Do I need a certification to do NMES?
The only certification that ASHA will recognize is their board certifications/specialities and the Certificate of Clinical Competence. A certificate from an ASHA CEU course is simply a piece of paper that proves you attended that course, calling it a certification is not consistent with the rigorous standards of ASHA and other organizations. The focus of our course is on establishing competency in the technique of NMES which is consistent with the Principle of Ethics I, Rule A which insists that clinicians provide all services “competently,” while Principle of Ethics III, Rule A admonishes against misrepresenting one’s competence. Principle of Ethics II, Rule A provides specific guidelines by stating that an individual’s level of education, training, and experience must be considered in determining the scope of their competence. For additional information and clarification please review the following articles:

Do I need a doctor’s prescription for NMES?

Not usually but check with your employer as some organizations may require it. In a typical outpatient or acute care setting setting you simply need a prescription or doctor’s order for swallowing therapy and your plan of treatment which is signed by the doctor includes NMES as part of your plan.
Can I bill separately for NMES?

We do not recommend it. We usually bill for dysphagia therapy 92526 regardless of what type of intervention we provide. Speech therapy billing for additional modalities is not consistent with standard best practice.

Can I use NMES with a pacemaker?
Yes but it is recommend that you go through the pacemaker interference protocol. However, Never use NMES with a defibrillator.

Can I use NMES with a cancer patient?
Yes, there is no scientific evidence for any risk when using NMES on a cancer patient. Indeed there is evidence that electrical stimulation can help shrink tumors and enhance radiation therapy. Click here to review the abstracts.

Is more amplitude better?
Not necessarily, remember the goal is to achieve a contraction at the lowest level possible with patient comfort kept paramount. Also the patient must be able to swallow comfortably with the level of stimulation and setting the amplitude too high can make it more difficult to do that.

How long is each treatment session?
30 minutes is average but certainly 20 minutes is good enough if you have other treatments that need to be administered. However, remember you can always capitalize on the 12 second rest time to work on any non swallowing tasks such as oral motor exercises, speech drills, language or cognitive tasks.

Is NMES painful?
No, the skilled use of NMES dictates that the parameters are modified and manipulated in order to maintain patient comfort while still achieving the desired muscle contraction. True NMES should never burn, sting, grab or be uncomfortable in any way, shape or form.

Is NMES and VitalStim the same thing?
No, although both may be used to provide electrical impulses through surface electrodes, NMES is fundamentally different than the VitalStim protocol. The standards for NMES have been well established in the literature with a very specific parameter range that is then modified and manipulated as needed. VitalStim can not be modified or manipulated and the pre-set protocol does not fit with the NMES parameters and therefore should not be referred to as NMES. To see a standard NMES protocol click here.

How do I know the therapy is working?
Good practice dictates that we assess our patient’s progress on a regular basis regardless of what intervention if being used. Medicare guidelines require an objective standardized measure every 10 visits. In clinical practice, we presume the therapy is working when you can objectively
document progress such as diet upgrade, less evidence of aspiration, increased ease with eating, decreased time to complete a meal etc.

What is the most common treatment parameter I need to change?
Pulse Duration. Remember to decrease the pulse duration when the patient cannot tolerate enough amplitude to achieve a contraction and increase it when they are at max amplitude and comfortable but have not achieved a contraction.

Are there any contraindications?
The use of NMES on a patient with a defibrillator is contraindicated. There are a few cautions to consider:
Patients ability to respond to painful stimuli – Although we can set the parameters very low for infants and other patients unable to verbalize and likely avoid any discomfort you should only proceed if you have some reliable indication of pain such as a grimace, withdrawal response, watery eyes, refusal etc.
Pacemaker (see interference protocol)
Radiation fibrosis – NMES alone will have little effect on tissue that is fibrotic but if combined with manual therapy may have a very positive outcome
Seizure disorders – although there is no evidence that NMES will contribute to seizures it is recommended that you double check with the neurologist
Post surgical changes or implants –
Any metal implants located in proximity to electrode placement should not cause adverse effects however the patient may experience some sensation in the area. If so, the patient will decide to continue or terminate treatment.
Any patient with any other implanted electronic devices such as cochlear implants, vagal nerve stimulation, deep brain stimulation etc may not be a candidate and the implanting surgeon should be contacted to discuss possible interference issues. Also if there is extensive surgical reconstruction and implants to replace structures you should consider what are you stimulating and why.

Why should I know how to change parameters?

You should be skilled in the use of NMES because it is a complex and powerful modality. When NMES is utilized correctly it can facilitate better outcomes in a shorter period of time than traditional exercise alone. When NMES is not used correctly the outcomes will not be optimal, could potentially be detrimental and the the treatment may be very uncomfortable for the patent. An excellent clinician will desire to know why and how something works, not just blindly follow a cookie cutter protocol.

Is the Guardian device and electrodes cleared by the FDA?
Yes, for a preview of the 510K summary please go to ___