Electrical Stimulation Therapy for Dysphagia: Descriptive Results of
Two Surveys
Michael A. Crary, PhD,1 Giselle D. Carnaby-Mann, MPH, PhD,2 and Allison Faunce, BA1
1Department of Communicative Disorders, College of Public Health and Health Professions, University of Florida Health Science Center,
Gainesville, Florida, USA; and 2Department of Behavioral Science and Community Health, College of Public Health and Health Professions,
University of Florida Health Science Center, Gainesville, Florida, USA
Abstract. Given the paucity of objective information
on neuromuscular electrical stimulation approaches
to dysphagia therapy, and the expanding utilization
of this clinical approach, we designed and conducted
two surveys to gather large-scale information
regarding reported practice patterns, outcomes,
complications, and professional perceptions associ-
ated with electrical stimulation approaches to dys-
phagia therapy. Self-administered questionnaires
were mailed to 1000 randomly selected speech-lan-
guage pathologists in each of two groups: (1)
clinicians who had completed a formal electrical
stimulation training course and were actively using
these techniques, and (2) clinicians who were mem-
bers of Special Interest Division 13 of the American
Speech-Language and Hearing Association. Survey
responses were anonymous and no incentive to re-
spond was included. Acceptable response rates were
achieved for both surveys (47% and 48%). Both
groups of respondents were demographically similar
and reported similar practice patterns. Stroke was the
most common etiology of dysphagia treated with this
approach. The majority of respondents identified no
specific dysphagia criteria for application of electrical
stimulation, used varied behavioral treatment meth-
ods, and did not follow patients beyond therapy.
Clinicians reported positive outcomes with no treat-
ment-related complications. Satisfaction with this
approach was reported to be high among patients
and professionals. Clinicians who did not report
using these techniques indicated that they were
waiting for more objective information on clinical
outcomes and safety. Results of these surveys form
an initial description of practice patterns and
outcomes associated with electrical stimulation
approaches to dysphagia therapy.
Key words: Dysphagia — Electrical stimulation —
Survey — Deglutition — Deglutition disorders.
Transcutaneous neuromuscular electrical stimulation
is a recent and novel approach to treatment for
swallowing disorders. The primary concept underly-
ing this approach is that electrical stimulation will
enhance muscle function during swallowing activity.
When combined with functional swallowing exercises,
the premise is that patients will experience improved
swallowing ability. However, limited data are avail-
able to evaluate potential benefits or risks from this
approach to dysphagia therapy. Two articles have
been published to date [1, 2], but both have design and
method limitations that reduce their impact and
threaten the external validity of obtained results.
VitalStim
(The Chattanooga Group, Hixson,
TN) is a commercially available neuromuscular elec-
trical stimulation (estim) device cleared by the FDA
for the treatment of pharyngeal dysphagia. VitalStim
refers to a specific program of estim combined with
behavioral therapy for swallowing disorders. The
manufacturer of VitalStim has mandated that clini-
cians complete a formal training course on the Vital-
Stim approach to dysphagia therapy before they will
be allowed to purchase this device. According to the
manufacturer, during the past two and a half years
over 5000 clinicians have completed this training
course and most have purchased equipment and
gained clinical experience in this technique. Anecdotal
information has emerged from this group of
Correspondence to: Michael A. Crary, PhD, P.O. Box 100174
Gainesville, FL, 32610, USA; E-mail: mcrary@phhp.ufl.edu
Dysphagia 22:165–173 (2007)
DOI: 10.1007/s00455-006-9068-x

practitioners regarding positive outcomeswith the estim
approach to dysphagia therapy. However, while anec-
dotal information may be encouraging, it offers little
toward the scientific evaluation of any technique.
Therefore, we completed a survey of this group of
practitioners (Endusers) to obtain more objective
information about practice parameters, clinical out-
comes, and professional perceptions from estim therapy.
Because estim approaches to dysphagia are
novel, we also sought to obtain information regard-
ing professional perceptions of these techniques from
individuals who have a declared interest in dysphagia
but may not be using estim approaches in treatment.
