Neuromuscular electric stimulation in heart transplantation candidates with cardiac pacemakers

Safety and preliminary efficacy of functional electrical stimulation cycling in an individual with cervical cord injury, autonomic dysreflexia, and a pacemaker: Case report

Context: Functional electric stimulation (FES) cycling is a commonly used therapeutic exercise modality after spinal cord injury (SCI); however, additional precautions must be taken in certain situations. The purpose of this study was to develop and apply a safety monitoring protocol for autonomic dysreflexia (AD) during FES cycling and to determine if an interval-FES cycling program can be safe and beneficial to an individual with cervical SCI, a history of AD, and a non-dependent cardiac pacemaker.The participant was a 36-year-old male with C6 AIS-C SCI sustained 9 years earlier, intermittent AD, and implanted cardiac pacemaker. Ten sessions of interval-FES cycling were performed twice weekly for 5 weeks. Rating of perceived exertion (RPE), blood pressure (BP), oxygen saturation (O2sat), and heart rate (HR) were monitored before, after, and every 5 min during cycling. ECG and cardiac pacemaker were evaluated by a cardiologist after ending the program.Findings: The participant reported self-limited chills 27 times over 10 sessions (19 "light", 3 "moderate", 5 "sharp"). Chills coincided with BP increases 59% of the time and their magnitudes moderately correlated (r = 0.32). The ECG was determined to be normal and the pacemaker fully functional at the end of the study, while blood glucose decreased (111-105 mg/dl), HbA1c levels increased (5.5-5.9%), and resting BP decreased (118/84-108/66 mmHg).Conclusion/Clinical Relevance: A person with cervical SCI, symptomatic AD, and a non-dependent pacemaker can safely participate and benefit from the interval-FES cycling program provided adequate monitoring of symptoms and vital signs.

Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular and Pulmonary Section of APTA, have commissioned the development of this clinical practice guideline to assist physical therapists in their clinical decision making when managing patients with heart failure. Physical therapists treat patients with varying degrees of impairments and limitations in activity and participation associated with heart failure pathology across the continuum of care. This document will guide physical therapist practice in the examination and treatment of patients with a known diagnosis of heart failure. The development of this clinical practice guideline followed a structured process and resulted in 9 key action statements to guide physical therapist practice. The level and quality of available evidence were graded based on specific criteria to determine the strength of each action statement. Clinical algorithms were developed to guide the physical therapist in appropriate clinical decision making. Physical therapists are encouraged to work collaboratively with other members of the health care team in implementing these action statements to improve the activity, participation, and quality of life in individuals with heart failure and reduce the incidence of heart failure-related re-admissions.

The safety of electrical stimulation in patients with pacemakers and implantable cardioverter defibrillators: A systematic review

Introduction

A number of patients are excluded from electrical stimulation treatment because there is concern that electrical stimulation could cause electromagnetic interference with pacemakers and implanted cardioverter defibrillators. The decision to use electrical stimulation in these patients needs to be supported by an assessment of benefit and harm.

Methods

We conducted a systematic review of the risk of electromagnetic interference between electrical stimulation and pacemakers or implanted cardioverter defibrillators. We included the electronic databases MEDLINE and EMBASE in the time period between 1966 and 26 August 2016.

Results

18 papers fulfilled the inclusion criteria (eight safety studies and ten case studies). Although we were unable to accurately estimate the risk of electromagnetic interference, the studies revealed that patients having electrical stimulation of the lower limb are less susceptible to electromagnetic interference.

Conclusions

The results suggest that electrical stimulation could be used safely to help drop foot in patients with pacemakers or implanted cardioverter defibrillators. However, in order to obtain an accurate estimate of the risk of electromagnetic interference, a large, long-term, and intervention-specific safety study is required. Until such a study is undertaken, electrical stimulation should be used with caution in patients with pacemakers and implanted cardioverter defibrillators.

Neuromuscular electrical stimulation improves exercise tolerance in patients with advanced heart failure on continuous intravenous inotropic support use-randomized controlled trial

OBJECTIVE

To evaluate the impact of a short-term neuromuscular electrical stimulation program on exercise tolerance in hospitalized patients with advanced heart failure who have suffered an acute decompensation and are under continuous intravenous inotropic support.

DESIGN

A randomized controlled study.

SUBJECTS

Initially, 195 patients hospitalized for decompensated heart failure were recruited, but 70 were randomized.

INTERVENTION

Patients were randomized into two groups: control group subject to the usual care ( n = 35); neuromuscular electrical stimulation group ( n = 35) received daily training sessions to both lower extremities for around two weeks.

