Ampcare………A new name for NMES

I love the ASHA convention.  Why?  It gives me an opportunity to not only see all the new products and offerings in the world of Speech Pathology, but a chance to sit down with the company reps to ask my questions and to actually try the product.

Ampcare is not new in the sense that they just started the company.  Ampcare has actually been around and researching NMES (Neuromuscular Electrical Stimulation) for swallowing rehabilitation since 1993.

I actually touched on Ampcare in a previous post regarding electrodes for NMES, however at that time, they were working on FDA approval of the device, so there was little information available.  I had received an email from Ampcare discussing their product, however it was very nice to sit down with Russ and Rick and to have them explain why they are superior in the NMES market.

The Electrodes:

The AmpCare electrodes are larger than other available electrodes.  The reason for this is the smaller electrodes concentrate on a smaller area, creating a “hot-spot” which can be painful for our patients.  The larger electrodes not only even the distribution of the stimulation, increasing patient comfort, they are made to fit directly over those submental muscles that target hyolaryngeal elevation and that anterior movement of the hyoid.

The electrodes offer low impedance (10 Ohms).  The electrodes are latex-free.  The VitalStim Electrodes offer impedance of 30 Ohms or less.  This means more current running to a smaller area.

The electrodes were comfortable and I was able to tolerate a higher intensity of stim with the electrodes in place.

The electrodes can be placed as shown above or on the face to target the muscles of the jaw.

The electrodes are also cost-effective.  There are 4 electrodes per package.  Which, if used in only one placement, hyoid or face can last 10 sessions.  The cost for 10 packages of electrodes (40 electrodes) will be $119.50.  To buy 400 electrodes or 100 packages the cost would be:  $895.  That would be 400 electrodes or 2000 sessions!

Price Comparison:

Freedom Electrodes:  12 Electrodes, single use $159 ($13.25 each)

Vital Stim Electrodes:  12 Electrodes, single use $209.00 ($17.42 each)

Alternative Electrodes:  40 Electrodes, single use $ 108.50 ($2.71 each)

AmpCare Electrodes:  40 Electrodes, Use 5 times $119.50 ($1.20 each or with 5 uses-.24 cents each)

 

The Posture Device:

The posture device alone costs $100.00

The posture device was created to help those who need a little assistance in achieving and/or maintaining good posture while eating.  The Restorative Posture Device (RPD) is indicated for those patients with :

  •  Head and neck alignment issue causing increased swallowing difficulty.
  • Forward head on neck posture resulting in decreased range of motion.
  • Weakness in the neck musculature.

This can also be used as a resistive device for a chin down exercise, similar to the Shaker or using the Neckline Slimmer as an alternative to the Shaker.

The NMES Device:


The biggest difference in Ampcare, to me, is the actual device.  The device actually allows you to set your own parameters.  The comparison between the Ampcare device and the VitalStim device is below.

Ampcare                                                            VitalStim

Treatment Time                  5-30 minutes                                                       up to 60 minutes

Ramp                                          1 second                                                               ?

Output                                       0-100 mAmps                                                    25 mAmps

Frequency                                5-50 Hz                                                                 80 Hz

Channel                                    Single or Co-Contraction                           Dual

Phase Duration                     50-250 MicroSeconds                                 300 MicroSeconds

Cycle Time                                5/15, 5/20, 5/25                                              59/1

The main differences between the devices is the frequency, which can be adjusted for comfort level and to increase the mAmps with the Ampcare device.

The other difference is the Cycle time.  VitalStim cycles 59 seconds on, 1 second off.  This means a muscle contraction of 59 seconds.  Ampcare has variable cycles with the time on always at 5 seconds.  You can adjust the stim off from 25 to 20 to 15.  The theory with this is that we are targeting Type II muscles, those fast-twitch muscles that contract and relax rapidly and fatigue easily.  Contracting a muscle for 59 seconds is not a natural activity.  A muscle contraction of 5 seconds is longer than the normal contraction time of the muscle during a swallow.

The Program:

Ampcare teaches and uses what they call ESP (Effective Swallowing Protocol).  This protocol involves 30 minutes of stimulation including 30 minutes of Mendelsohn Maneuver, Effortful Swallow and chin down (Shaker) exercise using the RPD.  All swallows with stimulation on are completed with dry swallows.

