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Learn about a treatment option for adult upper limb spasticity. Learn More


Welcome everyone to the No Plateau podcast. I am your host, Henry Hoffman, and I am joined today with Teresa Biber Lomonte, a speech language pathologist and a swallowing specialist from the beautiful Costa Rica. She's been there for a couple of years, which I just learned before the show. Teresa's claim to fame was in the late nineties when she created an NMES, which is electrical stimulation protocol for the treatment of dysphagia. And has been teaching therapists and patients worldwide since 2001. And that will be the focus today on the podcast. So Teresa, welcome. Thanks for joining today. And what's life like living in beautiful Costa Rica?

Podcast Transcript

Teresa Biber Lomonte (00:39.306):
Ah, thanks Henry for having me. Well, you know, the country's motto is Pura Vida, which translates into pure life. And it's really not just like a fun thing to put on a tattoo. It is literally the way they live life here. It is so pure and clean and beautiful, and the people are amazing, and it's just an incredibly peaceful and serene place to be, especially in the midst of these crazy times we're living in.

Henry Hoffman (01:08.888):
Yes, absolutely, absolutely. Well, Teresa, why don't we start from the top to set the stage. Can you share with the audience a bit more about your history in bio?

Teresa Biber Lomonte (01:18.974):
Sure. Well, again, I'm Teresa Biber Lomonte. Nice to meet everybody. I am an international dysphasia and electrotherapy expert with roughly 23 plus years of experience, clinical practice, primarily acute care, outpatient home care, skilled nursing facility, primarily adult population that I've clinically treated.

And I've also been teaching concurrently, ever since 2000, principles of electrotherapy as well as some manual therapy techniques. I have kind of a unique educational background in the sense that I very, because I kind of came to this aha moment very early, like literally in my first year of being a speech pathologist, I began teaming up with physical therapists and learning from them. So I'm kind of cross-trained in a lot of PT techniques including NMES, but as well as manual therapy techniques, which I teach as well. I've had three devices that have gone to the FDA based on my protocol, with a fourth one currently in the works.

Henry Hoffman (02:27.908):
Wow, that's amazing stuff. Well, the audience, as you know, are made up of patients and therapists, primarily occupational therapists, who do work really closely with speech therapists, but also a ton of patients and caregivers. And so I think we should start at the top, if you will. Since you're a swallowing specialist, can you just educate us a little bit on the basics on dysphagia, you know, any statistics you think are helpful for people to know, you know, how many people really have a swallowing problem? What exactly is dysphagia?

Teresa Biber Lomonte (02:57.866):
Right, right. Well, you say dysphagia, I say dysphasia. So it's a lot of a tomato. And I will tell you that a lot of people will use the term dysphagia to differentiate it from dysphasia, which is with an S as opposed to a G, so it does get a little confusing. But to back up a little bit, so what is dysphasia, or dysphagia?

Henry Hoffman (03:02.822):
Where did it go? Two minutes left.

Teresa Biber Lomonte (03:22.482):
So, DIS typically means there's something wrong. There's a, I think about DIS as disorder. There's a disorder in. And then, FASIA means to eat. So, there's a disorder in the ability of a person to be able to eat and drink normally. So, for example, I do this while I'm talking. I didn't think about it. It was a very reflexive act. It did everything kicked into place that needed to be done, which, by the way, that act that I just performed used 36 muscles and 6 cranial nerves. It's a highly sophisticated, highly complex act involving both motor and sensory components. And so, it's not only a very complex thing that we do, it's also essential for life. We have to eat and drink to live. So, the alternative is, if we're unable to successfully move food or liquid, or even our own saliva sometimes, into the throat and into the esophagus and ultimately into the stomach, the only alternative is to get what's called a feeding tube, which I'm sure many of your patients and your therapists are extremely familiar with. So, that's an alternative to being able to eat and drink by mouth, but it's more than just sustaining yourself nutritionally. Eating is incredibly important to our social well-being. I mean, if you think about it, you know, when was the last really great meal you enjoyed and who are you with when you enjoyed it, right? And you think about birthdays from birth to death. I mean, everything revolves around food. Every culture has very specific foods that are associated with the celebration, you know, of their culture. You can't have Thanksgiving without turkey and cranberry and stuffing.

And so, there's so much more to having a problem eating and drinking than simply, okay, maybe you can't get your nutritional needs met, but it's a substantial impact on the quality of life of any human being, and it doesn't even just affect them. So for example, if I have a hard time eating or drinking, and maybe I'm even on a feeding tube, then my partner feels guilty.

Teresa Biber Lomonte (05:44.33):
When they eat and drink, and then they don't want to cook because they don't want the food to be filling the, you know, it's just, it affects the whole family. And it's something people really just take for granted. It's like everything else. And it's invisible. It's an invisible disorder. So you can have somebody really suffering from dysphagia, but you'd look at them and you'd have no way of knowing unless they revealed that to you. And so they suffer in silence a lot too.

And when you say to somebody, well, I'm having a hard time swallowing, people look at you like a hard time swallowing, like what does that mean? Pills get stuck in your throat? Well, yes, maybe, but I mean, literally, they can't eat or drink by mouth in the most severe cases. So that's a little bit about what the disorder is. Yeah. It's a disorder, not a disease. Yeah.