MAIN MEASURES

The baseline 6-minute walk test to determine functional capacity was performed 24 hours after hospital admission, and intravenous inotropic support dose was daily checked in all patients. The outcomes were measured in two weeks or at the discharge if the patients were sent back home earlier than two weeks.

RESULTS

After losses of follow-up, a total of 49 patients were included and considered for final analysis (control group, n = 25 and neuromuscular electrical stimulation group, n = 24). The neuromuscular electrical stimulation group presented with a higher 6-minute walk test distance compared to the control group after the study protocol (293 ± 34.78 m vs. 265.8 ± 48.53 m, P < 0.001, respectively). Neuromuscular electrical stimulation group also demonstrated a significantly higher dose reduction of dobutamine compared to control group after the study protocol (2.72 ± 1.72 µg/kg/min vs. 3.86 ± 1.61 µg/kg/min, P = 0.001, respectively).

CONCLUSION

A short-term inpatient neuromuscular electrical stimulation rehabilitation protocol improved exercise tolerance and reduced intravenous inotropic support necessity in patients with advanced heart failure suffering a decompensation episode.

Neuromuscular electrical stimulation of the thighs in cardiac patients with implantable cardioverter defibrillators

Background

The aim of this systematic review was to update scientific knowledge concerning the safety of neuromuscular electrical stimulation (NMES) to increase exercise capacity and prevent cardiac cachexia in patients with implantable cardioverter defibrillators (ICDs).

Methods

A systematic review including the electronic databases PubMed, MEDLINE, and SCOPUS was conducted for the time period from 1966 to March 31, 2016.

Results

Only four articles fulfilled the inclusion criteria (three original articles/safety studies and one case report). The three (safety) studies used NMES to increase muscle strength and/or endurance capacity of the thighs. NMES did not show electromagnetic interference (EMI) with ICD function. EMI was described in a case report of 2 patients with subpectoral ICDs and application of NMES on abdominal muscles.

Conclusion

This review indicates that NMES may be applied in cardiac ICD patients if 1) individual risks (e. g., pacing dependency, acute heart failure, unstable angina, ventricular arrhythmic episode in the last 3 months) are excluded by performing a safety check before starting NMES treatment and 2) “passive” exercise using NMES is performed only for thighs and gluteal muscles in 3) compliant ICD patients (especially for home-based NMES) and 4) the treatment is regularly supervised by a physician and the device is examined after the first use of NMES to exclude EMI. Nevertheless, further studies including larger sample sizes are necessary to exclude any risk when NMES is used in this patient group.

Feasibility of neuromuscular electrical stimulation immediately after cardiovascular surgery

OBJECTIVE

To determine the safety and feasibility of neuromuscular electrical stimulation (NMES) from postoperative days (PODs) 1 to 5 after cardiovascular surgery.

DESIGN

Pre-post interventional study.

SETTING

Surgical intensive care unit and thoracic surgical ward of a university hospital.

PARTICIPANTS

Consecutive patients (N=144) who underwent cardiovascular surgery were included. Patients with peripheral arterial disease, psychiatric disease, neuromuscular disease, and dementia were excluded. Patients with severe chronic renal failure and those who required prolonged mechanical ventilation after surgery were also excluded because of the possibility of affecting the outcome of a future controlled study.

INTERVENTIONS

NMES to the lower extremities was implemented from PODs 1 to 5.

MAIN OUTCOME MEASURES

Feasibility outcomes included compliance, the number of the patients who had changes in systolic blood pressure (BP) >20 mmHg or an increase in heart rate >20 beats/min during NMES, and the incidence of temporary pacemaker malfunction or postoperative cardiac arrhythmias.

RESULTS

Sixty-eight of 105 eligible patients participated in this study. Sixty-one (89.7%) of them completed NMES sessions. We found no patients who had excessive changes in systolic blood pressure, increased heart rate, or pacemaker malfunction during NMES. Incidence of atrial fibrillation during the study period was 26.9% (7/26) for coronary artery bypass surgery, 18.2% (4/22) for valvular surgery, and 20.0% (4/20) for combined or aortic surgery. No sustained ventricular arrhythmia or ventricular fibrillation was observed.

CONCLUSIONS

The results of this study demonstrate that NMES can be safely implemented even in patients immediately after cardiovascular surgery.

Exercise training combined with electromyostimulation in the rehabilitation of patients with chronic heart failure: A randomized trial

AIM

Both aerobic training (AT) and electromyostimulation (EMS) of leg muscles improve exercise tolerance in patients suffering from chronic heart failure (CHF). It was speculated that combination of both methods might have an additive effect. This study was performed to evaluate the effects of a combination of AT and EMS in rehabilitation (RHB) of CHF patients.