When I asked AmpCare about the progress and maintenance of skills they see with patients, 3 of 5 patients they case studied were increased from NPO to an oral diet with no decrease in function since the end of therapy.  They also have a video that they demonstrate showing the effect of the stim with the fluoro on with tremendous movement of the hyoid causing increased laryngeal elevation.

In summary, the differences of AmpCare:

  •  A 5 second “on” stimulation, mimicking more of the Type II muscle contraction.
  • During the 5 seconds of stimulation, the patient exercises using a dry swallow as resistance.
  • Food is presented to the patient during the “off” time of the cycle (time without stim)
  • A posture device is used for a chin down resistive exercise, comparable to the Shaker
  • Electrodes are place above the hyoid only, without the downward pull on the suprahyoids
  • Frequency is lower, presenting increased comfort for the patient
  • Electrodes are larger, targeting a larger area with larger dispersion of the stimulation

If you have any questions, the company can be reached by email.

Trainings are available by searching the website.  Training costs just over $300 and includes freebies (One package of FDA 501k cleared Ampcare E-Series Electrodes, One posture device and the course material).

**I do not currently use the Ampcare system, nor do I endorse it at this time.

Electrodes…..Are they really all the same??

One of the biggest controversies in dysphagia therapy has to be NMES or Neuromuscular Electrical Stimulation, to use it or to not use it.  It has been extensively researched, although results of the research vary.

Whether you believe in NMES for dysphagia or use NMES, you need to understand the facts between the electrodes.  It’s not just about cost, the construct, impedance and versatility are also important.

One important thing to remember is that if the electrodes pull away from the patient, not only can it be uncomfortable for the patient but can interfere with your treatment.

VitalStim is the only company I’m aware that will only sell their electrodes given a certified clinician number, meaning that you HAVE to be certified in the modality to purchase the equipment.

The only training I have attended is VitalStim, which was worth every penny.  Whether you use the modality or not, the training is priceless with all the valuable information you gain.

One thing to remember is that NMES is not a cure.  Slapping the electrodes on a patient and turning on the machine will not make them swallow.  It is a modality, meaning that it may help improve the swallow when paired with swallowing exercises.

NMES stimulates Type II muscles, those fast twitch muscles predominant in the pharynx.  These are also the muscles that fatigue at a faster rate.

I have compiled information from websites (as available) regarding each of the electrodes available (of which I’m aware) for dysphagia therapy.

I do not endorse any of the electrodes.

Freedom Electrodes

Freedom Electrodes are distributed by North Coast Medical.  These electrodes are very much comparable to the VitalStim electrodes and work with the VitalStim and Guardian units.  


The tape holding the electrodes feels much like the VitalStim tape and the build of the electrode is much the same.


My patient who has used the eSwallow, VitalStim and Freedom electrodes stated that the Freedom Electrodes feel much like the VS electrodes.

The uniform current eliminates hot spots and provides maximum treatment across the entire electrode surface.

  • Freedom Stim™ Dysphagia Electrodes work with existing NMES devices for the treatment of dysphagia.
  • Silver (Ag) coated carbon film for reduced impedance, greater conductivity and uniform current dispersion.
  • Higher posts allow better adherence to the lead wires during treatment.
  • High quality, dual layer of gel formulated will adhere better during treatment.
  • Gel does not separate from carbon.
  • Latex Free.

Each kit contains:

  • (2) Tan Foam 2″ x 3.5″ (5cm x 9cm) Butterfly w/Snap Electrode.
  • (3) Skin-Barrier Wipes.
  • (3) Lotion Packets.

Freedom Stim™ 

Dysphagia Electrodes

 

 

Why Choose 

Freedom Stim™ Electrodes

 
  • Silver (Ag) Coated Carbon Film for Reduced Impedance,

    Greater Conductivity and Uniform Current Dispersion.

  • Extra Long 6” Pure Copper Lead Wires with Dispersive Heads.

    Helps to Prevent Wire Pull-Out from Body of Electrode.

