, Volume 28, Issue 4, pp 557–566 | Cite as

Combined Neuromuscular Electrical Stimulation (NMES) with Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Traditional Swallowing Rehabilitation in the Treatment of Stroke-Related Dysphagia

  • Shu-Fen Sun
  • Chien-Wei Hsu
  • Huey-Shyan Lin
  • Hsien-Pin Sun
  • Ping-Hsin Chang
  • Wan-Ling Hsieh
  • Jue-Long Wang
Original Article


Dysphagia is common after stroke. Neuromuscular electrical stimulation (NMES) and fiberoptic endoscopic evaluation of swallowing (FEES) for the treatment of dysphagia have gained in popularity, but the combined application of these promising modalities has rarely been studied. We aimed to evaluate whether combined NMES, FEES, and traditional swallowing rehabilitation can improve swallowing functions in stroke patients with moderate to severe dysphagia. Thirty-two patients with moderate to severe dysphagia poststroke (≥3 weeks) were recruited. Patients received 12 sessions of NMES for 1 h/day, 5 days/week within a period of 2–3 weeks. FEES was done before and after NMES for evaluation and to guide dysphagic therapy. All patients subsequently received 12 sessions of traditional swallowing rehabilitation (50 min/day, 3 days/week) for 4 weeks. Primary outcome measure was the Functional Oral Intake Scale (FOIS). Secondary outcome measures included clinical degree of dysphagia, the patient’s self-perception of swallowing ability, and the patient’s global satisfaction with therapy. Patients were assessed at baseline, after NMES, at 6-month follow-up, and at 2-year follow-up. Twenty-nine patients completed the study. FOIS, degree of dysphagia, and patient’s self-perception of swallowing improved significantly after NMES, at the 6-month follow-up, and at the 2-year follow-up (p < 0.001, each compared with baseline). Most patients reported considerable satisfaction with no serious adverse events. Twenty-three of the 29 (79.3 %) patients maintained oral diet with no pulmonary complications at 2-year follow-up. This preliminary case series demonstrated that combined NMES, FEES, and traditional swallowing rehabilitation showed promise for improving swallowing functions in stroke patients with moderate-to-severe dysphagia. The benefits were maintained for up to 2 years. The results are promising enough to justify further studies.


Dysphagia Fiberoptic endoscopic evaluation of swallowing Neuromuscular electrical stimulation Rehabilitation Stroke 



This study was supported by an academic research fund from Kaohsiung Veterans General Hospital (VGHKS96-079). The study is registered in (unique identifier: NCT01731847).

Conflict of interest

The authors have no conflicts of interest to declare.