PATIENTS AND METHODS

Patients (n=71; age 59 ± 10.2 yrs, NYHA II/III, EF 32 ± 7.1%) were randomized into 3 groups: a) group AT, b) group EMS, and c) group AT+EMS. AT protocol included standard activity on bicycle 3x a week at the level of individual anaerobic threshold. EMS (10 Hz, mode 20s "on"/20s "off") was applied to leg extensors for 2 h/day. Total time of given type of RHB was 12 weeks.

RESULTS

Data analysis revealed statistically significant improvements of patients in all experimental groups (averaged difference after 12 weeks of exercise as related to initial value: ∆VO2peak: +12.9%, ∆VO2AT: +9.3%, ∆Wpeak: +22.7%). No statistically significant difference among experimental groups was found. Quality of life (Minnesota Living with Heart Failure - MLHF) global score was significantly improved in all 3 groups: AT (∆MLHF: -27.9%; P=0.001), AT+EMS (∆MLHF: -29.1%; P=0.002), and EMS (∆MLHF: -16.6%; P=0.008). MLHF score in EMS group showed the smallest time-related improvement compared to AT and AT+EMS groups, and this difference in improvement between the groups was statistically significant (P=0.021).

CONCLUSION

No significant difference was found between the two types of exercise training.and nor did, their combination have any significant additional improvement.

Low-frequency electromyostimulation and chronic heart failure

Low-frequency electromyostimulation (EMS) acts on the skeletal muscle abnormalities that aggravate intolerance to effort in patients with chronic heart failure (CHF). It improves the oxidative capacity of muscles and thus enhances aerobic performance and physical capacity to almost the same degree, as does conventional physical training. No local or hemodynamic intolerance has been reported, even in cases of severe CHF. However, the presence of a pacemaker is one of the relative contra-indications (prior evaluation of tolerance is required), while that of an implanted defibrillator is one of the absolute contra-indications. EMS is an alternative to physical effort training when the latter is impossible due to a high degree of deconditioning or because there is a contra-indication, which may be temporary, due to the risk of acute decompensation and/or rhythm troubles. EMS can also be used in patients waiting for a heart transplant or in CHF patients who are unwilling to engage in physical activities. As EMS is not expensive and easy to set up, its use is likely to develop in the future.

Electrical Stimulation of Skeletal Muscles An Alternative to Aerobic Exercise Training in Patients With Chronic Heart Failure?

The aim of this study was to investigate whether electrical stimulation of skeletal muscles could represent a rehabilitation alternative for patients with chronic heart failure (CHF). Thirty patients with CHF and NYHA class II-III were randomly assigned to a rehabilitation program using either electrical stimulation of skeletal muscles or bicycle training. Patients in the first group (n = 15) had 8 weeks of home-based low-frequency electrical stimulation (LFES) applied simultaneously to the quadriceps and calf muscles of both legs (1 h/day for 7 days/week); patients in the second group (n = 15) underwent 8 weeks of 40 minute aerobic exercise (3 times a week). After the 8-week period significant increases in several functional parameters were observed in both groups: maximal VO2 uptake (LFES group: from 17.5 +/- 4.4 mL/kg/min to 18.3 +/- 4.2 mL/kg/min, P < 0.05; bicycle group: from 18.1 +/- 3.9 mL/kg/min to 19.3 +/- 4.1 mL/kg/min, P < 0.01), maximal workload (LFES group: from 84.3 +/- 15.2 W to 95.9 +/- 9.8 W, P < 0.05; bicycle group: from 91.2 +/- 13.4 W to 112.9 +/- 10.8 W, P < 0.01), distance walked in 6 minutes (LFES group: from 398 +/- 105 m to 435 +/- 112 m, P < 0.05; bicycle group: from 425 +/- 118 m to 483 +/- 120 m, P < 0.03), and exercise duration (LFES group: from 488 +/- 45 seconds to 568 +/- 120 seconds, P < 0.05; bicycle group: from 510 +/- 90 seconds to 611 +/- 112 seconds, P < 0.03). These results demonstrate that an improvement of exercise capacities can be achieved either by classical exercise training or by home-based electrical stimulation. LFES should be considered as a valuable alternative to classical exercise training in patients with CHF.

Low-Frequency Electrical Stimulation Increases Muscle Strength and Improves Blood Supply in Patients With Chronic Heart Failure

BACKGROUND

This study was designed to evaluate the effects of low-frequency electrical stimulation (LFES) on muscle strength and blood flow in patients with advanced chronic heart failure (CHF).