  • High Quality Gel for Optimal Skin Adhesion.
  • Gel Does Not Separate from Carbon.
  • Excellent Customer Support.
  • Prompt Turnaround Time on Orders.
  • Competitive Pricing.
 
 
 

Freedom Stim™ Electrode Conduction

 

 
 

 

Freedom Stim™ Electrode Current Dispersion

 
    • The unique manufacturing processes and material used in Freedom Stim™ electrodes provide a uniform current dispersion throughout the desired treatment site of each electrode. This uniform current dispersion eliminates “hot spots” and provides the maximum treatment to the entire electrode surface.
 
    • A leading brand electrode and a Freedom Stim™ electrode are placed on a “Current Dispersion Meter”. An electrical current is passed through each electrode for a period of 60 seconds. The electrical voltage output is identical for each electrode. Results are shown at right.
 
  • The Freedom Stim™ electrode displays optimal current dispersion while the leading brand treats less than 50% of the surface, mainly where the wire is placed.
 
 

The difference is clear…

 

Current is concentrated in a small area, creating a “hot spot” that is less effective.

 
 

Freedom Stim™ electrodes are able to fully disperse the electrical current throughout the entire surface of the electrode.
The cost:  12 electrodes for $159 or $13.25/each

30 electrodes for $379.95 or $12.65/each

50 electrodes for $595.00 or $11.90/each

VitalStim Electrodes
From personal experience, I have to wrap the VS electrodes or whenever the patient moves, they do tend to pull away from the skin.


The VitalStim electrodes are designed for single use. 


VitalStim virtually pioneered the NMES drive for dysphagia therapy.  It’s become the branded name, not unlike Kleenex or Coke.  


When ordering VS electrodes, you have to have a VS number to order, preventing untrained clinicians from ordering supplies.

From the electrode fact sheet:

The VitalStim electrode was specifically engineered to cope with this challenge of the

dysphagia therapy environment.
The conductive carbon film is covered by a layer of silver to decrease impedance. The snap is

secured to the carbon by a patented conductive bond tape. This assembly is

covered by the foam cover and finally the tape patch that connects the electrode pair.

Impedance
To ensure low impedance, an extra layer of silver was added between the carbon and the

gel. In addition, a special gel was used that could withstand a full 60 minutes of current

flow. The gel was later improved to provide better adhesion. This construction results in a

consistent impedance rating of 30 Ohms or less (excellent).
The impedance (resistance to current flow) of an electrode increases with the amount of

current that flows through it.   Each square inch of the VitalStim electrode is exposed to a current load that is 20 x higher than an electrode that is used during a typical NMES protocol. In other words, only after 20

typical NMES treatment sessions will the typical NMES electrode have been exposed to

the same amount of current concentration as what the VitalStim electrode withstands

during a single session. The electrode used during VitalStim Therapy must therefore be

one that is able to carry this current load without increasing in impedance.
The cost:    12 for $209.00 or $17.42/each

30 for $450.00 or $15.00/each

50 for $675.00 or $13.50/each

100 for $1300.00 or $13.00/each

Alternative Electrodes

I have not personally had the opportunity to use these electrodes.  


There is not a lot of information on the website, so I hope to soon receive a sample pack to try the electrodes.  On myself, not my patients!

All shipments are in bags that contain ten 4-packs, or 40 individual electrodes. These are reusable electrodes (on the same patient).

All electrode orders include paper tape.  Skin prep pads are included with snap electrodes only.  Additional tape and pads are available if needed.

Save money on shipping by ordering more than one bag.  Shipping and handling is $8.95 per order (regardless of the size of your order). Shipments are made by Fed-X or UPS Ground (no PO Boxes please). Shipments are usually made within 24 hours of receipt of your order, depending on inventory.

Overnight shipping is available upon special request at $35.00 per order.

1.   .8″ round electrode with mini-snap connector            $98.50 per bag*
2.   1″ round electrode with mini-snap connector             $102.50 per bag*

3.    Butterfly electrode with min-snap connector              $108.50 per bag*

4.    .8″ round electrode with pigtail connector                   $72.50 per bag*
5.   1″ round electrode with pigtail connector                     $75.00 per bag*

 

* each bag contains ten 4-packs, or a total of 40 electrodes

 

 

Quality Construction

                       
             AlternativeElectrodes          Most competitive electrodes

Many electrode manufacturers sacrifice quality for economy – not us.  All electrodes supplied by AlternativeElectrodes use a high-performance, specially applied layer of pure silver inside our electrodes. This highly-conductive layer of pure silver disperses the electrical signal quickly and evenly over the entire surface of the electrode resulting in a more comfortable and more effective treatment for the patient.