Henry Hoffman (06:27.554):
Yeah, I guess that's

Yeah, I guess that's a good way to put it. Sorry, there's a little delay there. Sorry for interrupting.

Teresa Biber Lomonte (06:37.91):
That's okay. Yeah. Now as far as prevalence, other question. Yeah. So the statistics are all over the place, and it is traditionally under-reported, because either the way that they've tried to determine these kind of global statistics for the generalized prevalence is either through survey, which means people have to know and understand that they have a difficulty swallowing, which when they did that just in 2020,

Henry Hoffman (06:40.624):

Teresa Biber Lomonte (07:07.706):
One out of six people were complaining. This is huge, right? One out of every six people is having difficulty swallowing. But you have people that don't even understand that when they cough and choke, when their voice is a little wet or gurgly afterwards, when they keep getting repeat respiratory infections, that that's actually more than likely due to an underlying swallowing disorder that has yet to be diagnosed.

Then you look at medical records of patients, you know, who've actually had a diagnosis. So the statistics are quite high. The latest statistics have gone up to 23% of the global population may have dysphagia. Now that's just, that's children and adults. And then you take, now if you specify that to anybody with any kind of a neurological disorder, it's as high as 80-85%.

Henry Hoffman (07:49.84):
That's amazing.

Teresa Biber Lomonte (08:04.462):
So for example, multiple sclerosis, Lou Gehrig's disease, Parkinson's disease, cerebral palsy, you know, any of these neuromuscular disorders are more than likely going to manifest themselves in problems moving food from the mouth to the throat, to the esophagus, to the stomach.

Henry Hoffman (08:22.284):
Well, that's amazing information, Teresa. Yeah, that's amazing. I didn't realize it was that prevalent. So let's then, now that we know that it's pretty darn prevalent, before we dive into your protocol, why don't you spend a few minutes explaining what are some of the traditional treatment interventions? Now, for instance, when, again, I work more with a hand in the arm as an occupational therapist, and we have our bag of tricks, right? So what are the bag of tricks to work with?

Teresa Biber Lomonte (08:22.647):
So does that answer your question?

Teresa Biber Lomonte (08:33.012):

Henry Hoffman (08:50.224):
Quote unquote dysphasia, I'll say dysphasia this time, that were used prior to your protocol. What would be the normal, and some of those things are probably still used today, but why don't you just kind of go over the bag of tricks.

Teresa Biber Lomonte (09:03.798):
Yeah, absolutely. Well, and let's just kind of clarify that the NMES, any NMES protocol is not a standalone protocol. That any good therapist worth their salt is employing whatever techniques and I like to use the term are biologically plausible. In other words, the first thing you have to understand the mechanism of dysfunction, where's the breakdown, right? Why can't this person eat and drink normally? Where's the breakdown?

And what tools do we have to be able to either A, help them compensate for that deficit, and B, more importantly, recover from that deficit to whatever degree of recovery is reasonable to expect. So we have compensatory strategies that are often used. And so this might be a position of the head, for example, a chin down or a head turn or to hold your breath. So these are things that you're doing while you're eating and drinking to prevent things from going awry. And the biggest thing that we wanna prevent is what's called aspiration. So that's when food or liquid goes down the wrong tube. We've all aspirated. You're sitting there talking, laughing, all right, okay? Imagine doing that all the time. I mean, it's a horrible event, even when it happens to you.

And then, of course, if it's an actual piece of food, you could actually choke. So we have these compensatory mechanisms that allow a patient to continue to eat and drink by mouth with employment of these compensatory strategies. But that's just like a band-aid, right? You're just kind of keeping them safe, keeping them eating and drinking, which of course is very important. You don't use it, you lose it, right? But it's not.

It's not going to fix anything, right? It's not going to solve the problem. It's just going to help them get by for now. So then you employ what's called more direct treatment techniques, and those will certainly be therapeutic exercises, which, you know, all of our rehabilitation disciplines use. There are modalities such as NMES, SEMG.

Teresa Biber Lomonte (11:12.082):
I employ a lot of manual therapy. I find that very useful, particularly with the post-radiation head and neck cancer population, which is a huge, they have huge problems with eating and drinking, obviously, if they're being radiated in this area, it does some pretty significant damage. And then there's medical management. So medical management is sometimes the only thing that's needed. So for example, a patient could have...what's called a stricture, which is a narrowing or a closing up of the top of the esophagus or anywhere mid esophagus that prevents them from swallowing normally. In that case, no amount of therapy is going to change that mechanical problem. They need an intervention such as a dilation. So I tend to separate when I'm teaching dysphasia.

I, rehabilitation, I tend to have people think about them in three kind of basic categories. So neuromuscular dysfunction and then what appropriate techniques that we know are going to help the nerves and muscles function better. Structural problems, which may not be anything we can do, but we can diagnose and then lead them to the right intervention for that or help them compensate. And then mucosal or tissue abnormalities.

You always have to go back to where's the problem and what is the most biologically plausible treatment to use to be able to restore, has a reasonable expectation that function could be at least partially restored, if not fully restored.

