Research Tuesday: NMES for Dysphagia in ALS?

I am happy to launch 2015 by rejoining my fellow #SLPBloggers in our #ResearchTuesday blog project! This month I’m faced with the need to investigate the use of neuromuscular electrical stimulation (NMES) in the treatment of dysphagia in people with amyotrophic lateral sclerosis (ALS). I have my own thoughts on the topic, but I chatted with friends. I sought input from experts. I searched for studies. Result: So far, there’s little to no published research to guide us pro or con on this topic.

So, what’s a conscientious clinician supposed to do when faced with such a dilemma? My go-to response is to weigh the issue against the full, three-part definition of evidence-based practice:

  • Can I find any published, high quality, unbiased research studies to inform my decision-making?
  • What is my clinical judgment telling me?
  • What are the patient’s goals, wishes, and expectations for outcome?

Here’s how I applied it in this situation.

Problem: To use or not to use e-stim on a patient with dysphagia due to ALS?

Analysis:

Is there quality, published research to support or contraindicate the use of NMES in people with ALS? Apparently not; at least not at this time. If anyone reading this blog knows of something I missed in my search, I’d welcome your comments!

What does the patient expect or hope to achieve with NMES treatments? Patients seeking NMES for dysphagia typically hope and expect it will help them improve oral consumption of a less restrictive diet.

What is my educated, experienced, trained, opinion regarding the use of NMES with people with ALS? All things considered, I still advocate for treatment of each patient according to his/her unique circumstances, overall health status, and stage when they present with a progressive disorder. NMES may (or may not) be an option early in the disorder before too many motor neurons have been lost and muscles have deconditioned. Later in the course of the disorder, the patient may be better served by manual therapy techniques to reduce perilaryngeal muscular tension and spasticity prior to meals. Also, proactive exploration and selection of augmentative and/or alternative communication (AAC) strategies is an important goal to help preserve quality of life for anyone with ALS, at any stage in their progression.

Conclusion: Seeking an answer to this question reminded me of a few facts. ALS is a progressive motor neuron disorder that causes muscles to weaken as motor neurons die. Muscle fatigue occurs rapidly in people with ALS. If motor neurons to muscles — including those of the swallowing mechanism — have died, and NMES stimulates neurons to trigger muscle contractions, it stands to reason that electrical stimulation of de-innervated muscles would provide little to no benefit. In that case, NMES is unlikely to help patients achieve their swallowing goals during later stages of disease progression. In my clinical judgment, there is insufficient evidence to support its use.

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