Clinician Resources

Clinician FAQ's

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Do I need a certification in NMES to perform with my patients?

The only certifications that ASHA recognizes are board certifications/specialties and the Certificate of Clinical Competence (CCCs). A certificate from an ASHA CEU course is simply proof of attendance. 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”. 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 references:

  • ASHA Scope of Practice
  • All Credentials Are Not Created Equal: ASHA Leader Article

Can I use NMES with a patient with a pacemaker?

Yes, but it is recommended that you go through the pacemaker interference protocol. This includes discussion with and approval by patient’s physician. 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.

Is more amplitude better?

Not necessarily, remember the goal is to achieve a contraction at the lowest level possible with patient comfort kept paramount. 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?

The average treatment time for NMES is 30 minutes. This may need to be reduced based on patient fatigue. Remember that 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.

Are 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.

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 and requirements for frequency vary per setting. 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:

  • Patient’s 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. If there is extensive surgical reconstruction and implants to replace structures you should consider what is being stimulated 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 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.

Pacemaker Protocol

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1. Contact the cardiologist.

  • Introduce yourself and explain that you are treating his/her patient for dysphagia and would like to use NMES
  • Explain placement in submental region and frequency of 50 Hz and a phase duration of 130 uSec to 400 uSec
  • Indicate that you plan to set up appointment with pacemaker rep for interrogation to check interference
  • If physician indicates that this is unnecessary, ask for documentation, such as script that indicates “Ok to proceed with NMES

2. Contact Pacemaker Company

  • Call number on back of patient’s pacemaker card
  • Request interrogation and interference testing
  • Give requested information, such as reason, location, etc.

3. Discussion with Pacemaker Rep

  • Explain that you want to use NMES with the patient
  • Indicate that you have spoken with cardiologist
  • Schedule time with rep to allow both of you to be present with the patient
  • Interrogation and test for interference is a free service

4. Appointment

  • Rep will set the patient up and interrogate the pacemaker
  • Place the electrodes and be ready to go
  • The rep will place a magnet over the pacer to prevent a shock from occurring, but still allows it to function
  • Explain to the patient that you need to increase as high as you can to ensure there will not be a problem during later treatments
  • Set the device with standard parameters indicated for treating that particular patient
  • Turn on and progress mA to max; the rep will have a digital display to tell if there is interference; if so discontinue and do not proceed with use; if not, you can proceed with use in treatment

5. Documentation

  • Ask rep for a printout of the graph
  • Sign it, along with signature from the rep
  • Write the date and the parameters used and document in the chart as well
  • Example: “Guidant rep Mary Smith provided pacemaker interrogation and interference testing for NMES in the submental region for potential treatment of dysphagia. Equipment tested at frequency of 50 Hz, phase duration of 180 uSec, placement in submental region. No interference noted.”
  • Send a copy of findings to cardiologist

American Cancer Society: Non-Medical Treatments for Pain

The American Cancer Society references the potential benefits of TENS for pain management. TENS is a type of electrical stimulation used for pain management. It delivers electrical pulses to the body via electrodes, similar to NMES but with different parameters that are not adjustable.

The Lancet Oncology journal: Electrotherapy: Enlightening Modern Medicine

The authors, Hills and Stebbing provide a nice review of the work done in using electrical stimulation to treat cancer and the following is a direct excerpt from their article:

“The technique involves the use of electrical fields, delivered through a non-invasive transducer array patch placed directly on the skin above the tumour, to alternate tumour cell polarity, thereby causing the physical disruption of the cell membrane and apoptosis. The treatment is delivered through a non-invasive, insulated transducer array patch. Electrical current is not delivered directly to the tissue, but the patch generates an artificial and alternating electric field within the tumour. The results of a trial in patients with treatment-resistant brain tumours showed a better quality of life and a lower frequency of side-effects in individuals receiving tumour-treating-fields therapy than in those receiving chemotherapy, serving as the basis for FDA approval for the treatment of recurrent glioblastoma multiforme in 2011. Another study of the efficacy of low-frequency low-intensity electrotherapy in the treatment of breast-cancer-related arm swelling (lymphoedema) also showed that despite no significant changes in lymphoedema volume, there was significant reduction in pain, heaviness, and tightness, further showing that electrotherapy could at least be used to improve a patient’s quality of life.”