Henry Hoffman (12:47.824):
Great, thanks for clarifying that and discussing the traditional concepts. And just like treating, you know, whether it's the leg or the arm, compensated compensation is real. And a lot of times it's used, obviously it's not going to help with rewiring the brain. And we all know the real prize is neuroplasticity. Most of the audience knows what neuroplasticity is. We're going to try to rewire the brain by doing novel, repetitive, intense, purposeful, meaningful tasks.

Clearly, swallowing is a meaningful and purposeful task. When I think about our interventions at work in stroke rehab for the upper limb, I think of Constraint-Induced Movement Therapy. Obviously, we'll get into eSTEM in a minute. I think of mass practice. I think of mental practice, where you imagine you're doing that task. When you imagine doing the task, the brain actually lights up as if you were physically doing the task. So besides a traditional concept.

Teresa Biber Lomonte (13:37.303):

Teresa Biber Lomonte (13:42.603):

Henry Hoffman (13:44.272):
There's things that work and there's things that kind of work and there's things that don't work. So is there some cross-pollination when it comes from OT interventions to speech interventions, when it comes to things that work such as CIMT? Is there a CIMT? And again, for the audience, Constraint-Induced Movement Therapy is when you restrain the affected limb, forcing to use your, excuse me, you restrain your healthy limb, forcing to use your affected side repeatedly and purposefully. And that actually works.

We know mental practice works where you imagine things. We know mirror box therapy works where you trick your brain to think that your affected limb is working. So do they have those options for swallowing as well? Those types of treatment interventions.

Teresa Biber Lomonte (14:30.086):
Well, Henry, you've really tapped on kind of a pet peeve or concern of mine, which I do believe, you know, is getting better. And this is this concept of speech therapy kind of came out of more of an educational model, you know, more stuttering, you know, articulation disorders, aphasia after World War II became a very much more common practice.

And for some strange reason, there's this kind of territorial phenomenon that occurs where I was, again, talking to PTs, NOTs very early in my career because I just wanted to learn. I'm like, what are you doing? And how come I don't know how to do that? And if that helps that muscle group, which is, and we'll probably get to this later, I owe everything to occupational therapists.

The reason why it was an OT using an MES that gave me my aha moment. Um, and so it's not traditional to have that cross-pollination, which I love that term, Henry, that's perfect. Um, but a good therapist obviously has eyes open, is observing, hopefully, is interdisciplinary teaming with therapists and learning from the therapist because there's so much out there that we could be doing that we're not.

Let's go back to some of the things you talked about. You talked about the mental imagery or the thinking about it. There is definitely significant studies looking at that cognitive aspect of swallowing. And this really...

helps in, for example, when you're dealing with somebody with dementia who may not be as attuned to what's going on. So if you feed a patient with dementia, first of all, you're feeding them. That's an unnatural process. We're not used to being fed, right? So there's a process that's involved where you're really taking your hand, picking up a utensil, bringing it to that brain, like you said, is already preparing for that process to occur. When you take that away...

Teresa Biber Lomonte (16:37.21):
Even if you arrive, somebody kind of came up to you and you weren't paying attention and they put a spoon of food in it, you're going to choke. So again, that mental preparation period is critical to being able to have a safe and efficient swallow. That said also, exactly what you said, more swallowing, more swallowing. Imagine yourself swallowing, imagine yourself swallowing stronger. You know, we do, again, a good therapist will employ a lot of these techniques.

Regarding Constraint-Inducement Theory, I seem to be one of the few speech language pathologists that ever even bring this up in my talks because I was fascinated with this and It's also a lot of PTs and OTs are not familiar with it and it's really it's unbelievable Because as you know

If you don't use it, you lose it, right? And all the studies have been done to show the effectiveness of this. And I remember, I used to go in when a patient was immediately post-stroke. And we actually did not have an OT in our acute setting. But you know how in acute care, they're only there for a couple of days and then they're going on to rehab. But I would actually teach the patient and I would tell them if they had, you know, upper extremity or even lower extremity impairment.

I would say your tenancy is going to be to use the arm that works. I'm telling you now, you have to try. You have to imagine yourself. And I would literally, and you could actually, I would do a test where I'd have them say, okay, move your right arm, and of course nothing barely moves or it barely moves. And then I would hold their left arm down and say, now look at your right arm and tell it to move and imagine yourself moving it, and they would move it.

Henry Hoffman (18:19.96):

Teresa Biber Lomonte (18:20.094):
And it would be like an immediate effect. I'm like, why isn't this standard of care for all stroke patients? So yeah, so I use that philosophy in my facial paralysis patients. That's where it would be a real definitive carryover. So if a patient is looking in a mirror and all she is this, well, that's just reinforcing this, right? So what you do is you say, when you look in the mirror, you need to do this. All right.

Just literally just push it up and give that feedback, you know, to those nerves and muscles that this is normal, this is not normal. And you see patient status post-bell’s palsy eight months later and their whole face is contorted and twisted because they've been overcompensating, you know, and then again looking in the mirror somebody told them to do exercises, you know, with no real thought process behind what they're actually doing to the brain and to those muscles and nerves.

