Efficacy of neuromuscular electrical stimulation in patients with COPD followed in intensive care unit

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

Effect of neuromuscular electrical stimulation and early physical activity on ICU-acquired weakness in mechanically ventilated patients: A randomized controlled trial

BACKGROUND

Intensive care unit-acquired weakness (ICU-AW) is common in critically ill patients and increases the duration of mechanical ventilation (MV) and weaning time. Early mobilization, range of motion (ROM) exercises, and neuromuscular electrical stimulation (NMES) can prevent ICU-AW by maintaining muscle mass. However, studies highlighting the effects of combining NMES with early physical activity in ICU patients are limited.

AIM

To evaluate the effect of NMES and early physical activity on ICU-AW in mechanically ventilated patients.

STUDY DESIGN

A single-blinded randomized controlled trial was conducted in Alexandria, Egypt. Patients were randomly assigned to one of four groups: NMES, ROM, combined therapy (ROM + NMES), or conventional care (control group). The Medical Research Council (MRC) scale was used to assess the ICU-AW for the study patients over a 7-day period. The duration of the patient's MV and ICU stays were recorded.

RESULTS

Of the 180 patients who were assessed for eligibility, 124 were randomly assigned to one of four groups: 32 patients in ROM exercises, 30 in NMES, 31 in combined therapy (ROM + NMES), and 31 in the control group. On day 7, ROM + NMES and NMES groups showed higher MRC scores than ROM and control groups (50.37 ± 2.34, 49.77 ± 2.19, 44.97 ± 3.61, and 41.10 ± 3.84, respectively). ANOVA test results indicated significant differences (p < .001) across the four groups. ICU-AW occurred in 0% of the ROM + NMES group, 60% of the ROM group, 13% of the NMES group, and 100% of the control group (p < .001). The MV duration (in days) in the ROM + NMES group was shorter (12.80 ± 3.800) than in the ROM, NMES, or control groups (21.80 ± 4.460, 18.73 ± 4.748, and 20.70 ± 3.932, respectively). ICU-LOS was shorter in the ROM + NMES group (17.43 ± 3.17 days) compared with the ROM group (22.53 ± 4.51 days), the NMES group (21.10 ± 5.0 days), and the control group (21.50 ± 4.42 days) with significant differences (p < .001) between the four groups.

CONCLUSION

Daily sessions of NMES and early physical activity were well tolerated, preserved muscle strength, prevented ICU-AW, and decreased the duration of the MV and ICU stay.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study support the use of NMES and early physical exercises by critical care nurses as part of routine care for critically ill patients.

Effectiveness of neuromuscular electrical stimulation in patients with acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

This study aimed to investigate the effectiveness and acceptability of neuromuscular electrical stimulation (NMES) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

We conducted a systematic review and meta-analysis to investigate the effectiveness and accessibility of NMES and compared them with usual care in patients with acute exacerbation of COPD by searching databases such as MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials published up to April 2022. Randomized controlled trials (RCTs) involving patients with COPD who were treated within 3 weeks of acute exacerbation onset were included. The risk of bias was assessed using the RoB 2 tools. We pooled limb muscle strength and adverse events and performed a comparison between NMES and usual care. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Five RCTs, including 168 patients, met the eligibility criteria. The meta-analysis showed that limb muscle strength was significantly higher in the NMES group (four studies with 148 patients; standardized mean difference, 0.95; 95% confidence interval, 0.60-1.30; p < 0.001). The quality of evidence was very low due to the risk of bias within the studies, imprecision of the estimates, and small number of studies. Any adverse events served as outcomes in three studies (86 patients), although no adverse events occurred.

CONCLUSION

NMES is safe for patients with acute exacerbation of COPD and may maintain and improve limb muscle strength; however, the quality of evidence was very low.

Clinical effect of pulmonary rehabilitation in patients with mechanical ventilation: A meta-analysis

OBJECTIVE

To systematically evaluate the clinical efficacy of pulmonary rehabilitation in patients with mechanical ventilation in an intensive care unit (ICU).

METHODS

Relevant studies were identified in the PubMed, Web of Science, National Library of Medicine, China National Knowledge Infrastructure and Wanfang databases. A meta-analysis was performed after screening based on the inclusion and exclusion criteria, data extraction and literature quality evaluation.

RESULTS

In total, 19 studies involving 2181 participants were included. The results of the meta-analysis revealed that compared with patients with conventional rehabilitation measures, patients with pulmonary rehabilitation measures had a higher offline success rate (relative risk (RR) = 1.16; 95% confidence interval (CI): 1.09, 1.24; p < 0.00001) and higher arterial oxygen partial pressure levels (mean difference (MD) = 8.96; 95%CI: 5.98, 11.94; p < 0.0001) and these measures significantly shortened the duration of mechanical ventilation (standardised MD (SMD) = -1.08; 95%CI: -1.58, -0.59; p < 0.0001) and ICU stay (SMD = -1.41; 95%CI: -1.94, -0.88; p < 0.0001). Aspiration significantly reduced the incidence of ventilator-associated pneumonia (RR = 0.35; 95%CI: 0.24, 0.51; p < 0.00001) and deep vein thrombosis (RR = 0.32; 95%CI: 0.13, 0.76; p = 0.01) in ICU patients with mechanical ventilation.

CONCLUSION

Pulmonary rehabilitation measures can improve the success rate of weaning from mechanical ventilation in ICU patients, shorten the time of mechanical ventilation and ICU hospitalisation and reduce the incidence of related adverse reactions, but the impact on mortality requires further study.

