# Electrical Stimulation May Improve the Feeding and Nutritional Status of Children with Dysphagia
## 6 Electrical Stimulation  
The usual methods of dysphagia therapy, based on exercises and dietary modifications, do not always achieve the desired results, which indicates the need for new therapeutic solutions [13; 22]. One of the promising approaches to aid dysphagia therapy is NMES, which employs low-frequency current for stimulation of the muscles involved in the swallowing process [65]. NMES is a modality that sends electrical impulses to the nerves, which causes the muscles to contract, mimicking the action potential coming from the central nervous system. In this manner, it is possible to restore proper muscle contractility [6].  
Electrical stimulation, through the use of direct, alternating, and pulsed current, is used mainly in the treatment of pain, improving circulation, and strengthening muscles. In adults, NMES has been successfully applied, for example, in the rehabilitation of the muscles of the musculoskeletal system, in the rehabilitation after myocardial infarction, after brain injury, or as an adjunct in the treatment of neck cancer or soft tissue and bone injuries [26; 27; 28; 29; 30; 31; 32; 33; 34; 35; 36].  
The available literature indicates the possibility of using different types of electrical stimulation in the therapy of the orofacial area. NMES therapy in the head and neck area has been successfully used for swallowing rehabilitation in adult patients with acquired dysphagia [66; 67]. Direct, alternating, and pulsed current are used in the treatment of pain, improving circulation, and strengthening muscles. NMES has been successfully used as an adjunctive therapy in numerous applications, including spinal cord injuries, muscle spasms and atrophy, urinary incontinence, gastroparesis, and temporomandibular joint dysfunction [68].  
NMES contributing to the swallowing apparatus has been successfully used as a feeding therapy in adults after myocardial infarction and acute brain injury and after treatment for head and neck cancer [28; 29; 69; 70]. Despite dysphagia, NMES of the orofacial complex muscles may be used in practice to treat temporomandibular joint dysfunction,rehabilitation after facial paralysis, improvement of facial aesthetics, treatment of sleep disorders such as snoring and sleep apnea, regeneration and improvement of muscle function after surgical procedures in the facial area, strengthening muscles in cases of facial hypotonia or hypertonia, and inhibition of skin aging [71]. It was also used in the treatment of sarcopenia dysphagia in elderly patients [72].  
NMES involves the application of electrical current to muscles transcutaneously using surface electrodes [21, 73]. The therapists combine transcutaneous stimulation with conventional swallowing therapy [47, 73, 74, 75]. An example of electrode placement during therapy and example of NMES device are given in Figure 3. It was suggested that NMES improves dysphagia by strengthening the muscles involved in swallowing and by enhancing the sensory signals of the swallowing response [73]. Typically, NMES is performed repeatedly over a period of time. For example, some protocols use NMES up to five days per week for four weeks, but there are variations [72, 74]. In adult patients, it was demonstrated that conventional dysphagia therapy is less effective than therapy, including NMES [20, 70, 76, 77, 78].  
In the treatment of dysphagia in children, NMES is a novel therapeutic method that is fundamentally different from traditional methods. These methods include compensatory techniques (e.g., changes in head position) and swallowing training using foods of varying consistencies, as well as manual passages and exercises for the muscles of the throat and larynx. Table 1 presents a comparison of NMES with traditional dysphagia therapy methods.  
Figure 3: An example of electrode placement during therapy using NMES device (Ecostim).