Toward that end, we randomly sampled and surveyed
members of Special Interest Division 13 (SID 13) of
the American Speech Language and Hearing Asso-
ciation (ASHA). SID 13 comprises professionals who
have a self-selected interest in swallowing and swal-
lowing disorders. As such, this group represents an
appropriate reference for opinions and perspectives
regarding various professional practices in the area of
dysphagia.
Surveys are appropriate tools to gather large
amounts of information in an efficient manner. Many
recent surveys have been conducted in the area of
dysphagia to identify practice patterns and profes-
sional perceptions of clinical practices [3–6]. At least
two of these surveys identified discrepancies between
clinical practices and supportive research [4, 6]. When
clinical practice changes rapidly and impacts sub-
stantial numbers of practitioners, surveys are useful
to describe those practices toward a better under-
standing of potential risks and benefits that may be
expected from newly emerging clinical applications.
Surveys also function to define or describe trends or
variables that serve as the content for subsequent
clinically relevant research [7]. The rapid growth in
estim therapy applications for dysphagia in the ab-
sence of well-designed outcome studies supports the
need to describe practice patterns and clinician-re-
ported outcomes and complications. On a cautionary
note, surveys may lack a high degree of specificity.
Because they are designed to gather large amounts of
information quickly, they often intentionally may be
brief or focus on more global rather than specific
details. In addition, surveys addressing patient care
issues rely on the perceptions and recollections of
respondents who provide patient care. Thus, any
obtained results depict the information provided by
the respondents rather than information obtained
directly from patients receiving care. Despite these
limitations, surveys can provide a substantial data-
base that is useful in understanding new or changing
clinical practices and their impact on patient care.
Collectively, our purpose was to survey two
groups of clinical speech-language pathologists who
had a specific interest in dysphagia. Our intent was to
describe reported practice patterns, clinical outcomes,
and complications associated with estim therapy
applications. Our secondary goal was to gather
information on clinician perceptions of estim as an
approach to dysphagia therapy both from profes-
sionals who were using these techniques and from
those who were not.
Materials and Methods
Subjects
Endusers
Enduser recipients were identified as speech-language pathologists
who had completed a VitalStim training course at least six months
before the initiation of the survey. A six-month interval was chosen
to increase the probability that these clinicians had the opportunity
to use this intervention strategy before completion of the survey. At
the initiation of this study, a database maintained by the Chatta-
nooga Group, manufacturers of VitalStim, contained 2022 names
that met this criterion. From this database, 1000 names were ran-
domly selected using a computer-generated random numbers list.
SID 13
SID 13 recipients were identified as a group of speech-language
pathologists who declare a special professional interest in swal-
lowing and swallowing disorders, but who do not necessarily
demonstrate an investment in estim therapy approaches (i.e., had
not necessarily completed specific training any estim treatment
application). Not all SID 13 members permit dissemination of their
name. Therefore, from an available database of 2256 entries, 1000
names were randomly selected by computer. These names and
corresponding addresses were purchased from ASHA on ready-
made mailing labels.
Survey Development
The Enduser survey was developed first and modified to accom-
modate SID 13 recipients. We selected initial survey items to rep-
resent four professional domains of information: sample
demographics, practice patterns, outcome measurement, and sat-
isfaction. Table 1 summarizes these domains and their compo-
nents. In this table the number of questions listed for each domain
reflects the final version of the survey, not the initial version.
Though not a direct component of estim-based therapy for dys-
phagia, dilatation of the upper esophageal sphincter has been
advocated by some individuals as an adjunct to these techniques.
Therefore, we included questions on dilatation within the treatment
protocol subarea of the practice patterns domain. The pilot version
of the survey contained 37 questions. Questions included both
multiple choice and binary responses. Content and face validity of
the initial survey were evaluated by review of issues raised in
published outcome studies [1, 2] and by a focus group (n = 5) of
166 M.A. Crary et al: Electrical Stimulation for Dysphagia