20 years of neuromuscular electrical stimulation in COPD

Although a lung disease, COPD is also associated with extrapulmonary manifestations including, among others, limb muscle dysfunction. Limb muscle dysfunction is a key systemic consequence of COPD that impacts patients' physical activity, exercise tolerance, quality of life and survival. Deconditioning is the main mechanism underlying the development of limb muscle dysfunction in COPD, which can be partially improved with exercise. However, some patients may not be able to tolerate exercise because of incapacitating breathlessness or unwillingness to undertake whole-body exercise. Alternative training modalities that do not give rise to dyspnoea, such as neuromuscular electrical stimulation (NMES), are urged. Over the past 20 years, NMES in COPD has presented conflicting conclusions in meta-analysis. In this review, we try to understand the reason for this result by analysing possible biases and factors that brought conflicting conclusions. We discuss the population (the intervention group, but also the control group), the outcome measures, the frequency of stimulation, the rehabilitation protocol (i.e. NMES alone versus standard care/rehabilitation or NMES plus conventional exercise training versus conventional exercise training alone or NMES versus sham treatment) and the trial design. The main reason for this discrepancy is the lack of dedicated guidelines for NMES. Further research is urged to determine the optimal parameters for an NMES programme. Despite this, NMES appears to be an effective means of enhancing quadriceps strength and exercise capacity in COPD with the potential to break the vicious circle induced by the disease and COPD patients' lifestyle.

The effects of neuromuscular electrical stimulation on hospitalised adults: systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Neuromuscular electrical stimulation (NMES) is a treatment to prevent or reverse acquired disability in hospitalised adults. We conducted a systematic review and meta-analysis of its effectiveness.

METHOD

We searched MEDLINE, EMBASE, Cumulative Index to Nursing & Allied Health (CINAHL) and the Cochrane library. Inclusion criteria: randomised controlled trials of hospitalised adult patients comparing NMES to control or usual care. The primary outcome was muscle strength. Secondary outcomes were muscle size, function, hospital length of stay, molecular and cellular biomarkers, and adverse effects. We assessed risk of bias using the Cochrane risk-of-bias tool. We used Review Manager (RevMan) software for data extraction, critical appraisal and synthesis. We assessed certainty using the Grading of Recommendations Assessment, Development and Evaluation tool.

RESULTS

A total of 42 papers were included involving 1,452 participants. Most studies had unclear or high risk of bias. NMES had a small effect on muscle strength (moderate certainty) (standardised mean difference (SMD) = 0.33; P < 0.00001), a moderate effect on muscle size (moderate certainty) (SMD = 0.66; P < 0.005), a small effect on walking performance (moderate certainty) (SMD = 0.48; P < 0.0001) and a small effect on functional mobility (low certainty) (SMD = 0.31; P < 0.05). There was a small and non-significant effect on health-related quality of life (very low certainty) (SMD = 0.35; P > 0.05). In total, 9% of participants reported undesirable experiences. The effects of NMES on length of hospital stay, and molecular and cellular biomarkers were unclear.

CONCLUSIONS

NMES is a promising intervention component that might help to reduce or prevent hospital-acquired disability.

Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023)

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Effect of Neuromuscular Electrical Stimulation in Patients With Critical Illness: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Neuromuscular electrical stimulation (NMES) is used in the rehabilitation of patients with critical illness. However, it is unclear whether NMES prevents ICU-acquired weakness (ICU-AW). For this purpose, we conducted an updated systematic review and meta-analysis.

DATA SOURCES

We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases from April 2019 to November 2022 to identify new randomized controlled trials to the previous meta-analysis.

STUDY SELECTION

We systematically searched the literature for all randomized controlled trials on the effect of NMES in patients with critical illness.

DATA EXTRACTION

Two authors independently selected the studies and extracted data. They calculated the pooled effect estimates associated with the occurrence of ICU-AW and adverse events as primary outcomes and muscle mass change, muscle strength, length of ICU stay, mortality, and quality of life as secondary outcomes. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS

Overall, eight studies were added to the previous 10 studies. Evidence suggests that the use of NMES reduces the occurrence of ICU-AW (six trials; risk ratio [RR], 0.48; 95% CI, 0.32-0.72); however, NMES may have little to no effect on pricking sensation in patients (eight trials; RR, 6.87; 95% CI, 0.84-56.50). NMES is likely to reduce the change in muscle mass (four trials; mean difference, -10.01; 95% CI, -15.54 to -4.48) and may increase muscle strength (six trials; standardized mean difference, 0.43; 95% CI, 0.19-0.68). Further, NMES may result in little to no difference in the length of ICU stay, and the evidence is uncertain about the effect on mortality and quality of life.

CONCLUSIONS

This updated meta-analysis revealed that the use of NMES may result in a lower occurrence of ICU-AW in patients with critical illness, but its use may have little to no effect on pricking sensation in patients.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Prevention of muscle atrophy in ICU patients without nerve injury by neuromuscular electrical stimulation: a randomized controlled study

Background

Extensive muscle atrophy is a common occurrence in orthopaedics patients who are bedridden or immobilized. The incidence is higher in intensive care unit (ICU) inpatients. There is still controversy about how to use neuromuscular electrical stimulation (NMES) in ICU patients. We aim to compare the effectiveness and safety of NMES to prevent muscle atrophy in intensive care unit (ICU) patients without nerve injury.

Methods

ICU patients without central and peripheral nerve injury were randomized into experimental group I (Exp I: active and passive activity training (APAT) + NMES treatment on the gastrocnemius and tibialis anterior muscle), experimental group II (Exp II: APAT + NMES treatment on gastrocnemius alone), and control group (Ctl: APAT alone). Changes in the strength of gastrocnemius, the ankle range of motion, and the muscle cross-section area of the lower leg were evaluated before and after the intervention. Also, changes in prothrombin time, lactic acid, and C-reactive protein were monitored during the treatment.