  1. 1.
    Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis. 2000;10:380–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Smithard DG, O’Neill PA, England RE, et al. The natural history of dysphagia following a stroke. Dysphagia. 1997;12:188–93.PubMedCrossRefGoogle Scholar
  3. 3.
    Teasell RW, Bach D, McRae M. Prevalence and recovery of aspiration poststroke: a retrospective analysis. Dysphagia. 1994;9:35–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Dziewas R, Ritter M, Schilling M, et al. Pneumonia in acute stroke patients fed by nasogastric tube. J Neurol Neurosurg Psychiatry. 2004;75:852–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Geeganage C, Beavan J, Ellender S et al. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012:CD000323.Google Scholar
  6. 6.
    Merletti R, Zelaschi F, Latella D, Galli M, Angeli S, Bellucci Sessa M. A control study of muscle force recovery in hemiparetic patients during treatment with functional electrical stimulation. Scand J Rehabil Med. 1987;10:147–54.Google Scholar
  7. 7.
    Hainaut K, Duchateau J. Neuromuscular electrical stimulation and voluntary exercise. Sports Med. 1992;14:100–13.PubMedCrossRefGoogle Scholar
  8. 8.
    Freed ML, Freed L, Chatburn RL, Christian M. Electrical stimulation for swallowing disorders caused by stroke. Respir Care. 2001;46:466–74.PubMedGoogle Scholar
  9. 9.
    Lake DA. Neuromuscular electrical stimulation. An overview, and its application in the treatment of sports injuries. Sports Med. 1992;13:320–36.PubMedCrossRefGoogle Scholar
  10. 10.
    Bulow M, Speyer R, Baijens L, Woisard V, Ekberg O. Neuromuscular electrical stimulation (NMES) in stroke patients with oral and pharyngeal dysfunction. Dysphagia. 2008;23:302–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Carnaby-Mann GD, Crary MA. Adjunctive neuromuscular electrical stimulation for treatment-refractory dysphagia. Ann Otol Rhinol Laryngol. 2008;117:279–87.PubMedGoogle Scholar
  12. 12.
    Hamdy S, Rothwell JC, Aziz Q, Thompson DG. Organization and reorganization of human swallowing motor cortex: implications for recovery after stroke. Clin Sci. 2000;99:151–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Fraser C, Rothwell J, Power M, Hobson A, Thompson D, Hamdy S. Differential changes in human pharyngoesophageal motor excitability induced by swallowing, pharyngeal stimulation, and anesthesia. Am J Physiol Gastrointest Liver Physiol. 2003;285:137–44.Google Scholar
  14. 14.
    Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing. Arch Otolaryngol Head Neck Surg. 2007;133:564–71.PubMedCrossRefGoogle Scholar
  15. 15.
    Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia. 1988;2:216–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Langmore SE, McCulloch TM. Examination of the pharynx and larynx and endoscopic examination of pharyngeal swallowing. In: Perlman A, Shulze C, editors. Deglutition and its disorders. San Diego: Singular Publishing; 1996. p. 201–26.Google Scholar
  17. 17.
    Langmore SE. Endoscopic evaluation and treatment of swallowing disorders. New York: Thieme; 2001.Google Scholar
  18. 18.
    Leder SB. Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia. Arch Phys Med Rehabil. 1998;79:1264–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Crary MA, Carnaby Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil. 2005;86:1516–20.PubMedCrossRefGoogle Scholar
  20. 20.
    Ludlow CL, Humbert I, Saxon K, Poletto C, Sonies B, Crujido L. Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia. 2007;22:1–10.PubMedCrossRefGoogle Scholar
  21. 21.
    Freed M, Wijting Y. VitalStim Certification Program. Training manual for patient assessment, treatment using VitalStim electrical stimulation. Hixson: Chattanooga Group; 2003.Google Scholar
  22. 22.
    Erketin C, Aydogdu I, Tarlaci S, Turman AB, Kiylioglu N. Mechanism of dysphagia in suprabulbar palsy with lacunar infarct. Stroke. 2000;31:1370–6.CrossRefGoogle Scholar
  23. 23.
    Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11:93–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Mann G, Hankey GJ, Cameron D. Swallowing function after stroke. Prognosis and prognostic factors at 6 months. Stroke. 1999;30:744–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Martin L, Cometti G, Pousson M, Morlon B. Effect of electrical stimulation training on the contractile characteristics of the triceps surae muscle. Eur J Appl Physiol. 1993;67:457–61.CrossRefGoogle Scholar
  26. 26.
    Leelamanit V, Limsakul C, Geater A. Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope. 2002;112:2204–10.PubMedCrossRefGoogle Scholar
  27. 27.
    Oh BM, Kim DY, Paik NJ. Recovery of swallowing function is accompanied by the expansion of the cortical map. Int J Neurosci. 2007;117:1215–27.PubMedCrossRefGoogle Scholar
  28. 28.
    Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am. 1995;77:1166–73.PubMedGoogle Scholar
  29. 29.
    DeKroon JR, Ijzermann MJ, Chae J, Lankhorst GJ, Zilvold G. Relation between stimulation characteristics and clinical outcome in studies using electrical stimulation to improve motor control of the upper extremity in stroke. J Rehabil Med. 2005;37:65–74.CrossRefGoogle Scholar
  30. 30.
    Shaw GY, Sechtem PR, Searl J, Keller K, Rawi TA, Dowdy E. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol. 2007;116:36–44.PubMedGoogle Scholar
  31. 31.
    Halper A, Cherney L, Cichowski K, Zhang M. Dysphagia after head trauma: The effects of cognitive-communicative impairments on functional outcomes. J Head Trauma. 1999;14:489–96.Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Shu-Fen Sun
    • 1
    • 2
  • Chien-Wei Hsu
    • 2
    • 3
  • Huey-Shyan Lin
    • 4
  • Hsien-Pin Sun
    • 5
  • Ping-Hsin Chang
    • 1
  • Wan-Ling Hsieh
    • 1
  • Jue-Long Wang
    • 1
  1. 1.Department of Physical Medicine and RehabilitationKaohsiung Veterans General HospitalKaohsiungTaiwan
  2. 2.National Yang-Ming University School of MedicineTaipeiTaiwan
  3. 3.Department of Internal MedicineKaohsiung Veterans General HospitalKaohsiungTaiwan
  4. 4.School of NursingFooyin UniversityKaohsiungTaiwan
  5. 5.Department of General SurgeryCheng Ching HospitalTaichungTaiwan

Personalised recommendations