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Biber Protocol

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The Biber Protocol is a rehabilitation method for patients with dysphagia[1] (difficulty swallowing) that utilizes neuromuscular electrical stimulation (NMES). It was created by Teresa Biber LoMonte, M.S., CCC-SLP in 1999.

Many treatment protocols, techniques and exercises have been developed for dysphagia. They include the Mendelsohn Maneuver,[2][3] Shaker Exercises,[4] Masako Exercises,[5] Supraglottic Swallow,[4] Super Supraglottic Swallow,[4] Effortful Swallow,[4] and Hyoid Lift Maneuver.[6] These techniques and exercises have been used to increase strength and coordination of swallowing muscles/functions. NMES, or Neuromuscular Electrical Stimulation, has also been used for swallowing rehabilitation. Many protocols have been developed for using NMES to treat dysphagia including Effective Swallow Protocol/AmpCare,[7] VitalStim,[8] and The Biber Protocol®.[9] The previously mentioned exercises and techniques can be performed while receiving NMES to maximize response and benefit from both.

Treatment with NMES involves the use of electrical stimulation that is generated by a device and delivered via electrodes placed on specific muscles to elicit a contraction. The pulses are painless and can activate weak or paralyzed muscles. The muscle activation is combined with specific tasks that can result in an improvement in swallowing, voicing and facial movement.[10]

Over 177 articles have been published between 2000 and 2020 investigating the effectiveness of electrical stimulation for treatment of dysphagia including multiple systemic reviews and meta-analyses. Miller, in 2014[10] identified 180 studies that were reviewed for effects of NMES on facial paralysis, laryngeal paralysis, dysphonia, and dysphagia. Their conclusion was, “Evidence collected to date is encouraging; particularly for the treatment of certain forms of dysphagia and laryngeal paresis.”

Key Factors[edit]

There are many similarities in protocols that employ NMES to treat dysphagia. The Biber Protocol is based on 5 principles that define how it is used and how it is different from other approaches to NMES for dysphagia treatment. Some of these principles are used by other approaches in different combinations; however, only the Biber Protocol combines all 5: 1) modification and manipulation of electrical stimulation parameters, 2) singular submental electrode placement, 3) use of specific swallowing movement patterns simultaneously while the stimulation cycle is on, 4) home use to provide easier access to the treatment modality, and 5) implementation that is not device specific.

Modification and manipulation of electrical stimulation parameters[edit]

As mentioned above, this capability is a key factor in The Biber Protocol. VitalStim has recently adapted their protocol to accommodate function of a new device that allows for manipulation of these parameters. Other approaches do not incorporate this capability into their protocol.

Alon[11] states that “Proper use of NMES dictates that you stimulate the right muscle, at the right time with the right parameters, to achieve the desired outcome”. This serves as the justification of allowing the clinician to modify and manipulate the parameters in order to achieve maximum physiological response.

Doucet, Lam and Griffin[12] discussed the concept of manipulation of parameters in the Yale Journal of Biology and Medicine; “The delivery of electrical stimulation can be customized to reduce fatigue and optimize force output by adjusting the associated stimulation parameters. A full understanding of the settings that govern the stimulation is vital for the safety of the patient and the success of the intervention. Consideration should be given to the frequency, pulse width/duration, duty cycle, intensity/amplitude, ramp time, pulse pattern, program duration, program frequency, and muscle group activated.”

Singular submental electrode placement[edit]

This placement is defined as a single, bipolar placement of electrodes in the submental region. Use of this placement is based on the works of Bogaart,[13] Palmer,,[14] Kim and Han,[15] Park,[16] and Toyama et al.[17]

This placement of the electrodes stimulates the suprahyoids. Stimulation of the suprahyoids elicits hyolaryngeal excursion (upward and forward movement). This movement is necessary for airway closure and upper esophageal sphincter (UES) opening during the swallow. Infrahyoids are not stimulated because they depresses the larynx for airway opening to take a breath after the swallow. The goal of NMES is to promote motor recovery by facilitating and improving the normal movement pattern and to avoid inhibiting it by providing stimulation that works against the patient’s efforts to swallow with the stimulation.[9]