Results

The gastrocnemius muscle strength, ankle joint range of motion, and cross-sectional muscle area of the lower leg in the three groups showed a downward trend, indicating that the overall trend of muscle atrophy in ICU patients was irreversible. The decrease in gastrocnemius muscle strength in Exp I and Exp II was smaller than that in the control group (P < 0.05), but there was no difference between Exp I and Exp II. The decrease in active ankle range of motion and cross-sectional area of the lower leg Exp I and Exp II was smaller than that in the control group (P < 0.05), and the decrease in Exp I was smaller than that of Exp II (all P < 0.05). The curative effect in Exp I was better than in Exp II. There were no significant differences in the dynamic changes of prothrombin time, lactic acid, and C-reactive protein during the three groups (P > 0.05).

Conclusion

In addition to early exercise training, NMES should be applied to prevent muscle atrophy for patients without nerve injury in ICU. Also, simultaneous NMES treatment on agonist/antagonist muscle can enhance the effect of preventing muscle atrophy.

Trial registration

This study was prospectively registered in China Clinical Trial Registry (www.chictr.org.cn) on 16/05/2020 as ChiCTR2000032950.

Early rehabilitation program and weaning outcomes in critically ill chronic obstructed airway disease patients: a randomized trial

Background

To compare the effectiveness of early rehabilitation program on mechanical ventilated COPD patient in RICU to those using current usual care regarding diaphragm function and weaning outcomes.

Methods

The study was a randomized controlled trial. It included 108 newly admitted COPD patients to RICU, Chest Department, Assiut University Hospital, Egypt, in the period from June 2018 to May 2020. They were divided into two groups: group Ι received the usual care plus pulmonary rehabilitation program, and group II received the usual care alone. The outcomes (MV duration, rates of successful weaning, diaphragm function, and lengths of hospital and ICU stay) were recorded and evaluated. The data was analyzed using Student t-test, Mann–Whitney U-test, Wilcoxon signed-rank test, chi-square (χ2) test or Fisher Exact test, receiver operating characteristics (ROC) curve, and logistic regression analysis.

Results

One-hundred and eight COPD patients were included. Early rehabilitation program for COPD patients in the ICU shortened the duration of their MV, increases the rates of successful weaning and decreases 30-day mortality, and shortened the duration of their ICU and hospital stays, as compared to COPD patients who received usual care.

Conclusions

Management of COPD patients with early rehabilitation program is associated with better outcome with improvement of the quality of life of COPD patients.

Trial registration

Clinical trial.gov: NCT03253380

Physical Rehabilitation Programs for Bedridden Patients with Prolonged Immobility: A Scoping Review

Bedridden patients usually stay in bed for long periods, presenting several problems caused by immobility, leading to a long recovery process. Thus, identifying physical rehabilitation programs for bedridden patients with prolonged immobility requires urgent research. Therefore, this scoping review aimed to map existing physical rehabilitation programs for bedridden patients with prolonged immobility, the rehabilitation domains, the devices used, the parameters accessed, and the context in which these programs were performed. This scoping review, guided by the Joanna Briggs Institute’s (JBI) methodology and conducted in different databases (including grey literature), identified 475 articles, of which 27 were included in this review. The observed contexts included research institutes, hospitals, rehabilitation units, nursing homes, long-term units, and palliative care units. Most of the programs were directed to the musculoskeletal domain, predominantly toward the lower limbs. The devices used included lower limb mobilization, electrical stimulation, inclined planes, and cycle ergometers. Most of the evaluated parameters were musculoskeletal, cardiorespiratory, or vital signs. The variability of the programs, domains, devices and parameters found in this scoping review revealed no uniformity, a consequence of the personalization and individualization of care, which makes the development of a standard intervention program challenging.

Therapeutic Potential of Electromyostimulation (EMS) in Critically Ill Patients—A Systematic Review

Ample evidence exists that intensive care unit (ICU) treatment and invasive ventilation induce a transient or permanent decline in muscle mass and function. The functional deficit is often called ICU-acquired weakness with critical illness polyneuropathy (CIP) and/or myopathy (CIM) being the major underlying causes. Histopathological studies in ICU patients indicate loss of myosin filaments, muscle fiber necrosis, atrophy of both muscle fiber types as well as axonal degeneration. Besides medical prevention of risk factors such as sepsis, hyperglycemia and pneumonia, treatment is limited to early passive and active mobilization and one third of CIP/CIM patients discharged from ICU never regain their pre-hospitalization constitution. Electromyostimulation [EMS, also termed neuromuscular electrical stimulation (NMES)] is known to improve strength and function of healthy and already atrophied muscle, and may increase muscle blood flow and induce angiogenesis as well as beneficial systemic vascular adaptations. This systematic review aimed to investigate evidence from randomized controlled trails (RCTs) on the efficacy of EMS to improve the condition of critically ill patients treated on ICU. A systematic search of the literature was conducted using PubMed (Medline), CENTRAL (including Embase and CINAHL), and Google Scholar. Out of 1,917 identified records, 26 articles (1,312 patients) fulfilled the eligibility criteria of investigating at least one functional measure including muscle function, functional independence, or weaning outcomes using a RCT design in critically ill ICU patients. A qualitative approach was used, and results were structured by 1) stimulated muscles/muscle area (quadriceps muscle only; two to four leg muscle groups; legs and arms; chest and abdomen) and 2) treatment duration (≤10 days, >10 days). Stimulation parameters (impulse frequency, pulse width, intensity, duty cycle) were also collected and the net EMS treatment time was calculated. A high grade of heterogeneity between studies was detected with major cofactors being the analyzed patient group and selected outcome variable. The overall efficacy of EMS was inconclusive and neither treatment duration, stimulation site or net EMS treatment time had clear effects on study outcomes. Based on our findings, we provide practical recommendations and suggestions for future studies investigating the therapeutic efficacy of EMS in critically ill patients.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021262287].

Effects of neuromuscular electrical stimulation on exercise capacity, muscle strength and quality of life in COPD patients: A Systematic Review with Meta-Analysis

OBJECTIVE

To determine the effects of neuromuscular electrical stimulation on disabilities and activity limitation of individuals affected by chronic obstructive pulmonary disease.

