standardized swallowing assessment; VFSS: Videofluoroscopic Swallowing Study; SWAL-QOL: Swallowing-related quality
of life

2.3 Correlation Analysis of sEMG Value, SSA, VFSS VFSS, SWAL-QOL scores in each group. Results dem-
and SWAL-QOL Scores prior to and after Treatment onstrated that any two of the measures were, to some
Prior to and after treatment, correlation analysis was extent, correlated (P<0.01) (table 4).
performed between the sEMG value scores and the SSA,

Table 4 Correlation analysis among sEMG value, SSA, VFSS, and SWAL-QOL scores
Parameters sEMG SSA VFSS SWAL-QOL
sEMG – –0.781a 0.832a –0.654a
SSA –0.781a – –0.877a 0.706a
a a
VFSS 0.832 –0.877 – –0.739a
a a a
SWAL-QOL –0.654 0.706 –0.739 –
a
P<0.01; For designations refering to table 3
phagia, which is consistent with a previous report[19]. (2)
3 DISCUSSION The swallowing function was obviously improved in
patients receiving VitalStim therapy or conventional
In recent years, a large number of studies on swallowing therapy, indicating that VitalStim therapy
post-stroke dysphagia have been conducted to investigate and conventional swallowing therapy are both effective
its treatment and management strategies, and a wide ar- for post-stroke dysphagia. But the therapeutic effects of
ray of novel therapeutic approaches are being devel- neuromuscular electrical stimulation are controversial.
oped[16–18]. Neuromuscular electrical stimulation uses Gallas et al[20] reported that neuromuscular electrical
designated electric impulses to stimulate pharyngeal stimulation can improve the swallowing function by en-
muscles and elicit muscle contraction or mimic normal hancing swallowing coordination of post-stroke dys-
automatic contraction, thereby improving or recovering phagia patients. Ludlow et al[21] concluded that surface
the function of stimulated muscles. VitalStim therapy is a electrical stimulation can help raise the hyoid bone of
specific neuromuscular electrical stimulation that re- patients during swallowing. Park et al[22] observed that
quires post-stroke dysphagia patients to perform a series electrical stimulation can increase the range of motion of
of procedures including perception of swallowing action, hyoid bone if swallowing action can be actively cooper-
followed by initial automatic swallowing, and then com- ated. Freed et al[23] thought that electrical stimulation
pletely automatic swallowing[15]. yields better therapeutic effects than hot-cold stimulation.
sEMG used in this study is a safe, simple, noninva- Leelamanit et al[24] reported that electrical stimulation
sive assessment means that can collect electromyog- can increase pharyngeal and laryngeal activities by in-
raphic signal of muscle activity for quantitative and creasing the contraction force of hyoid bone muscle.
qualitative analysis of neuromuscular functions. VFSS, Logemann et al[25] reported that the therapeutic effects of
as a gold standard for detection of post-stroke dys- VitalStim therapy lacks convincing supporting evidence.
phagia[6], remains an ideal detection means and is widely Therefore, the therapeutic effects of VitalStim therapy
used in clinical practice. The present study used SSA, needs further clinical investigation.
VFSS and sEMG to more objectively analyze the exist- In clinical practice, a combination of several tech-
ing problems and then select proper rehabilitation strate- niques, rather than one method, is often used to enhance
gies to promote the recovery of post-stroke dysphagia. the therapeutic effects on post-stroke dysphagia. The
Results from this study demonstrated that: (1) Vi- present study was designed to compare the curative ef-
talStim therapy and conventional swallowing training do fects of VitalStim therapy coupled with conventional
not yield obviously different effects on sEMG value, swallowing therapy and the conventional swallowing
SSA, VFSS and SWAL-QOL scores in post-stroke dys- therapy or VitalStim therapy alone to clarify if curative
phagia patients, indicating that these two techniques effect each component of the combined method is syn-
produce similar therapeutic effects on post-stroke dys- ergetic or mutually cancelled, or not changed? This study
 76 J Huazhong Univ Sci Technol［Med Sci］ 31(1):2011

demonstrated that the sEMG value, SSA, VFSS scores in extensor digitorum communis by surface EMG. J
the VitalStim therapy plus conventional swallowing Neurophysiol, 2008,100(6):3225-3235
training group were significantly higher than those in the 11 O’Neil KH, Purdy M, Falk J, et al. The dysphagia
conventional swallowing training group and VitalStim outcome and severity scale. Dysphagia, 1999,14(3):
group (P<0.01), indicating that the VitalStim therapy 139-145
coupled with conventional swallowing therapy is the best 12 Han TR, Paik NJ, Park JW, et al. Quantifying swallowing
alternative for improving post-stroke dysphagia. The function after stroke: A functional dysphagia scale based
possible mechanisms[26, 27] are as follows: Repeated on videofluoroscopic studies. Arch Phys Med Rehabil,
rehabilitation training and electrical stimulation help to 2001,82(5):677-682
13 McHorney CA, Bricker DE, Robbins J, et al. The
reconstruct cerebral functions or arouse resting synapses
SWAL-QOL outcome tool for oropharyngeal dysphagia in
to transmit nerve impulses, (2) elicit muscular contrac-
adults:Ⅰ. Conceptual foundation and item development.
tion and prevent disuse atrophy, (3) accelerate the recov- Dysphagia, 2000,15(3):115-121
ery of swallowing muscle power. 14 McHorney CA, Bricker DE, Robbins J, et al. The
Results of the correlation analysis on sEMG value, SWAL-QOL outcomes tool for oropharyngeal dysphagian
SSA, VFSS and SWAL-QOL scores prior to and after in adults: Ⅱ . Item reduction and preliminary scaling.
treatment exhibited that there was a good correlation Dysphagia, 2000,15(3):134-135
between any two indices, suggesting that improved mus- 15 Kiger M, Brown CS, Watkins L. Dysphagia management:
cle power of swallowing-related muscles can promote an analysis of patient outcomes using VitalStim therapy
the recovery of swallowing functions, thereby contribut- compared to traditional swallow therapy. Dysphagia, 2006,
ing to the improved quality of life. A significant correla- 21 (4) : 243-253
tion between SSA and VFSS (R =–0.877, P<0.01) sug- 16 Martino R, Silver F, Teasell R, et al. The Toronto Bedside
gests that the SSA score could be used to evaluate the Swallowing Screening Test (TOR-BSST): development
swallowing function in place of the VFSS in clinical and validation of a dysphagia screening tool for patients
practice. with stroke. Stroke, 2009,40(2):555-561
To sum up, VitalStim therapy coupled with conven- 17 Dziewas R, Warnecke T, Olenberg S, et al. Towards a
tional swallowing therapy can alleviate post-stroke dys- basic endoscopic assessment of swallowing in acute
phagia and thereby improve patients’ quality of life. stroke- development and evaluation of a simple dysphagia
Studies involving larger subject population are needed score. Cerebrovasc Dis, 2008,26(1):41-47
and long-term curative effects of this combined method 18 Foley N, Teasell R, Salter K, et al. Dysphagia treatment
warrants further investigation. post stroke: a systematic review of randomised controlled
trials. Age Ageing, 2008,37(3):258-264
19 Bülow M, Speyer R, Baijens L, et al. Neuromuscular
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