Use of swallowing movement patterns with stimulation[edit]

If stimulation is applied externally to the suprahyoid muscles, it evokes a movement pattern the same as what occurs when we swallow; that is, the hyolaryngeal complex moves upward and forward. This repetitive movement achieved through stimulation when combined with active swallowing as a part of rehabilitation results in cortical reorganization and neuromuscular re-education.[18]

Stimulation of the suprahyoids using an NMES protocol with two electrodes in the submental region facilitates an observable and palpable hyolaryngeal excursion. The combination of purposeful skilled electrical stimulation combined with the active task of real swallowing results in true neuromuscular reeducation.

Like many protocols that incorporate swallowing/eating into the therapy protocol; this protocol also uses stimulation with functional swallowing activity. It also emphasizes the importance of timing the active swallow with the stimulation for maximum effect.

Home use[edit]

The Biber Protocol incorporates home use. This means that the patient is provided with a device and is taught how to apply electrodes and perform therapeutic swallows during the stimulation. The initial training and follow up is provided under the supervision of a treating clinician and with a physican prescription. The premise is that home use puts the treatment directly in the hands of a patient who can then receive many more sessions in the privacy of their own home and at their leisure with much less cost to the health care system.[19]

Not device specific[edit]

This protocol was the basis for the development of many devices. Since it is based on the science of electrotherapy, any device can be used as long as the parameters can be customized during treatment. It can be used in any standard NMES device as long as there are adjustable parameters and the clinician has been properly educated via the Biber method. The Protocol is not device specific. The focus is on proper training and education in the principles of electrotherapy as opposed to sales of a particular device.


The Biber Protocol was developed by Teresa Biber LoMonte in 1999 while working at the Cleveland Clinic in Florida. She observed a patient receiving NMES for dense paralysis of the right arm and hypothesized that this treatment could be beneficial for individuals with dysphagia as well.

She developed the protocol in collaboration with the departments of otolaryngology and physical therapy and implemented it under their supervision for 2 years.


Legal issues[edit]

VitalStim filed a lawsuit against Teresa Biber LoMonte for patent infringement in 2002 which was settled out of court. Teresa was able to continue using her protocol and conduct research. In 2017 Teresa filed a lawsuit against Spectramed for unpaid wages, this was also settled out of court. Both cases were amicably resolved and are a matter of public record.

Some professionals continue to claim that NMES does not work and to argue against using it in dysphagia rehabilitation. It should be noted that the placement of electrodes and protocols used in the studies are not consistent with teachings of The Biber Protocol .

See also[edit]