DATA SOURCES

MEDLINE, PEDro database, Cochrane Controlled Trials Register, and SciELO, were searched from inception until October 2021.

REVIEW METHODS

Inclusion criteria were patients with COPD, randomized controlled trials comparing neuromuscular electrical stimulation alone or combined conventional pulmonary rehabilitation and neuromuscular electrical stimulation versus control or sham or pulmonary rehabilitation in disabilities and activity limitation in COPD. There were no mandatory language or publication date restrictions. Two reviewers selected studies independently. Weighted mean differences and 95% confidence intervals were calculated.

RESULTS

32 studies met the study criteria, including 1.269 participants. Neuromuscular electrical stimulation improved exercise capacity (MD 1.10, 95% CI: 0.33, 1.86, N = 147), and muscle strength (0.53, 95% CI: 0.20, 0.87, N = 147) compared to sham group. Combined neuromuscular electrical stimulation and conventional rehabilitation improved exercise capacity (MD 34.28 meters, 95% CI: 6.84, 61.73, N = 262) compared to conventional rehabilitation alone. No adverse events were reported.

CONCLUSIONS

Neuromuscular electrical stimulation resulted in small improvement in disabilities and activity limitation (below the MCID) in COPD. Thus, the inclusion of neuromuscular electrical stimulation in rehabilitation programs must consider the cost Because of inadequate methodological conduction and reporting of methods, some studies were of low quality.

Immediate Hemodynamic Responses to Transcutaneous Electrical Diaphragmatic Stimulation in Critically Ill Elderly Patients

Background

Critically ill patients admitted to intensive care units (ICUs) may develop diaphragmatic dysfunction, especially when artificial airways are used. Positive effects have been observed when using the transcutaneous electrical diaphragmatic stimulation (TEDS) technique in different clinical conditions. However, no study has evaluated the safety of TEDS in patients admitted to ICUs. This study is aimed at evaluating the influence of TEDS on the hemodynamic and vital parameters of critically ill elderly patients under invasive mechanical ventilation (IMV).

Methods

Forty-seven patients aged >60 years under IMV were evaluated for hemodynamic variables before and after TEDS. The procedure lasted 30 minutes and was performed once.

Results

The sample consisted of 33 men and 14 women with a mean age of 69.9 ± 7.64 years. The mean systolic blood pressures pre-TEDS and post-TEDS were 126.6 ± 23.7 and 122.9 ± 25.9, respectively (p = 0.467). The mean diastolic blood pressures pre-TEDS and post-TEDS were 71.1 ± 12.2 and 67.7 ± 14.2, respectively (p = 0.223). No significant differences in the mean arterial pressure or heart rate were found between the pre-TEDS and post-TEDS time points (p = 0.335 and p = 0.846, respectively).

Conclusion

Our findings suggest that TEDS does not have clinically relevant impacts on hemodynamic or vital parameters in critically ill elderly patients. These findings point to the possible safety of TEDS application in this population.

Effectiveness of neuromuscular electrostimulation in COPD subjects on mechanical ventilation. A systematic review and meta-analysis

OBJECTIVE

To estimate the effectiveness of Neuromuscular Electrostimulation (NMES) in adults with COPD undergoing MV.

METHOD

A sensitive search was performed in MEDLINE, Embase, CENTRAL, CINAHL and other resources. Randomized Controlled Clinical Trials (RCTs) or non-RCTs that enrolled adults with COPD on MV due to an exacerbation of their disease were included. Two independent reviewers screened, extracted information, and assessed the risk of bias (RoB 2 tool) and the certainty of evidence (GRADE approach) from the included studies.

RESULTS

Four RCTs (144 participants) were included. Subjects who underwent NMES were able to move from bed to chair independently in less time (MD = 4.98 days less; 95% CI -8.55 to -1.47; 2 RCTs; low certainty of the evidence) and they were fewer days on MV (MD = 2.89 days less; 95% CI -4.58 to -1.21); 3 RCTs; low certainty of the evidence) than the control group. However, the effect of NMES on muscle strength is unclear (very low certainty of the evidence).

CONCLUSIONS

NMES may improve functional independence and decrease MV time in adults with COPD; however, its effectiveness on muscle strength is uncertain. More and better RCTs are needed to determine with greater certainty the effectiveness of NMES in this population.

Rehabilitation Programs for Bedridden Patients with Prolonged Immobility: A Scoping Review Protocol

Bedridden patients usually stay in bed for long periods, presenting several motor problems caused by immobility, such as reductions in muscle mass, bone mineral density and physical impairment, resulting in a long recovery process. Thus, identifying physical rehabilitation programs for bedridden patients with prolonged immobility is a matter of urgent research for a solution that will help health professionals and stakeholders to develop more adjusted programs and identify possible gaps. To date, no previous scoping reviews addressing this purpose have been found. This scoping review will be guided by the Joanna Briggs Institute (JBI) methodology, will focus on physical rehabilitation programs for bedridden patients with prolonged immobility and aims to map the programs, the devices used, and the parameters assessed. A relevant set of electronic databases and grey literature will be searched. Data extraction will be conducted using a tool developed by the research team that will address the review objectives and questions. Data synthesis will be presented in tabular form and a narrative summary aligned with the review's objective. This scoping review will contribute to the improvement of clinical practice, identifying key challenges that might justify the need to develop new programs suitable in clinical and organizational contexts.

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

OBJECTIVES

To establish the evidence for rehabilitation interventions tested in populations of patients admitted to ICU and critical care with severe respiratory illness, and consider whether the evidence is generalizable to patients with COVID-19.