Additional references:

  • Baldwin, E. R. L., Baldwin, T. D., Lancaster, J. S., McNeely, M. L., & Collins, D. F. (2012). Neuromuscular Electrical Stimulation and Exercise for Reducing Trapezius Muscle Dysfunction in Survivors of Head and Neck Cancer: A Case-Series Report. Physiotherapy Canada, 64(3), 317–324.
  • Windholz T, Swanson T, Vanderbyl BL, Jagoe RT. The feasibility and acceptability of neuromuscular electrical stimulation to improve exercise performance in patients with advanced cancer: a pilot study. BMC Palliat Care.2014 May 1;13:23. doi: 10.1186/1472-684X-13-23. eCollection 2014. Erratum in: BMC Palliat Care. 2014;13:33. PubMed PMID: 24808760; PubMed Central PMCID:PMC4012222.
  • Lacouture ME, Davis ME, Elzinga G, Butowski N, Tran D, Villano JL, DiMeglio L,Davies AM, Wong ET. Characterization and management of dermatologic adverse events with the NovoTTF-100A System, a novel anti-mitotic electric field device for the treatment of recurrent glioblastoma. Semin Oncol. 2014 Jun;41 Suppl 4:S1-14. doi: 10.1053/j.seminoncol.2014.03.011. Epub 2014 Mar 19. PubMed PMID:24794308.
  • Bhatt AD, Goodwin N, Cash E, Bhatt G, Silverman CL, Spanos WJ, Bumpous JM.
  • Potts K, Redman R, Allison WA, Dunlap NE. Impact of transcutaneous neuromuscular electrical stimulation on dysphagia in patients with head and neck cancer treated with definitive chemoradiation. Head Neck. 2015 Jul;37(7):1051-6. doi: 10.1002/hed.23708. Epub 2015 Apr 6. PubMed PMID: 24710791.
  • Loh J, Gulati A. Transcutaneous electrical nerve stimulation for treatment of sarcoma cancer pain. Pain Manag. 2013 May;3(3):189-99. doi: 10.2217/pmt.13.15. PubMed PMID: 24654762.
  • Kulsh J. Low-level electric current and cancer--a promising, but languishing non-toxic cancer therapy. Explore (NY). 2014 Jan-Feb;10(1):53-4. doi: 10.1016/j.explore.2013.10.004. Epub 2013 Oct 17. PubMed PMID: 24439096.
  • Charest-Hallée, S., & Léonard, G. (2013). Electrical Stimulation for Reducing Trapezius Muscle Dysfunction in Cancer Patients: Traditional Treatment Protocols Also Work.Physiotherapy Canada, 65(4), 401–403. http://doi.org/10.3138/ptc.2013-38
  • Shawki MM, Farid A. Low electric field parameters required to induce death of cancer cells. Electromagn Biol Med. 2014 Jun;33(2):159-63. doi: 10.3109/15368378.2013.800105. Epub 2013 Jun 3. PubMed PMID: 23730818.
  • Baldwin ER, Baldwin TD, Lancaster JS, McNeely ML, Collins DF. Neuromuscular electrical stimulation and exercise for reducing trapezius muscle dysfunction in survivors of head and neck cancer: a case-series report. Physiother Can. 2012Summer;64(3):317-24. doi: 10.3138/ptc.2011-23O. PubMed PMID: 23729969; PubMed Central PMCID: PMC3396583.
  • Davies AM, Weinberg U, Palti Y. Tumor treating fields: a new frontier in cancer therapy. Ann N Y Acad Sci. 2013 Jul;1291:86-95. doi: 10.1111/nyas.12112. Epub 2013 May 9. Review. PubMed PMID: 23659608.
  • Loh J, Gulati A. The use of transcutaneous electrical nerve stimulation (TENS)in a major cancer center for the treatment of severe cancer-related pain and associated disability. Pain Med. 2015 Jun;16(6):1204-10. doi: 10.1111/pme.12038. Epub 2013 Feb 25. PubMed PMID: 23438255.
  • Kirson ED, Giladi M, Gurvich Z, Itzhaki A, Mordechovich D, Schneiderman RS, Wasserman Y, Ryffel B, Goldsher D, Palti Y. Alternating electric fields (TTFields) inhibit metastatic spread of solid tumors to the lungs. Clin Exp
  • Metastasis. 2009;26(7):633-40. doi: 10.1007/s10585-009-9262-y. Epub 2009 Apr 23. PubMed PMID: 19387848; PubMed Central PMCID: PMC2776150.
  • Salzberg M, Kirson E, Palti Y, Rochlitz C. A pilot study with very low-intensity, intermediate-frequency electric fields in patients with locally advanced and/or metastatic solid tumors. Onkologie. 2008 Jul;31(7):362-5. doi: 10.1159/000137713. Epub 2008 Jun 24. PubMed PMID: 18596382.