Henry Hoffman (19:17.98):
Right, no, that's excellent. Great, great explanation there. And you brought up learning on use. And regardless, if it's a leg, arm, swallowing, you know, it is literally, I just wrote a piece on this, it is neuronal death. If we continue to tell our clients to compensate and don't do what you just said, you're going to have more pruning that's going to occur cortically, more cellular death, and it's going to lead to

Teresa Biber Lomonte (19:38.53):

Henry Hoffman (19:45.748):
A larger problem. So excellent. Well, this is a perfect transition from what's been going on in the past, what still works today. And now let's talk about really the meat of the matter today, which is going to be on NMS and the BIBR Protocol. So I want you to spend a few minutes talking about where this BIBR Protocol came from, how it got started, and what the heck is it.

Teresa Biber Lomonte (20:07.89):
Great. Well, like I say, I owe an immense gratitude to the occupational therapy world. So, I was just to backtrack a little bit. When a speech language pathologist graduates, typically with a master's degree level of entry, there's a nine-month period.

During which they are literally supervised by a more master clinician, really to make sure that they're kind of on the right track, that, I mean, literally your notes are reviewed, your evaluations are looked at, they might physically observe you working with a patient, and essentially have to sign off so that you can get your Cs, your 3Cs, Certificate of Clinical Competence, all right? So that's the MSCCCSLP, that's what those 3Cs stand for. So it's basically saying, okay, you've proven that you know basically what you're doing and we're good with you guys, you know, going on. And it's interesting that PTs and OTs don't really have that kind of setup. But I bring that up because it was during that actual, literally the first nine months of my speech pathology career, I was working in a subacute rehab hospital. And this was a hospital, highly aggressive rehab, so patients had to qualify for two out of the three disciplines. And they got daily, sometimes...

Twice a day treatment, PTOT speech, if indicated all three, but usually at least two of them. And so you would come to work and you would have a master schedule that was literally on a giant whiteboard at that time. We're talking, you know, the 90s here. And then that would be your schedule for the day. So you'd sit and write it out so you know that at 10 o'clock, I got to see Mrs. Smith. So at 10 o'clock, Mrs. Smith isn't in your room.

Henry Hoffman (21:37.185):

Yeah. Oh yeah.

Teresa Biber Lomonte (21:50.114):
Then you would look up on the schedule and say, oh, she's an OT. I'll just walk down the hall to the OT department and gather my patient and bring her back, which is precisely what happened on this particular day. So I go down and there's Mrs. Smith, who's a very typical post-stroke patient with upper and lower extremity paresis. And the OT had the arm on the table with two pads placed, and the arm was moving. And I'm like,

Teresa Biber Lomonte (22:22.042):
How in the world do you get a paralyzed muscle to move? I was blown out of the water, and she looked at me like, ah, it's electrical stimulation, duh. And I'm like, well, I've never seen anything like this. How does it work? And, of course, I'm picking her brain. And then the next words out of my mouth were, why don't we have access to this, number one, in the speech pathology community? And why can't we use this for our patients with swallowing disorders and facial paralysis?

Henry Hoffman (22:31.371):

Teresa Biber Lomonte (22:47.114):
And her response was, well, you can't do that. You can't put electrodes on the neck. Nobody's ever done that, blah, blah. And so I went down to the PTs. They told me the same thing. I'm like, okay, well, this makes no sense whatsoever. They have access to this unbelievably powerful tool. And if it works for those muscles, why wouldn't it work for these muscles, for these muscles? It just makes no sense at all. But I was also very new.

In my career, so I figured, well, let me get better at what I'm doing and understanding the anatomy, the physiology, the function. And then I started going to, you remember the libraries? Remember when you had to like drive to the library, get through the card catalogs, go through the journal articles, which were like in this one big binder, and then you have to photocopy, and of course, the photocopies never turned out great because it's all bent like this. So that's what I did. I was just fascinated with this concept. And lo and behold, I found out that in eight...

A German scientist first used electrical stimulation for swallowing. What? And then there was lots of animal research that was done, again, not just NMS, NMS and swallowing. And then finally the seminal article was in 1973 by a physician named George Larson, and he took five patients that had difficulty swallowing, did some mental stimulation on them and after a series of trials, four out of five of them.

Henry Hoffman (23:51.29):

Teresa Biber Lomonte (24:13.162):
Recovered their swallow function. I was like, well, why aren't we doing this? So that started the process. So I was very fortunate in that setting; there wasn't a lot of openness. But I got a phone call shortly thereafter to go back with the Cleveland Clinic in Florida, where I had done my internship, and I got a job offer. Now I'm in a teaching hospital. Now I can talk with these physicians who are tend to be much more open to innovations and new ideas. And we sat down with the head of laryngology, one of our top physical therapists who's really strong in the modalities, and myself and my boss, and we're like, okay, how can we do this? And we basically, you know, they asked me some basic questions, what muscles do you want to stimulate and why, and then I spent the next two years.

Working side by side with the physical therapist at the Cleveland Clinic employing this protocol. Now, it just so happened that we were asked to be part of the NAHMS project, which stands for National Outcome Measurement System, and the NAHMS project was trying to validate the usefulness and utility of therapy to be able to go to payer sources and say, look, therapy works, you know, and here's the proof. So they...contacted some of the top facilities in the nation, asked us to share our outcomes with them, which we did. And my outcomes were off the chart. Phone starts ringing. What the heck are you doing that we're not doing? Why are your outcomes on a seven-point functional scale, average gain of 2.5 points higher than anywhere else? So that was then. And initially, I literally was just, whoever wanted to know,

Come to my office, I'll teach you, spend the day with me. You know, I just started training and then eventually was contacted by the Arizona Speech and Hearing Association to be their primary speaker at their annual conference. And that first conference, I had 80 participants show up, not realizing it's very hard to train 80 people at NMES if you wanna do hands-on, but it was like the loaves and the fishes. I had 12 devices to train 80 people.