METHODS

The authors undertook a rapid systematic review. Medline (via OvidSP), CINAHL Complete (via EBSCOhost), Cochrane Library, Cochrane Database of Systematic Reviews and CENTRAL (via Wiley), Epistemonikos (via Epistemonikos.org), PEDro (via pedro.org.au) and OTseeker (via otseeker.com) searched to 7 May 2020. The authors included systematic reviews, RCTs and qualitative studies involving adults with respiratory illness requiring intensive care who received rehabilitation to enhance or restore resulting physical impairments or function. Data were extracted by one author and checked by a second. TIDier was used to guide intervention descriptions. Study quality was assessed using Critical Skills Appraisal Programme (CASP) tools.

RESULTS

Six thousand nine hundred and three titles and abstracts were screened; 24 systematic reviews, 11 RCTs and eight qualitative studies were included. Progressive exercise programmes, early mobilisation and multicomponent interventions delivered in ICU can improve functional independence. Nutritional supplementation in addition to rehabilitation in post-ICU hospital settings may improve performance of activities of daily living. The evidence for rehabilitation after discharge from hospital following an ICU admission is inconclusive. Those receiving rehabilitation valued it, engendering hope and confidence.

CONCLUSIONS

Exercise, early mobilisation and multicomponent programmes may improve recovery following ICU admission for severe respiratory illness that could be generalizable to those with COVID-19. Rehabilitation interventions can bring hope and confidence to individuals but there is a need for an individualised approach and the use of behaviour change strategies. Further research is needed in post-ICU settings and with those who have COVID-19. Registration: Open Science Framework https://osf.io/prc2y.

Physical rehabilitation in Intensive Care Unit in acute respiratory distress syndrome patients with COVID-19

BACKGROUND

The risk of muscle weakness is high in the survivors of acute respiratory distress syndrome with COVID-19 following discharge from intensive care unit.

AIM

To evaluate the effects of early rehabilitation program in intensive care unit in patients with acute respiratory distress syndrome secondary to COVID-19.

DESIGN

The design of the study is observational.

SETTING

The setting of the study is inpatient.

POPULATION

Thirty-five patients with acute respiratory distress syndrome secondary to COVID-19 were enrolled.

METHODS

This study was performed in an intensive care unit of a university hospital. Early rehabilitation program consisting of passive or active range of motion exercises and neuromuscular electrical stimulation in addition to standard intensive care (N.=18) compared to standard intensive care (N.=17). Primary outcome was hand grip strength following discharge.

RESULTS

Rehab group had higher prevalence of chronic pulmonary diseases and neurologic diseases. There was no difference in hand grip or manual muscle strength following discharge between rehab and non-rehab groups. No adverse event was noted.

CONCLUSIONS

The results did not support the beneficial effects of early rehabilitation in intensive care unit on improving muscle strength. More patients with pulmonary and neurologic diseases in rehab group might impede the impact of rehabilitation on outcomes. On the other hand, these comorbidities underline the role and need of rehabilitation. It is safe both for the patients and the health care workers when necessary precautions are taken.

CLINICAL REHABILITATION IMPACT

This study guide how to rehabilitate patients with acute respiratory distress syndrome with COVID-19 during intensive care unit in a safe way.

Early neuromuscular electrical stimulation reduces the loss of muscle mass in critically ill patients - A within subject randomized controlled trial

PURPOSE

To investigate the effect of Neuromuscular Electrical Stimulation (NMES) on muscle thickness, strength and morphological and molecular markers of the quadriceps.

MATERIALS AND METHODS

Adult critically ill patients with an expected prolonged stay received unilateral quadriceps NMES sessions for 7 consecutive days. Before and after the intervention period, quadriceps thickness was measured with ultrasound. After the intervention period, strength was assessed in cooperative patients and muscle biopsies were taken. Multivariable regression was performed to identify factors affecting muscle thickness loss.

RESULTS

Muscle thickness decreased less in the stimulated leg (-6 ± 16% versus -12 ± 15%, p = 0.014, n = 47). Strength was comparable. Opioid administration, minimal muscle contraction and more muscle thickness loss in the non-stimulated muscle were independently associated with better muscle thickness preservation. Stimulated muscles showed a shift towards larger myofibers and higher MyHC-I gene expression. NMES did not affect gene expression of other myofibrillary proteins, MuRF-1 or atrogin-1. Signs of myofiber necrosis and inflammation were comparable for both muscles.

CONCLUSIONS

NMES attenuated the loss of muscle mass, but not of strength, in critically ill patients. Preservation of muscle mass was more likely in patients receiving opioids, patients with a minimal muscle contraction during NMES and patients more prone to lose muscle mass.

TRIAL REGISTRATION

clinicaltrials.govNCT02133300.

Physical Therapy and Rehabilitation in Chronic Obstructive Pulmonary Disease Patients Admitted to the Intensive Care Unit

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition that affects a person's ability to exercise and undertake normal physical function due to breathlessness, poor physical fitness, and muscle fatigue. Patients with COPD often experience exacerbations due to pulmonary infections, which result in worsening of their symptoms, more loss of function, and often require hospital treatment or in severe cases admission to intensive care units. Recovery from such exacerbations is often slow, and some patients never fully return to their previous level of activity. This can lead to permanent disability and premature death.Physical therapists play a key role in the respiratory management and rehabilitation of patients admitted to intensive care following acute exacerbation of COPD. This article discusses the key considerations for respiratory management of patients requiring invasive mechanical ventilation, providing an evidence-based summary of commonly used interventions. It will also explore the evidence to support the introduction of early and structured programs of rehabilitation to support recovery in both the short and the long term, as well as active mobilization, which includes strategies to minimize or prevent physical loss through early retraining of both peripheral and respiratory muscles.

