Percutaneous Electrical Stimulation in Speech-Language Pathology

Speech-language pathologists have to keep up with new technological developments that affect their field all the time, even if the latest techniques for treating swallowing and speech disorders actually comes from one of the oldest technologies of them all: electricity.

Electrical stimulation with implantable electrodes, as well as some surface electrode use, is being used to help treat dysphagia and dysphonia in cases where the causes can be traced to muscular weakness, paralysis, or spasticity.

Although the idea of applying raw electricity to the human body isn’t a new one, few studies have been done on the efficacy of these techniques and there is open debate in SLP circles about whether or not they provide legitimate therapeutic effects. But SLPs working in every venue, from schools to hospitals, are increasingly being asked to program electrical stimulation (e-stim) devices for their patients.

Electrical Stimulation is an Ancient Technique With Modern Applications

Ever since electricity was first discovered, medical practitioners have looked to it for miracle solutions to health problems. Reports from the first century show that the court physician to Roman emperor Claudius, Scribonius Largus, occasionally prescribed a period of standing atop the naturally electrically discharging torpedo fish as treatment for patients suffering maladies ranging from headache or gout.

Ben Franklin, famously fascinated with electricity, also proposed using electrical current for pain management. As in so many other ways, Ben was well ahead of his time. Today’s TENS (Transcutaneous Electrical Nerve Stimulus) devices are widely used for exactly that purpose, pulsing a current through a set of electrodes placed on the skin near a source of pain.

Unfortunately for TENS, it is often applied just as haphazardly and optimistically as a panacea as some of the ancient mechanisms of electrical pain relief. Consequently, studies of its effectiveness have largely been contradictory and inconclusive.

The mechanism by which electrical stimulation effects muscles, however, is well-understood and uncontroversial. And a common limitation warned of with TENS use provides a glimpse of other uses for e-stim that can be a useful tool for SLPs: the units are generally prohibited from being used on the front of the neck for pain management due to their potential effect on the vocal folds, leading to laryngospasm.

But certain dysphagia cases result from neuromuscular problems in the musculature in exactly that region. And if stimulating those muscles electrically can artificially put them into the wrong state, it turns out that it can also take malfunctioning muscles and put them into the correct state.

Studies of both trans- and sub-cutaneous e-stim have shown that proper application can alter the position of the hyoid and shape of the larynx. This stimulation has the potential to assist:

• Airway function
• Voice rehabilitation
• Swallowing function

E-stim is used to treat various muscle-related conditions, such as Bell’s Palsy. But dysphagia is the single most common condition being treated SLPs using e-stim today.

Electrical Stimulation Retrains Swallowing Muscles in Dysphagia Cases

In 2001, the U.S. Food and Drug Administration approved an e-stim therapy called VitalStim for dysphagia treatment.

VitalStim works by attaching electrodes near the swallowing musculature in the throat. Small, precisely calibrated electrical impulses that are calculated and initiated by the SLP stimulate the muscles. While the current is applied, the therapist will undertake conventional strengthening and agility exercises with the patient.

The current stimulates motor nerves in the throat, prompting the swallowing muscles to contract where the patient’s natural system would otherwise fail to control them.

This results in increased muscle strength, improved cortical reorganization, and increased effectiveness of the therapy exercises.

Certification Options for SLPs Working with Electrical Stimulation Devices

ASHA only recognizes a handful of third-party certifications and VitalStim is not one of them. Part of the code of ethics for CCC-SLPs, however, requires that “they shall provide all services competently.”

Becoming Certified to Perform Electrical Stimulation Therapy

The VitalStim certification is one route to assure competency with the equipment and technique.

VitalStim certificates are issued by Career Improvement and Advancement Opportunities Seminars (CIAO). There are two tracks for certification, adult and pediatric. Both tracks required taking a two-week online seminar followed by two days of live training.

To be eligible to take the certification seminar, you must have:

• Experience with dysphagia cases to the extent of being solely responsible for evaluation, treatment planning, and discharge of at least 50 dysphagia patients.
• At least three years of a caseload with at least 25 percent dysphagia patients.
• Skill sufficient to evaluate and interpret the results of instrumental dysphagia evaluations.
• A current SLP or OTR (Occupational Therapist) license.

If your work history doesn’t provide evidence of those qualifications, it’s possible to request a clinical interview by CIAO staff who can make a judgement call on your individual qualifications.

The course costs $775 although discounts are available for groups of 10 or more individuals taking it at the same time.

You must renew the certification every three years by taking a dedicated VitalStim renewal course (also from CIAO). The course can be taken in person or online and costs $125. You can take either the pediatric or the adult version of the course regardless of which track your original certification was made in.

Becoming Certified as a Swallowing Specialist

ASHA does recognize a Clinical Specialty Certification in swallowing that may also be useful for SLPs providing e-stim treatments. Although no e-stim training is provided as part of the BCS-S (Board Certified Specialist-Swallowing), e-stim is never a stand-alone treatment in SLP—it is always paired with more traditional therapies, which a BCS-S provides additional qualification to perform.

Acquiring a BCS-S is accomplished through the American Board of Swallowing and Swallowing Disorders. The credential is only open to currently certified CCC-SLPs. You also must have:

• At least 7.5 continuing education units specific to dysphagia treatments within the past three years.
• A minimum of 3 years of post CCC-SLP practical experience with a focus in dysphagia treatment or research. Clinical track qualifiers must have 350 clock hours of evaluation or treatment activities, while academic track qualifiers must have 100 hours of that work and a position in academics or administration with a focus on dysphagia treatment.
• Perform additional activities, such as publishing or mentorship, demonstrating advanced experience in dysphagia treatment.

Having met these standards, applicants can obtain the BCS-S by paying a $100 fee and passing a written examination.

SLPs can provide far more effective e-stim therapy with the improved understanding of dysphagia that comes with a BCS-S. Since more and more e-stim applications are likely in the coming years, this is an excellent way to position yourself ahead of the crowd.