Teresa Biber Lomonte (26:31.614):
And I can't even tell you how it occurred. It literally was a miracle. And that's kind of it.

Henry Hoffman (26:37.168):
Wow, that is amazing.

So that's amazing. I think of our stories are kind of parallel. And I want the audience to kind of really capture that moment. So for you, the big moment was there's a device out there that's not used by speech therapists that speech therapists do not know about that can literally change the way people swallow, which could really change and transform your industry.

It's similar to when Sabo started, when my brother and I created the SaboFlex, there was no way to incorporate the hand. So you couldn't use the hand for a stroke's fiber, pick something up, and let go of it. You literally had to move in with the patient, if you will, and open the hand physically and manually each time they wanted to do repetition. So by creating the SaboFlex, it allowed patients to allow them to use their hands so they can grasp things and let go of it. So from that moment, we had to go on the road and train.

Therapists to think differently. So at this moment you're training speech therapists. This is late 90s To think differently and you had to change the profession to think differently and embrace Easton And that's a scary thought back then is gee electrodes on the neck. No, no No, so now you have this massive paradigm shift in your industry and you have to change behaviors And you have to educate which is very expensive and exhausting. So what was your first few years like? I want to dive into the protocol next I want to get into differences between different e-STEMs. But briefly, what was the following two, three, four, five years like knowing that this is a special opportunity? You set the stage and now pour some gas on that fire. What did you do?

Teresa Biber Lomonte (28:24.134):
Well, Henry, how much time do you have? I'll try to... Yeah, I know. So, what I will tell you is, it was both incredibly encouraging and remarkable and incredibly discouraging and, quite frankly, physically challenging. I was in the ER twice because I was threatened. Yeah, yeah, threatened.

Henry Hoffman (28:27.256):
That's why I said briefly. Ha ha ha.

Henry Hoffman (28:46.512):
Wow, geez, threatened.

Teresa Biber Lomonte (28:53.19):
It's just, I don't know what it is that there seem to be people out there that are just born obstructionists. They're just born with this negative attitude that can't work. There's no way you can't do that. It's like that's their go-to. It's never, oh, show me what you're learning.

Educate me on how this would work, oh, and then maybe let's investigate it. No, it's like there's no way that they just automatically write it off. And what was absurd to me, it was like I didn't invent something out of the blue. I didn't even invent anything. All I did was take the standard NMES treatment, and that's where the Biber Protocol is kind of unique. The standard NMES treatment, or you modify and manipulate those parameters within a certain range, right?

And applying it to a different muscle group. And by the way, I'm not actually on the neck. That's the best part. I don't need to be on the neck because the muscles here are the infrahyoids, or your strap muscles. So they're gonna be pulling the larynx down. We don't need that. What we need is the laryngeal elevators, the suprahyoids, to lift the larynx up and bring it forward. So I'm not even on the neck; I'm on the chin, neck, two different parts of your anatomy, right? So that was the first thing is just educating people that I'm not on the neck.

But there was a protocol that was placing it on the neck. And guess what? They got that passed, you know, through the FDA. So clearly, a lot of the old-school thinking about where electrodes can be safely placed has been counteracted.

Problem is people don't pay attention and they don't read, they don't stay current with the literature. So you've got people that have their thinking that they learned 20 years ago or 30 years or sometimes even 40 years ago in their classes and they've never evolved a day since. They heard it once and that's the truth. They don't look at where are we now. I mean...

Teresa Biber Lomonte (30:53.994):
You could take this with any disorder, any disability. You know, science is constantly evolving. Look what we've learned about the gut microbiome and the immense value that is. Nobody was talking about the gut microbiome, you know, 10 years ago, it's a handful of people. Now everybody's talking about it. Why? Because we learn. So again, this is historically, NMES works if you understand it and you use it correctly. It works. I mean, there's, it's been proven for hundreds of years to have a positive therapeutic effect on nerves and muscles, as well as many other, you know, we talk about wound care, let's not even go there with all the pain management, all of these things. Electrotherapy is, our body runs on electrical impulses. Why does it not make sense that we could superimpose some better electrical impulses to kind of give the messages we note, we talk about neuroplasticity? You know, again, they did...

One study where they did 10 NMES treatments on a patient, this is out of Korea, and they did functional MRI imaging and transcranial magnetic stimulation imaging, they showed a 400% increase in cortical activation after, this is posted not while they're under NMES, after they've actually completed the course and gotten their swallowing back, 400% increase in cortical activation. How do you argue with that?

Henry Hoffman (32:20.112):
Amazing. Yeah. Yeah, that's amazing stuff. Well, thank you for giving us.

Teresa Biber Lomonte (32:20.734):
Well, apparently people still like to. So, kind of a lot of people don't do that.