Acute effect of passive cycle-ergometry and functional electrical stimulation on nitrosative stress and inflammatory cytokines in mechanically ventilated critically ill patients: a randomized controlled trial

Early mobilization is beneficial for critically ill patients because it reduces muscle weakness acquired in intensive care units. The objective of this study was to assess the effect of functional electrical stimulation (FES) and passive cycle ergometry (PCE) on the nitrous stress and inflammatory cytometry in critically ill patients. This was a controlled, randomized, open clinical trial carried out in a 16-bed intensive care unit. The patients were randomized into four groups: Control group (n=10), did not undergo any therapeutic intervention during the study; PCE group (n=9), lower-limb PCE for 30 cycles/min for 20 min; FES group (n=9), electrical stimulation of quadriceps muscle for 20 min; and FES with PCE group (n=7), patients underwent PCE and FES, with their order determined randomly. The serum levels of nitric oxide, tumor necrosis factor alpha, interferon gamma, and interleukins 6 and 10 were analyzed before and after the intervention. There were no differences in clinical or demographic characteristics between the groups. The results revealed reduced nitric oxide concentrations one hour after using PCE (P<0.001) and FES (P<0.05), thereby indicating that these therapies may reduce cellular nitrosative stress when applied separately. Tumor necrosis factor alpha levels were reduced after the PCE intervention (P=0.049). PCE and FES reduced nitric oxide levels, demonstrating beneficial effects on the reduction of nitrosative stress. PCE was the only treatment that reduced the tumor necrosis factor alpha concentration.

Effects of neuromuscular electrical stimulation in patients with pulmonary arterial hypertension: a randomized controlled pilot study

BACKGROUND

Patients with pulmonary arterial hypertension (PAH) present impairments in muscle strength and exercise capacity. There is growing evidence about the benefits of neuromuscular electrical stimulation (NMES) in patients with respiratory diseases, except in patients with PAH. The aim of this study was to investigate the effects of NMES on muscle strength, and other physical and psychosocial variables in patients with PAH.

METHODS

Patients with PAH were randomly divided into two groups as NMES and control. The NMES was applied to the bilateral deltoid and quadriceps femoris muscles with 50 Hz for 3 days/week, 8 weeks for the NMES group. Muscle strength, muscle cross-sectional area and thickness, arterial stiffness, exercise capacity, functional mobility and balance, balance confidence, fatigue, physical activity, and quality of life were assessed at baseline and after 8 weeks by blinded assessors.

RESULTS

There was no significant difference in the demographic and clinical characteristics between the patient groups (p > 0.05). The improvements in muscle strength, muscle cross-sectional area and thickness, pulse wave velocity, exercise capacity, functional mobility and balance, balance confidence, fatigue, physical activity, and quality of life were significantly higher in the NMES group compared to the control group (p < 0.05).

CONCLUSIONS

This study suggests that NMES intervention is safe and effective for patients with PAH.

An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease

Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.

Neuromuscular Electrical Stimulation: A New Therapeutic Option for Chronic Diseases Based on Contraction-Induced Myokine Secretion

Myokines are peptides known to modulate brain neuroplasticity, adipocyte metabolism, bone mineralization, endothelium repair and cell growth arrest in colon and breast cancer, among other processes. Repeated skeletal muscle contraction induces the production and secretion of myokines, which have a wide range of functions in different tissues and organs. This new role of skeletal muscle as a secretory organ means skeletal muscle contraction could be a key player in the prevention and/or management of chronic disease. However, some individuals are not capable of optimal physical exercise in terms of adequate duration, intensity or muscles involved, and therefore they may be virtually deprived of at least some of the physiological benefits induced by exercise. Neuromuscular electrical stimulation (NMES) is emerging as an effective physical exercise substitute for myokine induction. NMES is safe and efficient and has been shown to improve muscle strength, functional capacity, and quality of life. This alternative exercise modality elicits hypertrophy and neuromuscular adaptations of skeletal muscles. NMES stimulates circulating myokine secretion, promoting a cascade of endocrine, paracrine, and autocrine effects. We review the current evidence supporting NMES as an effective physical exercise substitute for inducing myokine production and its potential applications in health and disease.

Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review

Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.

Neuromuscular electrostimulation for adults with chronic obstructive pulmonary disease

BACKGROUND

In people with chronic obstructive pulmonary disease (COPD), the use of neuromuscular electrostimulation (NMES) either alone, or together with conventional exercise training, might improve the condition of the peripheral muscles, increase exercise capacity and functional performance, reduce symptoms and improve health-related quality of life (HRQoL).

OBJECTIVES

To determine the effects of NMES, applied in isolation or concurrently with conventional exercise training to one or more peripheral muscles, on peripheral muscle force and endurance, muscle size, exercise capacity, functional performance, symptoms, HRQoL and adverse events in people with COPD.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register, the Physiotherapy Evidence Database, clinical trial registries and conference abstracts on 14 March 2018.

SELECTION CRITERIA

Randomised controlled trials that recruited adults with COPD if they had compared outcomes between a group that received NMES and a group that received usual care or compared outcomes between a group that received NMES plus conventional exercise training and a group that participated in conventional exercise training alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. We expressed continuous data as either the standardised mean difference (SMD) or mean difference (MD) with the corresponding 95% confidence interval (CI). We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Nineteen studies met the inclusion criteria of which 16 contributed data on 267 participants with COPD (mean age 56 to 76 years and 67% were men). Of these 16 studies, seven explored the effect of NMES versus usual care and nine explored the effect of NMES plus conventional exercise training versus conventional exercise training alone. Six studies utilised sham stimulation in the control group. When applied in isolation, NMES produced an increase in peripheral muscle force (SMD 0.34, 95% CI 0.02 to 0.65; low-quality evidence) and quadriceps endurance (SMD 1.36, 95% CI 0.59 to 2.12; low-quality evidence) but the effect on thigh muscle size was unclear (MD 0.25, 95% CI -0.11 to 0.61; low-quality evidence). There were increases in six-minute walk distance (6MWD) (MD 39.26 m, 95% CI 16.31 to 62.22; low-quality evidence) and time to symptom limitation exercising at a submaximal intensity (MD 3.62 minutes, 95% CI 2.33 to 4.91). There was a reduction in the severity of leg fatigue on completion of an exercise test (MD -1.12 units, 95% CI -1.81 to -0.43). The increase in peak rate of oxygen uptake (VO_2peak) was of borderline significance (MD 0.10 L/minute, 95% CI 0.00 to 0.19).For NMES with conventional exercise training, there was an uncertain effect on peripheral muscle force (SMD 0.47, 95% CI -0.10 to 1.04; very low-quality evidence) and there were insufficient studies to undertake a meta-analysis on the effect on quadriceps endurance or thigh muscle size. However, there was an increase in 6MWD in favour of NMES combined with conventional exercise training (MD 25.87 m, 95% CI 1.06 to 50.69; very low-quality evidence). In people admitted to either in an intensive care unit or a respiratory high dependency centre, NMES combined with conventional exercise reduced the time taken for participants to first sit out of bed by 4.98 days (95% CI -8.55 to -1.41; very low-quality evidence), although the statistical heterogeneity for this analysis was high (I² = 60%). For both types of studies (i.e. NMES versus usual care and NMES with conventional exercise training versus conventional exercise training alone), there was no risk difference for mortality or minor adverse events in participants who received NMES.

