[Dysphagia] vital stim & mentally retarded population

[sem at new-vis.com (Suzanne Morris)]

I am not trained in VitalStim and thus, do not consider using it in  
my practice.   I have had extensive experience with individuals who  
have severe and profound developmental disabilities.  Many of these  
individuals who have severe swallowing problems also have substantial  
problems with muscle tone and movement coordination throughout their  
body.   The swallowing issues, in my experience, are rarely an issue  
of the oral-pharyngeal mechanism independent of what is going on in  
the rest of the body.   The mouth and pharynx are very much  
influenced by head and trunk position, postural tone and reflexive  
movements.  You may be able to stimulate specific muscles in the neck  
that influence the physiological swallow, but this is going to be in  
strong competition with the shifts in tone and movement that occur on  
a daily basis with reflexes that respond to the vestibular input of  
gravity and the proprioceptive stimulation of muscles in the neck.

 From time to time I view videotapes of children who are receiving  
VitalStim.   Their parents will be participating in an intensive  
workshop that I teach or I will be seeing the kids themselves for  
assessment and treatment at a later time.   I just reviewed one of  
these recordings yesterday which shows a VitalStim session.  It was  
very similar to others I have viewed in the past.  In this instance  
the client was a young pre-teen boy who had been in a near-drowning  
accident as a toddler.   He shows stiff extension throughout his body  
and strong hyperextension of his head/neck in all positions. While  
sitting in his wheelchair his trunk is pulling down toward the left  
side and there is increased tension and shoulder girdle elevation on  
the right side.  His ribcage is stiff and shows slight movement  
predominantly in the upper thoracic and clavicular areas.  His jaw is  
open widely in a thrust position and there is limited jaw movement.   
There is minimal movement of the facial muscles at rest or with  
emotion.  The electrodes for the VItalStim are on his neck and I  
assume that stimulation is occurring throughout the session. In the  
filmed treatment session the therapist stimulates his mouth with a  
cotton swab with taste and then with small spoonfuls of pudding.    
The stimulation of the mouth itself elicits greater lip/cheek  
movement and some purse-string closure of the lips; slight downward  
pressure of the spoon on the tongue stimulates a very weak and  
inconsistent backward-forward suckle motion of the tongue.  There is  
intermittent coughing up of mucus and food, usually occurring after  
the 3rd or 4th spoonful of pudding.   This suggests to me that a  
swallow is not being triggered (despite the therapists comments that  
he has swallowed).  I think that food i simply falling over the back  
of the tongue and disappearing into the valleculae and pyriform  
sinuses until they fill up and trigger the cough.    What concerned  
me the most about this session is that his head was in severe  
hyperextension the whole time and at times went into greater  
extension with the oral stimulation.  The therapist was working on  
lip closure and swallowing but with a wide-open jaw.   We know that  
neck hyperextension can increase extensor tone in the jaw and reduce  
oral coordination.  Mechanically it is extremely difficult to get a  
good and efficient swallow with the head pushing back into extension.

So my question is a common-sense one.  Why do we choose to use a  
specialized piece of equipment (VitalStim) to stimulate specific  
muscles in the neck for swallowing (even assuming that this does  
work) when the underlying foundation for the swallow really isn't  
there?   This therapist and family have continued with VitalStim  
because the child's MBS has shown some "improvement over time" (I  
haven't seen copies of the MBS reports so I don't know the  
specifics).  But even if there is some improvement in this artificial  
setting, how does this relate to his life and to how we choose to  
spend our time and money to improve swallowing function?

I have worked with numerous children whose physical involvement and  
cognitive impairment was similar to that seen in this boy.  The focus  
of treatment has been on working in an integrated way with postural  
tone and movement to reduce tone and the constant stimulation of  
reflexive movements.   A major focus has been to reduce the extension  
patterns in the body and neck and help the child learn how to get a  
"soft body" or "soft neck" just with a verbal or touch reminder. This  
is combined with oral stimulation of the suckle to elicit a stronger  
and more sustained suckle-swallow movement pattern.  I have found  
that this has been highly effective, and children have learned more  
functional swallowing skills (especially for handling their own  
secretions and reducing the amount of drooling or need for constant  
suctioning to clear the airway) without any electrical stimulation of  
the swallowing muscles.

Suzanne
__________________________________
Suzanne Evans Morris, Ph.D.
Speech-Language Pathologist
New Visions
1124 Roberts Mountain Rd.
Faber, VA 22938
(434) 361-2285 ext. 5
www.new-vis.com


On Sep 7, 2007, at 11:36 AM, Michele.Graziadei at dhs.state.nj.us wrote:

>  Does anyone have any information regarding Vital Stimulation  
> Therapy with the severe and profound developmentally disabled
> population (MR)?  I presently am employed at a residental facility  
> for the MR population -mainly severe & profound whom are not able  
> to follow directions. Thanks!!!!!