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

Do Electrical Stimulation Devices Reduce Pain and Improve Function?-A Comparative Review

BACKGROUND

Multiple forms of electrical stimulation (ES) potentially offer widely varying clinical benefits. Diminished function commonly associated with acute and chronic pain lessens productivity and increases medical costs. This review aims to compare the relative effects of various forms of ES on functional and pain outcomes.

METHODS

A comprehensive literature search focused on studies of commonly marketed forms of ES used for treatment of pain and improvement of function. Peer-reviewed manuscripts were categorized as "Important" (systematic review or meta-analysis, randomized controlled trial, observational cohort study) and "Minor" (retrospective case series, case report, opinion review) for each identified form of ES.

RESULTS AND DISCUSSION

Varying forms of ES have markedly different technical parameters, applications, and indications, based on clinically meaningful impact on pain perception, function improvement, and medication reduction. Despite being around for decades, there is limited quality evidence for most forms of ES, although there are several notable exceptions for treatment of specific indications. Neuromuscular electrical stimulation (NMES) has well-demonstrated beneficial effects for rehabilitation of selective spinal cord injured (SCI), post-stroke, and debilitated inpatients. Functional electrical stimulation (FES) has similarly shown effectiveness in rehabilitation of some stroke, SCI, and foot drop outpatients. H-Wave® device stimulation (HWDS) has moderate supportive evidence for treatment of acute and refractory chronic pain, consistently demonstrating improvements in function and pain measures across diverse populations. Interestingly, transcutaneous electrical nerve stimulation (TENS), the most widely used form of ES, demonstrated insignificant or very low levels of pain and functional improvement.

CONCLUSION

Ten of 13 reviewed forms of ES have only limited quality evidence for clinically significant reduction of pain or improvement of function across different patient populations. NMES and FES have reasonably demonstrated effectiveness, albeit for specific clinical rehabilitation indications. HWDS was associated with the most clinically significant outcomes, in terms of functional improvement combined with reduction of pain and medication use. More rigorous long-term clinical trials are needed to further validate appropriate use and specific indications for most forms of ES.

LEVEL OF EVIDENCE

II.

Effectiveness of physical exercise and neuromuscular electrical stimulation interventions for preventing and treating intensive care unit-acquired weakness: A systematic review of randomized controlled trials

OBJECTIVE

Intensive care unit-acquired weakness is a frequent problem that develops as a secondary disorder while patients are suffering from life-threatening conditions. This study aimed to evaluate the effectiveness of physical exercise or neuromuscular electrical stimulation interventions on (i) preventing loss of muscle mass and weakness in critically ill patients admitted to intensive care units; (ii) recovering patients discharged from the intensive care unit with acquired weakness.

METHODS

A systematic review of randomized controlled trials was carried out, with studies identified in PubMed, Scopus, and Web of Science. The studies included assessed muscle mass and muscle strength, and performed a time × group analysis of effects. The risk of bias assessment was performed using the Revised Cochrane risk-of-bias tool for randomized trials.

RESULTS

Six trials with low risk of bias examined muscle mass, muscle strength, and functionality in 182 adult patients. In critically ill patients admitted to intensive care units, both neuromuscular electrical stimulation and bed/chair cycling for five to ten days prevented significant muscle loss. neuromuscular electrical stimulation in lower and upper limbs resulted in a significant reduction in the length of the hospitalization. In addition, cycle ergometer increased muscle strength and functionality. In patients discharged from the intensive care unit with acquired weakness, both neuromuscular electrical stimulation and physical exercise interventions increased muscle strength, but only physical exercise increased functionality.

CONCLUSIONS

Physical exercise and neuromuscular electrical stimulation interventions prevent excessive muscle mass loss in critically ill patients admitted to the intensive care unit and increase muscle strength in patients discharged from the intensive care unit with acquired weakness. Physical exercise seems more adequate for improving functionality.

Effectiveness of neuromuscular electrical stimulation in improving mobility in children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate whether neuromuscular electrical stimulation improves mobility in children with spastic cerebral palsy.

METHODS

PubMed, Cochrane, EMBASE, and Scopus were searched for randomized controlled trials studying the effects of NMES on the lower limbs in children with spastic CP. Randomized controlled trials comparing the effect of neuromuscular electrical stimulation with that of placebo or conventional therapy on mobility in children with cerebral palsy were eligible for inclusion. Two reviewers independently screened studies, extracted data, and examined the risk of bias and quality of evidence by using the revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2.0) and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method. The final search was conducted on May 23, 2022.

RESULTS

A total of 14 randomized controlled trials (2 crossover studies and 12 parallel studies including 421 patients) were included in this meta-analysis. Compared with the control group (conventional physical therapy), the treatment group exhibited greater improvement in walking speed (standardized mean difference = 0.29; 95% confidence interval = 0.02-0.57) and the standing, walking, running, and jumping dimension of the Gross Motor Function Measure (standardized mean difference = 1.24; 95% confidence interval = 0.64-1.83).