AUTHORS' CONCLUSIONS

NMES, when applied in isolation, increased quadriceps force and endurance, 6MWD and time to symptom limitation exercising at a submaximal intensity, and reduced the severity of leg fatigue on completion of exercise testing. It may increase VO_2peak, but the true effect on this outcome measure could be trivial. However, the quality of evidence was low or very low due to risk of bias within the studies, imprecision of the estimates, small number of studies and inconsistency between the studies. Although there were no additional gains in quadriceps force with NMES plus conventional exercise training, there was evidence of an increase in 6MWD. Further, in people who were the most debilitated, the addition of NMES may have accelerated the achievement of a functional milestone, that is, the first time someone sits out of bed.

Relevance of nutritional support and early rehabilitation in hospitalized patients with COPD

Exacerbation of COPD is associated with a worsening of lung function and symptoms, and a serious loss in functional status and health related quality of life. It also represents the major cause for emergency hospitalization in COPD patients which places the patient at risk for developing further muscle weakness. Actually, loss of muscle function developed fast and continued to decrease over time during hospitalization and may be further compromised when disease deterioration would require the use of ventilator support. Exacerbations have long term consequences on physical performance, physical activity and health-related quality of life as recovery of skeletal muscle function is slow and incomplete and may even be compromised in case of re-exacerbation. Factors such as bed rest, reduced physical activity, hypoxia, inflammation, drug treatment and negative protein balance due to insufficient dietary intake and increased resting energy expenditure are all potential contributors to skeletal muscle weakness during exacerbation. Because low levels of physical activity and poor physical performance are predictor of hospital re-admission and are associated with lower survival in these patients, interventions to prevent the additional loss of muscle function during exacerbation or to hasten functional recovery have been recently explored. This review focuses on the knowledge regarding the potential benefit of early rehabilitation and nutritional supplementation as modifiable factors susceptible to ameliorate muscle weakness during exacerbation in hospitalized COPD patients.

Safety of neuromuscular electrical stimulation among critically ill patients: systematic review

OBJECTIVE

To review the evidence on the safety of neuromuscular electrical stimulation when used in the intensive care unit.

METHODS

A systematic review was conducted; a literature search was performed of the MEDLINE (via PubMed), PEDro, Cochrane CENTRAL and EMBASE databases, and a further manual search was performed among the references cited in randomized studies. Randomized clinical trials that compared neuromuscular electrical stimulation to a control or placebo group in the intensive care unit and reporting on the technique safety in the outcomes were included. Hemodynamic variables and information on adverse effects were considered safety parameters. Articles were independently analyzed by two reviewers, and the data analysis was descriptive.

RESULTS

The initial search located 1,533 articles, from which only four randomized clinical trials were included. Two studies assessed safety based on hemodynamic variables, and only one study reported an increase in heart rate, respiratory rate and blood lactate, without clinical relevance. The other two studies assessed safety based on reported adverse effects. In one, 15% of patients described a prickling sensation, without any clinically relevant abnormalities. In the other, one patient suffered a superficial burn due to improper parameter configuration.

CONCLUSION

Neuromuscular electrical stimulation is safe for critically ill patients; however, it should be applied by duly trained professionals and with proper evidence-based parameters.

Oxidative stress and immune system analysis after cycle ergometer use in critical patients

OBJECTIVE:

The passive cycle ergometer aims to prevent hypotrophy and improve muscle strength, with a consequent reduction in hospitalization time in the intensive care unit and functional improvement. However, its effects on oxidative stress and immune system parameters remain unknown. The aim of this study is to analyze the effects of a passive cycle ergometer on the immune system and oxidative stress in critical patients.

METHODS:

This paper describes a randomized controlled trial in a sample of 19 patients of both genders who were on mechanical ventilation and hospitalized in the intensive care unit of the Hospital Agamenom Magalhães. The patients were divided into two groups: one group underwent cycle ergometer passive exercise for 30 cycles/min on the lower limbs for 20 minutes; the other group did not undergo any therapeutic intervention during the study and served as the control group. A total of 20 ml of blood was analysed, in which nitric oxide levels and some specific inflammatory cytokines (tumour necrosis factor alpha (TNF-α), interferon gamma (IFN-γ) and interleukins 6 (IL-6) and 10 (IL-10)) were evaluated before and after the study protocol.

RESULTS:

Regarding the demographic and clinical variables, the groups were homogeneous in the early phases of the study. The nitric oxide analysis revealed a reduction in nitric oxide variation in stimulated cells (p=0.0021) and those stimulated (p=0.0076) after passive cycle ergometer use compared to the control group. No differences in the evaluated inflammatory cytokines were observed between the two groups.