Henry Hoffman (32:27.868):
Yeah, yeah, thanks for giving us the backstory there. And we'll have to do offline a little bit more, maybe over a virtual cocktail, I can learn a little bit more about those other stories that you alluded to. So let's dive into, for the audience, obviously we're bringing up NMS a lot. And so there's NMS, which is neuromuscular electrical stimulation. We literally just keep it simple. You have electrodes placed over the targeted muscle group.

Teresa Biber Lomonte (32:29.279):

Teresa Biber Lomonte (32:39.135):
Yeah, I read the book.

Henry Hoffman (32:55.864):
You place them typically on the surface of your skin, and you have electrical current contracting those muscles, causing a muscle contraction. You can have what's called cyclical stim, which is eight seconds on, eight seconds off, or whatever the program is set to. You can have triggered stim, where the therapist literally has a triggered button or the patient or caregiver, where you can time the stim with the functional task, whether it's in this case swallowing or potentially picking up an object or firing your shoulder deltoids to strengthen your shoulder or walking, there's a lot of foot drop devices. Then there's something called EMG-triggered stim, and EMG is also known as biofeedback, where you literally can monitor and record muscle activity, and you can see, gee, look how much of a contraction I have, and, or, gee, my muscle's really weak here, and I'm not picking up a signal, and that's biofeedback. And you can either hear, or you can feel, like a vibration response or it could be an auditory or visual response, which is kind of awarding you when you actually achieve a certain muscle contraction. So I just mentioned NMES. The triggered stim is called FES, which is functional electrical stimulation, where you literally time the movement with a functional task. Then we just talked about biofeedback or EMG triggered stim. Now I know your protocol is NMES, and so I have a two-part question. If you can get in the weeds a little inside baseball for the therapist listening, what is the actual...

What's so special about the protocol, the NMS protocol, that makes it effective? And then part two to that question is, do like we do with legs and arms, is there any benefit to having an EMG-triggered stim or regular manual-triggered stim version as well?

Teresa Biber Lomonte (34:45.99):

Okay, great question. I love talking with you, Henry Hoffman. This is great. So basically, let's just go back to some fundamental principles of NMES. So are you familiar with Gad Alon? He's very prolific. Yeah, yeah, he's like these written textbooks, literally, and Tim Watson. And these are both men that I know personally. These are like my mentors. It's like I'm learning from the best of the best.

Henry Hoffman (34:49.284):

Henry Hoffman (35:01.944):

Teresa Biber Lomonte (35:14.13):
But, you know, Gad would say that, you know, NMES requires that you stimulate the right muscles at the right time with the right parameters to achieve your desired outcome. And along with that, and there Tim would say that, you know, it's the, what he calls like the dose and treatment considerations, that it's all about refining the protocol, that you can have intervention X in some studies shows no effect, yet the same intervention will show an effect in a different study. And what's the difference? Sometimes the dose and the treatment parameters. And so there are standards in the industry that have been long established and proven historically over time, for example, to evoke an action potential, which is NMES is a very, you have electrotherapy, right? Which is simply the use of electrical pulses applied externally to the body to evoke a physiological response, right?

And then you have NMES, which is the very tailored use of that electrical stimulation current specifically designed to evoke an action potential. Now, we can get muscles to move, and Galvani showed this, and they all showed this, that even paralyzed muscles can move, but does that relate back to function? Right? So just stimulating a muscle repeatedly, is that going to necessarily mean that patient is going to get better? And the answer is probably not. Although you would be finding some benefit. The key to NMES is functional task specific activities. So.

What makes the BIBR protocol unique is not only is it the only protocol that's based on the standard, if you were to pick up any electrotherapy textbook and look at neuromuscular electrical stimulation protocols, it'd be highly consistent with that. So that's number one. And number two is that the specific contraction time is identical to the actual volitional act of swallowing. So, you're tying the swallowing with the stimulation.

Teresa Biber Lomonte (37:17.578):
Simultaneously. That is the key. That's how neuroplasticity and cognitive reorganization take effect, is you tie the stimulation with the functional task. So you're saying, well, Teresa, you just said they can't swallow, so how are they going to swallow when the stimulation is on? Well, they many times can swallow in the sense they do have a reflexive motion to be able to do that. In very rare cases, they may not. Brainstem CVA might be that, but

Generally speaking, they can swallow. They just don't swallow well, right? They just don't swallow efficiently or they don't swallow safely. It's not that they can actually swallow. They just can't swallow to a degree that keeps them safe or comfortable when they're eating or drinking. So they can, for example, just swallow their own saliva. If they're unable to eat anything by mouth, which, by the way, is a terrible thing we do to our patients, talk about learn on use, we just take away all food and all ability to swallow. And in some cases, nurses and even well-meaning physicians will say, you're going to aspirate your saliva, so don't swallow that. So, they're not even swallowing their own saliva. So, we time the swallowing with the stimulation, and that gets into some of their other things. So, in an ideal world, if you have a cognitively intact patient that can follow directions and doesn't have any motor deficit such as apraxia, where they can't initiate something on command, you can just say, okay, whenever you feel the stimulation, that's your cue to go ahead and swallow with the stimulation at the height of the stimulation. Swallow hard, swallow strong, but just swallow. Now you've got patients that are unable to do that for a variety of reasons, in which case that's where the triggered stem comes in. So maybe they're safe for a... maybe they can only swallow when they have a bolus. In other words, there's something in the mouth to swallow because saliva is kind of really not... doesn't give a lot of sensory...input into the region. And they are safe for maybe a small consistency of something. So then you could feed them, trigger the stim, hold the stimulation on until the swallow is completed, and then, sorry, the cat just jumped up. And then you can, again, combine the swallowing with the stimulation. EMG would be similar in the sense that they're getting that visual feedback, and that would certainly tie into that.

