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??

Pre-Made Pureeds…..Not All the Same

I’ve had the opportunity recently to sample some different pureed foods.  Ok, so I wasn’t exactly jumping for joy with the thought of trying different pureeds, or pureed food at all, but I figured it couldn’t hurt.  Besides, if I’m going to feed patients this food or recommend it for my patients, I should know the best pureed foods to recommend.

This is what I’ve always seen with a pureed diet:

A lot of food that I can make an educated guess as to what it is, I’m just not really sure what it is.

With food molds becoming more readily available, your pureed food can actually look like this:

Blossom Foods has pureed foods available, however I’ve never seen or tried their food.

Thick-It has had foods available for some time.  I’ve looked at these foods and could never stomach trying them.  I think most of us know Thick-It though for the thickeners they produce.

The Thick-It website states their purees are:

Ideal for Caregivers & Healthcare Providers with Dysphagia Patients

Thick-It® Purees were designed to be convenient for people with dysphagia and their caregivers who may not have the time, resources or patience to blend their own pureed foods. At a ready-to-eat consistency, Thick-It® Purees can be swallowed safely and easily, and may reduce the risk of aspiration pneumonia, a potentially life-threatening complication of dysphagia. Patients can receive the proper nutritional benefits while enjoying a wide variety of food options. A complete list of nutrition information is available, including our list of gluten-free products and allergen information.

 

Thick-It® Purees are Ideal for Any Time of Day


Our purees come in 15 varieties and are perfect for breakfast, lunch, dinner and snacks.

      • Entrees: Beef in Barbecue Sauce, Beef Lasagna, Beef Stew, Chicken a la King, Salisbury Steak, and Seasoned Chicken Patty
      • Breakfast: Maple Cinnamon French Toast, Omelet with Sausage and Cheddar Cheese 
      • Sides: Carrot & Pea, Seasoned Green Bean, Sweet Corn, Seasoned Spinach and Seasoned Broccoli
      • Dessert: Caramel Flavored Apple Pie and Mixed Fruit and Berry

 

Features and Benefits

 

  • Convenient, just open, heat and serve
  • Can be easily shaped for appealing plate presentation
  • Consistent texture and reliable nutrition
  • Great for Emergency stock
  • 5 to 8 servings per can

Once opened, remaining portions can be stored immediately in an air-tight container for 5 – 7 days in the refrigerator or placed in the freezer for up to one year. For quality assurance, unopened products should be consumed within two years of being manufactured, which is determined by the number on the bottom of the can.  For assistance with reading the Julian code, please visit our frequently asked questions.

 Thick-It® Purees may be covered by Medicaid providers and insurance companies.  Contact your or your loved one’s insurance provider to see if they will cover the Thick-It® Purees, as some may cover the expenses associated with swallowing disorders. Visit our frequently asked questions page to learn more about HCPCS codes, which are used for billing insurance purposes.

Today, I received several samples of Thick-it.  Pasta, frozen meats, vegetables and fruits in molded trays and several cans of food.  The box was huge and heavy with a large thermo container for the frozen foods with dry ice, which my kids thought was the coolest thing when my husband dumped it in the sink in the bathroom.

I opened the first can of Thick It food, which was Berry Fruit Puree.  It was actually good, tasting like flavored applesauce.  My 8 year-old, very picky daughter loved it.

The frozen pureeds in the molds took close to an hour and a half for the meats to cook in the oven, a little less for the fruits and vegetables.  I tried the berry, peaches, corn, green beans, chicken, turkey, ham and roast pork.  These are made to look like the actual foods after cooking and turning over and dumping on the plate.  The corn was good.  The peaches and berries were ok, but very gel textured.  The meat, I couldn’t eat.  It was very fake tasting and just over-powering and gritty.  The green beans were bland.  The only foods that kept that shape of the molds were the corn and meats.

My husband stated the meats tasted very gritty and the ham was a very fake, smoky taste that he didn’t much like.   He liked the corn and the taste of the fruits, but not the gel texture of the fruits.  The chicken and turkey he thought were bland but not as bad tasting as the ham and the green beans did not taste like green beans at all.

I couldn’t eat the canned foods.  Not only did it look like something I would feed my dogs, it smelled the same.  I took a small bite and food was either very bland or tasted nothing like what it was supposed to taste.

My husband, didn’t mind the canned pureed corn and green beans, just thought they were a little flavorless, but the canned lasagna and seasoned chicken tasted nothing like they were supposed to taste.

I commend Thick-It though on a good effort.  It seems they’re on the right track, just some of the food needs some work.

I did have the opportunity to not only meet, but sample Pure-A foods at ASHA 12 in Atlanta, GA.  I tried the taco and cheesecake at that time.  It was actually not bad.  The cheesecake was very good.  The taco looked like pureed food, but tasted surprisingly like a taco.

The Pure-a website offers a list of advantages of their products:

PURE A ADVANTAGES

Pure-a meal components have many advantages over frozen options. Below is a brief list of the many benefits Pure-a offers vs frozen.

Pure-a items can make both pureed meals and shakes (Nectar/ Honey Like Consistencies). Just follow the simple directions, in addition, you can make ice cream from Pure-a desserts.   