 
 

The tape material holding the ESwallow electrodes is thin and a bit more flexible, however I still had to wrap the neck to ensure that the material did not pull away from the patient as they moved and ate.

 

With the thinner tape holding the electrodes, the actual electrode pulled away from the tape upon removal of the electrode after the session was over.

 

The ELI Premium Ag+ has a bold new look and even better performance.  The newly re-formulated electrode may be used for up to 3 treatment sessions on an individual patient.  The extremely low impedance electrode features total surface dispursion.  This makes the ELI Premium Ag+ the most advanced electrode on the market, delivering improved therapeutic results and greater patient comfort.  2 electrodes are conveniently pre-positioned on each butterfly shaped electrode patch.


The solitary plus electrode kit features the same, high performance electrode used in the ELI Premium Ag+. But, each electrode resides on it’s own self-adhesive patch.  This allows the SLP to have maximum control over the exact placement of the electrodes. 


The ELI Premium Ag+ is manufactured from an advanced silver – carbon – silver film.  A layer of carbon is sandwiched between two layers of silver chloride for complete dispersion of current.  A high quality 35 mil gel (compared to competition’s 25 mil gel) ensures maximum conductivity between the electrode and target muscle.  The result is an electrode with extremely low impedance.  Lower impedance means improved therapeutic results and greater patient comfort.


Ampcare

This is a newer company to me.  I first learned of this company on Twitter.  I went to their website, which gave me virtually no information.  This company has designed an NMES system that conducts stim to the submental muscles.  They offer a protocol called ESP (Effective Swallowing Protocol).
I could only find one piece of information on ESP through a Google search.  In this slide show which was presented, the “RX3ESP utilized a portable muscle stimulator using pulsed electrical current to depolarize nerve endings and produce a muscle contractions.”  5 patients were studied using this protocol.  Sessions were 30 minutes using 3 exercises 10 minutes each:  a modified Shaker using their posture device, the Mendelsohn Maneuver for 4 seconds followed by a swallow and the Effortful Swallow.  Of the 5 patients, 2 patients returned to full oral diet.
I have contacted the company multiple times with no response to date.  There is no information on the site regarding construct of the electrodes nor can I find any efficacy for use of this system.

**UPDATE:

Ampcare responded!

Unfortunately, they do no provide samples of their product.  You can receive their products when you attend the training.

Ampcare “utilizes any portable powered muscle stimulator that will house our parameters, Ampcare’s patented E-series FDA cleared pie shaped electrodes and a neuro-orthosis to address posture and add a resistive load to the exercise program.”

Ampcare began research in the US in 1997 with completion of a controlled trial in 2007.

The Ampcare electrodes are made to:

  •   Specifically designed to match the curvature of the jaw line.
  •   Made with a unique composition and highest quality materials.
  •   Extremely low impedance (10 Ohms) with total surface dispersion.
  •   Reusable, pre –gelled, self adhering, single patient use electrodes.
  •   Latex free, ISO Certified, made in the USA and up to 5 times cost
    savings.

Ampcare also offers a Restorative Posture Device (RPD)

AMPCARE Restorative Posture Device (RPD) – is indicated for patients that present with poor neck posture. This includes any individual with a:

  •   Head and neck alignment issue causing increased swallowing difficulty.
  •   Forward head on neck posture resulting in decreased range of motion.
  •   Weakness in their neck musculature.

Guardian
The Guardian electrodes, are made much the same as the other electrodes (Eswallow, VitalStim, Freedom) with a flexible tape, which still requires wrapping to ensure that the electrodes stick through movement.  


One difference with Guardian is that they advertise the electrodes as reusable.


The electrodes come in a variety of sizes as does Eswallow and Alternative electrodes.

     
     
     



        


Which electrodes do you believe work the best??