Teresa Biber Lomonte (39:30.794):
And I have used that in the past. As a matter of fact, one of the protocols, I designed the EMG program. But I don't know, I just, for me, I think that's really good for kids that can't comprehend what it is you're talking about. With adults, I don't really feel, there's just not enough data out there. I haven't really seen a big difference whether I used SEMG and NMES or just NMES alone. NMES is such a powerful tool. Again, I'm gonna say it again.

It works if you understand it and you use it correctly. And using it correctly means right parameters, right dosage, combining with functional tasks with big activities.

Henry Hoffman (40:10.448):
Okay, good. Thank you for clarifying that. And obviously, as you mentioned already, there's research out here to show the efficacy. Before we get into contraindications, prescription insurance, I did some research and learned about what's called PES, pharyngeal electrical stimulation. Can you spend just a few seconds on that? I never even saw this before. I don't know if that's even popular. Is that when – I mean, is this something they do?

Teresa Biber Lomonte (40:29.843):

Henry Hoffman (40:40.28):
Under anesthesia or is this a home unit somehow? Doesn't look comfortable. So if you can just spend a few seconds on that.

Teresa Biber Lomonte (40:47.166):
Well, and there it lies around. So again, this is this kind of mindset that can't work, so we're going to come up with something that does. And there's two parts to this. There was actually a researcher who spent five years trying to debunk NMES for swallowing for a very specific purpose. She was developing an implantable laryngeal stimulator. So these patients are undergoing a major surgical procedure putting hardware in their laryngeal vestibule that can be triggered by them like, oh my gosh why in the world? And guess what? They all failed, right? Now that she finally did on five patients yeah, and we know it was interesting. Her control group was an external vibrating source. Those patients actually got better.

So, right, so that's again, so this PES is kind of, I can see absolutely one use and one use only for this, and that would be on patients in a semi-comatose or comatose ICU position, because there are a multitude of patients who will get an aspiration pneumonia from their own secretions in that state when they're unable to eat or drink by mouth, they're not, you know, alert and awake.

And so, with that population, phenomenal. The only thing is, is the only people that have done the studies are the people that develop the protocol, and I always kind of, you have to take that with a grain of salt. So I'm sure your OTs in the audience, you know, can appreciate the fact that a single study really doesn't show you anything, right? It's just an inch. It's like, huh, okay, there may be something here.

Right? The only way you can know, but you always have to look at funding sources and all of that. And I use this in my teaching. I said, you know, years ago when I grew up, there was a commercial that said, if you drink two glasses of orange juice a day, not one, but two, you can lower your blood pressure. Right? Well, who funded that study? Tropicana. Right? And why did they say two instead of one? Because they were trying to find a way to get the blood pressure to go up.

Henry Hoffman (42:58.352):
There you go.

Teresa Biber Lomonte (43:00.642):
Double the profits and does orange juice lower your blood pressure? No, you know what it does to increase the diabetes epidemic that we have in this country. So again, it's you have to really look at studies very critically. So the real way to know if something has validity is obviously historical precedent. Over hundreds of years, you know, studies have been shown, you know, like for example with NMES, we've got the most amazing historical precedent with it, even with swallowing back to 1893.

You know, and then you have, so you have a group in China that does a study that shows a positive effect, and then a group in Canada that doesn't have anything to do with a group in China, and they do the same study. So your replication of studies, that's really where you begin to see that yes, there is definitely a very good chance that this is a valid and efficacious and safe, you know, treatment technique.

Henry Hoffman (43:53.696):
Yeah, okay, well thanks for clearing that up. I know when I first saw the PES and how they insert the catheter through the nasal cavity down to the throat and you're stimulating internally, I was like, geez, that cannot be too comfortable. So yeah, so I think surface electrodes can be just.

Teresa Biber Lomonte (44:06.598):
No. It really doesn't. Yeah. And also the thing about the PES is it's kind of unusual because it really doesn't take into account the true anatomy and physiology of the swallowing mechanism. So our pharynx does not arbitrarily contract on its own. It only contracts when there's a bolus in the mouth. There's something to swallow. And then it's like a peristaltic wave. It's like the esophagus, right? You know, very similar to a peristaltic wave and squeeze.

And just the pharynx squeezing and moving and being having a parasolid wave will not clear the pharynx Your larynx has to move up and forward your airway has to close off your ues has to open so there's again this lack of understanding of the Complexity and the muscles and nerves that are involved in moving something from the mouth to the throat So again, I can see it benefiting as opposed to nothing, I mean, they've already got all tubes and stuff in them anyway, and they're not awake, so why don't we go ahead and put something in there that may have a benefit. But I cannot see any benefit beyond that at all, because it doesn't vie with the anatomy and physiology of the swallowing mechanism. It's not biologically plausible, right?