Pureed products use flavorful, dried ingredients. Dried ingredients are used in many of your favorite foods to help boost flavor. They offer great taste, color and aroma while maintaining nutrition. In addition, our products are made wth all natural flavors. Pure-a can afford to use better ingredients because of the shipping savings realized by not shipping water.

Pure-a products are less expensive. Compare the delivered cost of Pure-a products vs frozen products. Because frozen shipping is so expensive, you can save almost $2.00 per unit on a 3 oz protein item by using Pure-a vs frozen options.

Pure-a products are safe, the drying process sterilizes the food, making it safe to eat even if it is not prepared properly. Many frozen items must be heated to 165 degrees in order to be sterilized and safe to eat. In addition, frozen items can thaw during shipping if not handled properly.

Pure-a products are shelf stable, which allows for inexpensive shipping and storage. The savings from shipping can be over $1.00 per 3 oz serving. In addition, you can store Pure-a items in your pantry and do not need to buy and run an expensive second freezer.

Pure-a products are easy to prepare. All you need to do is pour the powder into a bowl, add water, whisk and let sit for 1 minute. No need to use a microwave, oven or steamer which frozen products require.

Pure-a products are better for the environment. Pure-a products do not require significant packaging such as dry ice or gel packs to keep the product frozen.

I sampled several of the Pure-A foods when I received samples for a patient.  Grilled asparagus, fiesta taco, cheesecake, baked mac and cheese.  Pure-A comes in a small pouch and is shipped in powder form.  The box you receive for a variety of packets is small.  It is mixed with hot boiling water/liquid and cold water for most of the desserts.

The Pure-A food was actually fairly good.  It tasted like a taco or cheesecake filling.  It is a little gritty, but I can get used to that given the exceptional taste.   The vegetables were not bland and the dessert was enjoyable.  The only downside for Pure-A is the smaller selection of food.  I am very excited to see the new foods the Pure-A company develops as they continue to grow.

**UPDATE**  Today, I received 14 samples of Pure-a in the mail.  I tried all of them.  The food continues to be very good.  The only foods I really didn’t like were the spaghetti, sweet and sour chicken and the asparagus.  Other than that, the food was really good and I could tell what it was supposed to be.

My husband wasn’t able to sample the Pure-a, however a pediatric patient really liked the foods and his caregiver was excited at the small size of the packaging and the ease of the preparation.  She also stated the food was actually pretty good.

Thick It offers 6 different entrees (Beef in Barbecue Sauce, Beef Lasagna, Beef Stew, Chicken a la King, Salisbury Steak, and Seasoned Chicken Patty), 2 breakfast items (Maple Cinnamon French Toast, Omelet with Sausage and Cheddar Cheese), 5 side items ( Carrot & Pea, Seasoned Green Bean, Sweet Corn, Seasoned Spinach and Seasoned Broccoli) and 2 desserts ( Caramel Flavored Apple Pie and Mixed Fruit and Berry).  Pure-A offers 9 entrees (Turkey/Mashed Potatoes & Gravy, BBQ Beef and Southern Corn Bread, Italian Spaghetti with Fennel, Fiesta Beef Taco and Corn Tortilla, Sweet and Sour Chicken, Roast Beef/Mashed Potatoes and Gravy, Baked Mac and Cheese, Chicken Parmesan, Teriyaki Beef Bowl), 7 sides (Sauted Spinach and Mushrooms, Fully Loaded Baked Potato, Autumn Harvest Sweet Potato, Creole  Corn and Tomatoes, Grilled Asparagus, Green Bean and Tomato Salad, Almond Seasoned Green Beans) and 5 desserts (New York Style Cheesecake, Blueberry Cobbler, Strawberry Shortcake, Georgia Peach Cobbler, Banana Cream Pie).

Both companies also offer samples, so that you or your patients can try these products prior to purchasing large amounts.

The cost comparison from Pure-a states costs as follows:

Save almost $2.00 per unit vs frozen options with Pure-a!

Pure-a meal components offer restaurant quality flavor and aroma at a lower delivered price than frozen options. Because Pure-a meal components are shelf stable, they do not require frozen shipping allowing Pure-a to use better, all natural flavors. In addition to saving on your purchase, you will not need to take up valuable frozen storage space or run an expensive second freezer.

See for yourself how much you can save with Pure-a. Below is an example showing the price for 24 units of Roasted Turkey. Pure-a allows you to save almost $2.00 per unit vs some frozen options.

Pure-a Frozen Option #1 Frozen Option #2
Price per unit $2.99 $3.99 $3.45
Price for 24 units $71.76 $95.76 $82.80
Shipping $12.00 $59.54 $50.00
Delivered Price $83.76 $155.30 $132.80
Delivered Price per unit $3.49 $6.47 $5.53

One concern with both Thick-It and Pure-a is this.  My husband and I have recently completely revamped the way we eat.  We have stopped eating salt, high fructose corn syrup, corn starch, wheat, basically we eat very fresh food.  I would love to see both companies strive to create an alternative for those health-conscious people that don’t want preservatives, salt or gluten, however want a quick and easy fix for pureed.  That might not be possible with the packaging, but would be a great advantage for any company!

I highly recommend that you request samples to try this for yourself.

I will still say, if any of you reading this are my SLP someday, please don’t put me on a pureed diet.  However, I think I could actually eat some of the pre-made from Thick-It and all from Pure-a.