CONCLUSION:

We can conclude that the passive cycle ergometer promoted reduced levels of nitric oxide, showing beneficial effects on oxidative stress reduction. As assessed by inflammatory cytokines, the treatment was not associated with changes in the immune system. However, further research in a larger population is necessary for more conclusive results.

Effectiveness of neuromuscular electrical stimulation for the rehabilitation of moderate-to-severe COPD: a meta-analysis

PURPOSE

Patients with COPD often experience skeletal muscle dysfunction. For those who are unable or unwilling to undertake physical training, neuromuscular electrical stimulation (NMES) may provide an alternative method of rehabilitation. The purpose of this meta-analysis was to investigate the controversial topic of whether this therapy is effective in patients with moderate-to-severe COPD.

PATIENTS AND METHODS

We pooled data from nine trials published between January 9, 2002 and January 4, 2016 across PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, and relevant websites for randomized controlled trials. In these trials, patients with moderate-to-severe COPD were randomly allocated to receive NMES. Primary outcomes were quadricep strength and exercise capacity. The secondary outcome was health-related quality of life.

RESULTS

We extracted data from 276 patients. NMES contributed to statistically improved quadricep strength (standardized mean difference 1.12, 95% confidence interval [CI] 0.64-1.59, I²=54%; P<0.00001) and exercise capacity, including longer exercise distance (weighted mean difference 51.53, 95% CI 20.13-82.93, I²=90%; P=0.001), and longer exercise endurance (standardized mean difference 1.11, 95% CI 0.14-2.08, I²=85%; P=0.02). There was no significant difference in St George's Respiratory Questionnaire scores (weighted mean difference -0.07, 95% CI -2.44 to 2.30, I²=56%; P=0.95).

CONCLUSION

NMES appears an effectual means of enhancing quadricep strength and exercise capacity in moderate-to-severe COPD patients. Further research is demanded to clarify its effect on other outcomes and determine the optimal parameters for an NMES program.

Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease

BACKGROUND

This review is an update of a previously published review in the Cochrane Database of Systematic Reviews Issue 1, 2013 on Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease.Patients with advanced progressive disease often experience muscle weakness, which can impact adversely on their ability to be independent and their quality of life. In those patients who are unable or unwilling to undertake whole-body exercise, neuromuscular electrical stimulation (NMES) may be an alternative treatment to enhance lower limb muscle strength. Programmes of NMES appear to be acceptable to patients and have led to improvements in muscle function, exercise capacity, and quality of life. However, estimates regarding the effectiveness of NMES based on individual studies lack power and precision.

OBJECTIVES

Primary objective: to evaluate the effectiveness of NMES on quadriceps muscle strength in adults with advanced disease. Secondary objectives: to examine the safety and acceptability of NMES, and its effect on peripheral muscle function (strength or endurance), muscle mass, exercise capacity, breathlessness, and health-related quality of life.

SEARCH METHODS

We identified studies from searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), and Database of Abstracts of Reviews of Effects (DARE) (the Cochrane Library), MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO), and PsycINFO (OVID) databases to January 2016; citation searches, conference proceedings, and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials in adults with advanced chronic respiratory disease, chronic heart failure, cancer, or HIV/AIDS comparing a programme of NMES as a sole or adjunct intervention to no treatment, placebo NMES, or an active control. We imposed no language restriction.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on study design, participants, interventions, and outcomes. We assessed risk of bias using the Cochrane 'Risk of bias' tool. We calculated mean differences (MD) or standardised mean differences (SMD) between intervention and control groups for outcomes with sufficient data; for other outcomes we described findings from individual studies. We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

Eighteen studies (20 reports) involving a total of 933 participants with COPD, chronic respiratory disease, chronic heart failure, and/or thoracic cancer met the inclusion criteria for this update, an additional seven studies since the previous version of this review. All but one study that compared NMES to resistance training compared a programme of NMES to no treatment or placebo NMES. Most studies were conducted in a single centre and had a risk of bias arising from a lack of participant or assessor blinding and small study size. The quality of the evidence using GRADE comparing NMES to control was low for quadriceps muscle strength, moderate for occurrence of adverse events, and very low to low for all other secondary outcomes. We downgraded the quality of evidence ratings predominantly due to inconsistency among study findings and imprecision regarding estimates of effect. The included studies reported no serious adverse events and a low incidence of muscle soreness following NMES.NMES led to a statistically significant improvement in quadriceps muscle strength as compared to the control (12 studies; 781 participants; SMD 0.53, 95% confidence interval (CI) 0.19 to 0.87), equating to a difference of approximately 1.1 kg. An increase in muscle mass was also observed following NMES, though the observable effect appeared dependent on the assessment modality used (eight studies, 314 participants). Across tests of exercise performance, mean differences compared to control were statistically significant for the 6-minute walk test (seven studies; 317 participants; 35 m, 95% CI 14 to 56), but not for the incremental shuttle walk test (three studies; 434 participants; 9 m, 95% CI -35 to 52), endurance shuttle walk test (four studies; 452 participants; 64 m, 95% CI -18 to 146), or for cardiopulmonary exercise testing with cycle ergometry (six studies; 141 participants; 45 mL/minute, 95% CI -7 to 97). Limited data were available for other secondary outcomes, and we could not determine the most beneficial type of NMES programme.

AUTHORS' CONCLUSIONS

The overall conclusions have not changed from the last publication of this review, although we have included more data, new analyses, and an assessment of the quality of the evidence using the GRADE approach. NMES may be an effective treatment for muscle weakness in adults with advanced progressive disease, and could be considered as an exercise treatment for use within rehabilitation programmes. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate. We recommend further research to understand the role of NMES as a component of, and in relation to, existing rehabilitation approaches. For example, studies may consider examining NMES as an adjuvant treatment to enhance the strengthening effect of programmes, or support patients with muscle weakness who have difficulty engaging with existing services.