Henry Hoffman (45:20.772):
Right. Yeah, no, very good, very good. Yeah, that makes sense to me. So as we wrap up, just a couple of quick ones. First, is a prescription required? I know patients listening, caregivers listening, saying, gee, I want this, I have dysphagia now, and what's the process? Do they have to go to a speech therapist, get a prescription to get the eSTIM, to get the Biber Protocol? What are those steps?

Teresa Biber Lomonte (45:45.81):
Okay, excellent question. So our discipline runs a little differently than PT and OT, where you have very specific prescriptions for the modalities, for example, that you might be using. In speech therapy, speech pathology, speech language pathology for the correct term, and swallowing therapy, that's all you need. Literally a description that says diagnosis, dysphasia, treatment, dysphasia treatment.

Evalent treat, that's it. Like that's literally all you need. So it's going to be up to the individual therapist or for the patient that's looking for this to find out whether or not that particular therapist is using electrical stimulation. Now the Biber protocol obviously is one of a few protocols out there. And so I can only speak to the efficacy and safety of my protocol and the amazing historical presence to it.

But I will tell you this, any electrical stimulation that's combined with the act of swallowing is going to get you a much better, much quicker result than no electrical stimulation. And you know that from, you know, you can do exercises until you're blue in the face, but if you can't move your hand, you can't move your hand. But if you get your hand to move via an external electrical impulse, now again, the brain's lighting up, things are starting to kick in, and now you've got a chance at literally getting that hand back.

And so it's the same with swallowing. So, you know, basically that would be the question asked is, are you combining the electrical stimulation? You can ask them, are you using the Viber protocol? Are you combining electrical stimulation with the actual act of swallowing? And if they're doing that, then, you know, then that is true NMES. Doesn't mean that the other protocol might not work. It might very well work. But that would be as an informed patient, that would be what I would ask. But there's no prescription needed.

Henry Hoffman (47:44.309):
Okay. And as far as insurance reimbursement, it's speech therapy. So if speech therapy is reimbursed, this would be in reimbursement.

Teresa Biber Lomonte (47:51.686):
No, we don't get... Yeah, exactly. Now, that I will segue quickly into the concept of home use. So, I am the only teacher out there that promotes the home use of an NMES device. As a matter of fact, that is the fourth device I'm trying to get FDA clearance for that. So, because...eSTIM has been set home with patients throughout history. So why would this be any different? Again, if it's safe, it's efficacious, you can teach the patient, they have a competent caregiver or they themselves are capable of doing it. Why not give them an opportunity to be able to perform this therapy daily, even three times a day? You can do NMS, you can do it five times a day, right? And for every day of the week, if you wanted to, compared to once a week or twice a week in a therapeutic setting. So I'm really all about empowering the patient and I have trained patients myself, how to be able to do this at home. We did a big clinical trial with cancer patients. They were all capable of doing it. So this is something that I'm, and that they would need a prescription for because then they're getting a home device. But there are also ways to get that for them.

Henry Hoffman (49:16.696):

Wow, Teresa, I'm telling you, this has been a wonderful discussion. No doubt patients and caregivers can benefit from everything that you've mentioned, and they can learn more, and I want to thank you for joining me today. Folks, whether you're a patient or caregiver, hopefully you found this information helpful. We will definitely put Teresa's contact details in the show notes, so please, you can find her and ping her or email her or call her for more information, additional questions. Any patients or family members or therapists that are involved in dysphagia treatment or want to learn more or identify a place where they can go to get more, definitely reach out to Teresa and ask her some additional questions. Teresa, it's been wonderful. You're packed with information. I mean, my brain right now is just I have so many other questions, but I'm trying to always limit the podcast to less than an hour. We're going to have to do a part two.

Teresa Biber Lomonte (49:59.615):
I'm sorry.

Teresa Biber Lomonte (50:05.01):
Yeah, yes we will. And for your listens out there, you can check out thebiberprotocol.com. That's thebiberprotocol.com. There's 40 pages of information on there for you. For therapists particularly, it tends to be a lot of clinical information. So for your therapists out there that want to learn more, there's an entire write-up about how the protocol came about, all the science behind it. So, and there's a contact me on that website so that you can contact me directly, and I am just delighted to answer questions. I mean, this is my passion. This is my love. I don't care. You know, I guess you could tell I'm a little enthusiastic about it. I just love helping people. Yeah.

Henry Hoffman (50:46.672):
I couldn't tell. You're starting to concern me. You're starting to concern me how lethargic you looked during the presentation. No, I'm just kidding. Carly, our producer, will definitely put all your contact details in the show notes. And we want to thank you again. Our audience is definitely going to eat this up. No pun intended. A lot of great stuff there. And thanks again, Teresa. It's an honor and a pleasure to interview you today on the podcast.

Teresa Biber Lomonte (51:07.15):

Teresa Biber Lomonte (51:15.958):
Thank you so much, Henry, and thank you for all the work you're doing. You're like one of my heroes in the East End world, so I just want you to know that. And it's my great honor and pleasure to be here with you today.

Henry Hoffman (51:26.264):
Well, thank you. Likewise, I appreciate that. Well, you have a good one, Teresa.

Teresa Biber Lomonte (51:31.554):
Thanks so much.

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