  1. Shiel WC. "Medical Definition of Dysphagia". Unknown parameter |url-status= ignored (help)
  2. McCullough GH, Kim Y (December 2013). "Effects of the Mendelsohn maneuver on extent of hyoid movement and UES opening post-stroke". Dysphagia. 28 (4): 511–9. doi:10.1007/s00455-013-9461-1. PMC 3718861. PMID 23494471.
  3. Wijaya A (2018-02-06). "Mendelsohn Maneuver".
  4. 4.0 4.1 4.2 4.3 Vose A, Nonnenmacher J, Singer ML, González-Fernández M (December 2014). "Dysphagia Management in Acute and Sub-acute Stroke". Current Physical Medicine and Rehabilitation Reports. 2 (4): 197–206. doi:10.1007/s40141-014-0061-2. PMC 4608439. PMID 26484001.
  5. Byeon H (July 2016). "Effect of the Masako maneuver and neuromuscular electrical stimulation on the improvement of swallowing function in patients with dysphagia caused by stroke". Journal of Physical Therapy Science. 28 (7): 2069–71. doi:10.1589/jpts.28.2069. PMC 4968508. PMID 27512266.
  6. "Best Exercises for Dysphagia". Verywell Health. Retrieved 2020-12-22. Unknown parameter |url-status= ignored (help)
  7. "Effective Swallow Protocol". Ampcare ESP™. Retrieved 2020-12-22. Unknown parameter |url-status= ignored (help)
  8. Shaw GY, Sechtem PR, Searl J, Keller K, Rawi TA, Dowdy E (January 2007). "Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality?". The Annals of Otology, Rhinology, and Laryngology. 116 (1): 36–44. doi:10.1177/000348940711600107. PMID 17305276. Unknown parameter |s2cid= ignored (help)
  9. 9.0 9.1 Biber T (February 2012). "NMES Manual". Manual Therapy. 17 (1): i. doi:10.1016/s1356-689x(11)00214-1. ISSN 1356-689X.
  10. 10.0 10.1 Miller S, Kühn D, Jungheim M, Schwemmle C, Ptok M (February 2014). "[Neuromuscular electric stimulation therapy in otorhinolaryngology]". HNO. 62 (2): 131–8, quiz 139-40. doi:10.1007/s00106-013-2810-4. PMID 24549514.
  11. Alon G (1997). "Principles of Electrical Stimulation". In Nelson KM, Hayes KW, Currier DP. Clinical Electrotherapy (3rd ed.). Connecticut: Appleton and Large. pp. 55–139. Search this book on
  12. Doucet BM, Lam A, Griffin L (June 2012). "Neuromuscular electrical stimulation for skeletal muscle function". The Yale Journal of Biology and Medicine. 85 (2): 201–15. PMC 3375668. PMID 22737049.
  13. Bogaardt H, van Dam D, Wever NM, Bruggeman CE, Koops J, Fokkens WJ (April 2009). "Use of neuromuscular electrostimulation in the treatment of dysphagia in patients with multiple sclerosis". The Annals of Otology, Rhinology, and Laryngology. 118 (4): 241–6. doi:10.1177/000348940911800401. PMID 19462842. Unknown parameter |s2cid= ignored (help)
  14. Palmer PM, Luschei ES, Jaffe D, McCulloch TM (December 1999). "Contributions of individual muscles to the submental surface electromyogram during swallowing". Journal of Speech, Language, and Hearing Research. 42 (6): 1378–91. doi:10.1044/jslhr.4206.1378. PMID 10599620.
  15. Kim SJ, Han TR (April 2009). "Effect of surface electrical stimulation of suprahyoid muscles on hyolaryngeal movement". Neuromodulation. 12 (2): 134–40. doi:10.1111/j.1525-1403.2009.00200.x. PMID 22151287. Unknown parameter |s2cid= ignored (help)
  16. Park JW, Oh JC, Lee HJ, Park SJ, Yoon TS, Kwon BS (September 2009). "Effortful swallowing training coupled with electrical stimulation leads to an increase in hyoid elevation during swallowing". Dysphagia. 24 (3): 296–301. doi:10.1007/s00455-008-9205-9. PMID 19255707. Unknown parameter |s2cid= ignored (help)
  17. Toyama K, Matsumoto S, Kurasawa M, Setoguchi H, Noma T, Takenaka K, Soeda A, Shimodozono M, Kawahira K (2014). "Novel neuromuscular electrical stimulation system for treatment of dysphagia after brain injury". Neurologia Medico-chirurgica. 54 (7): 521–8. doi:10.2176/nmc.oa.2013-0341. PMC 4533457. PMID 24670314.
  18. Scremin AM, Kurta L, Gentili A, Wiseman B, Perell K, Kunkel C, Scremin OU (December 1999). "Increasing muscle mass in spinal cord injured persons with a functional electrical stimulation exercise program". Archives of Physical Medicine and Rehabilitation. 80 (12): 1531–6. doi:10.1016/s0003-9993(99)90326-x. PMID 10597802.
  19. O'Connor D, Lennon O, Wright S, Caulfield B (November 2020). "Self-directed home-based neuromuscular electrical stimulation (NMES) in patients with advanced cancer and poor performance status: a feasibility study". Supportive Care in Cancer. 28 (11): 5529–5536. doi:10.1007/s00520-020-05394-0. PMC 7547042 Check |pmc= value (help). PMID 32179996 Check |pmid= value (help).

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