METHODS AND RESULTS

Patients with CHF (n=15; age 56.5 +/- 5.2 years; New York Heart Association III - IV; ejection fraction 18.7 +/- 3.3%) were examined before and after 6 weeks of LFES (10 Hz) of the quadriceps and calf muscles of both legs (1 h/day, 7 days/week). Dynamometry was performed weekly to determine maximal muscle strength (F(max); N) and isokinetic peak torque (PT(max); Nm); blood flow velocity (BFV) was measured at baseline and after 6 weeks of LFES using pulsed-wave Doppler velocimetry of the right femoral artery. Six weeks of LFES significantly increased F(max) (from 224.5 +/- 96.8 N to 340.0 +/- 99.4 N; p<0.001), and also PT(max) (from 94.5 +/- 41.5 Nm to 135.3 +/- 28.8 Nm; p<0.01). BFV in the femoral artery increased after 6 weeks from 35.7 +/- 15.4 cm/s to 48.2 +/- 18.1 cm/s (p<0.05); BFV values at rest before and after 6 weeks of LFES did not differ significantly.

CONCLUSIONS

LFES may improve muscle strength and blood supply, and could be recommended for the treatment of patients with severe CHF.

Long-term Transcutaneous Neuromuscular Electrical Stimulation in Patients with Bipolar Sensing Implantable Cardioverter Defibrillators: A Pilot Safety Study

Neuromuscular electrical stimulation (NMES) is an option for increasing thigh muscle strength and endurance capacity in patients with chronic heart failure. Electromagnetic interference (EMI) by the signals with sensing of implantable cardioverter defibrillators (ICDs) is possible. The aim of the present pilot safety study was to test the safety of a long-term NMES in patients with ICDs. Six patients with subpectoral ICDs were subjected to long-term NMES of thigh muscles. Four inpatients received NMES to increase muscle strength, and two outpatients performed NMES as a home treatment to increase endurance capacity. During long-term NMES, all patients together received 14 139 799 biphasic electrical pulses and 412 425 on-phases without adverse events. ICD function after the stimulation period revealed no abnormalities in any patient. These results indicate that long-term NMES of thigh muscles seems to be safe in patients with ICDs, providing that an individual risk is excluded before.

Safety of a combined strength and endurance training using neuromuscular electrical stimulation of thighs muscles in patients with heart failure and bipolar sensing cardiac pacemakers

Neuromuscular electrical stimulation (NMES) is an effective and non-strenuous therapy to enhance the strength and endurance capacity of the skeletal muscles in patients with severe chronic heart failure. NMES in patients with pacemakers is controversial because potential electromagnetic interference may result in pacemaker malfunction. Therefore, such patients are in general excluded from NMES. The aim of this pilot study was to evaluate the safety of a combined NMES protocol to increase strength and endurance capacity of the skeletal muscles in patients with heart failure and implanted pacemakers. Seven patients with chronic heart failure and implanted cardiac pacemakers with bipolar sensing leads received NMES treatment of thigh muscles, using a combined protocol comprising biphasic, symmetric, rectangular constant current impulses at different frequencies (8-50 Hz), pulse width up to 60 s (8 Hz), 4 s (15 Hz), 4 s (30 Hz), and 6 s (50 Hz), and amplitudes up to +/- 100 mA (all frequencies) applied to both knee extensor and flexor muscles via surface electrodes (8 x 13 cm each). Acute electromagnetic interference during a safety procedure (telemetric monitoring) before therapeutic NMES application was not observed in any of the patients. The 7 patients received during 20 therapeutic NMES sessions a total of 23,380 on-phases, comprising 2194.08 x 10(3) biphasic electrical pulses, without adverse events. Heart rate monitoring during stimulation and pacemaker interrogation revealed no abnormalities. NMES treatment of thigh muscles using a combined NMES protocol to enhance strength and endurance capacity appears to be safe in patients with heart failure and implanted pacemakers with bipolar sensing, as far as the described electrode configuration and parameter range is applied.

Electromagnetic interference by transcutaneous neuromuscular electrical stimulation in patients with bipolar sensing implantable cardioverter defibrillators: a pilot safety study

Neuromuscular electrical stimulation (NMES) is a frequently applied therapy for the treatment of pain and a therapeutic option to increase thigh muscle strength and endurance capacity in patients with heart failure. Electromagnetic interference (EMI) by the signals with sensing of ICDs is possible. Eight patients with subpectoral ICD systems and different transvenous bipolar sensing leads were subjected to electrical stimulation of the neck and shoulder and of the thighs using different stimulation algorithms. EMI with ventricular sensing was detectable in three of eight subjects. EMI occurred during stimulation of the neck (n = 2) and thigh (n = 2). EMI by NMES with atrial sensing was seen in two of four subjects with dual chamber ICDs. The safety of peripheral NMES has to be individually tested as EMI can also occur in ICD patients with bipolar sensing.