CONCLUSION

Neuromuscular electrical stimulation improved mobility in children with spastic cerebral palsy, particularly in standing, running, and jumping function, and it is safe for children with spastic cerebral palsy.

Efficacy and safety of neuromuscular electrical stimulation in the prevention of pressure injuries in critically ill patients: a randomized controlled trial

Background

Pressure injuries (PIs), especially in the sacral region are frequent, costly, and increase morbidity and mortality of patients in an intensive care unit (ICU). These injuries can occur as a result of prolonged pressure and/or shear forces. Neuromuscular electrical stimulation (NMES) can increase muscle mass and improve local circulation, potentially reducing the incidence of PI.

Methods

We performed a randomized controlled trial to assess the efficacy and safety of NMES in preventing PI in critically ill patients. We included patients with a period of less than 48 h in the ICU, aged ≥ 18 years. Participants were randomly selected (1:1 ratio) to receive NMES and usual care (NMES group) or only usual care (control group—CG) until discharge, death, or onset of a PI. To assess the effectiveness of NMES, we calculated the relative risk (RR) and number needed to treat (NNT). We assessed the muscle thickness of the gluteus maximus by ultrasonography. To assess safety, we analyzed the effects of NMES on vital signs and checked for the presence of skin burns in the stimulated areas. Clinical outcomes were assessed by time on mechanical ventilation, ICU mortality rate, and length of stay in the ICU.

Results

We enrolled 149 participants, 76 in the NMES group. PIs were present in 26 (35.6%) patients in the CG and 4 (5.3%) in the NMES group (p ˂ 0.001). The NMES group had an RR = 0.15 (95% CI 0.05–0.40) to develop a PI, NNT = 3.3 (95% CI 2.3–5.9). Moreover, the NMES group presented a shorter length of stay in the ICU: Δ = − 1.8 ± 1.2 days, p = 0.04. There was no significant difference in gluteus maximus thickness between groups (CG: Δ = − 0.37 ± 1.2 cm vs. NMES group: Δ = 0 ± 0.98 cm, p = 0.33). NMES did not promote deleterious changes in vital signs and we did not detect skin burns.

Conclusions

NMES is an effective and safe therapy for the prevention of PI in critically ill patients and may reduce length of stay in the ICU.

Trial registration RBR-8nt9m4. Registered prospectively on July 20th, 2018, https://ensaiosclinicos.gov.br/rg/RBR-8nt9m4

Upper Extremity Contralaterally Controlled Functional Electrical Stimulation Versus Neuromuscular Electrical Stimulation in Post-Stroke Individuals: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Electrical stimulation has been employed as a safe and effective therapy for improving arm function after stroke. Contralaterally controlled functional electrical stimulation (CCFES) is a unique method that has progressed from application in small feasibility studies to implementation in several randomized controlled trials. However, no meta-analysis has been conducted to summarize its efficacy.

OBJECTIVE

To summarize the effect size of CCFES through measures of upper extremity motor recovery compared with that of neuromuscular electrical stimulation (NMES).

METHODS

The PubMed, Cochrane Library, EMBASE, Scopus, and Google Scholar databases were searched. Randomized controlled trials (RCTs) were selected and subjected to meta-analysis and risk of bias assessment.

RESULTS

6 RCTs were selected and 267 participants were included. The Upper Extremity Fugl-Meyer assessment (UEFMA) was included in all studies, the Box and Blocks test (BBT) and active range of motion (AROM) were included in 3 and 4 studies, respectively. The modified Barthel Index (mBI) and Arm Motor Abilities Test (AMAT) were included in 2 and 3 studies, respectively. The CCFES group demonstrated greater improvement than the NMES did in UEFMA (SMD = .42, 95% CI = .07-.76), BBT (SMD = .48, 95% CI = .10-.86), AROM (SMD = .54, 95% CI = .23-.86), and mBI (SMD = .54, 95% CI = .12-.97). However, the results for AMAT did not differ significantly (SMD = .34, 95% CI = -.03-.72).

CONCLUSION

Contralaterally controlled functional electrical stimulation produced greater improvements in upper extremity hemiplegia in people with stroke than NMES did. PROSPERO registration number: CRD42021245831.

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.

Long-term effect of task-oriented functional electrical stimulation in chronic Guillain Barré syndrome-a single-subject study

OBJECTIVE

Functional electrical stimulation (FES) can enhance motor learning of hand fine motor skills in neurological diseases with upper motoneuron lesions. Nevertheless, FES is rarely applied in patients with chronic Guillan-Barré syndrome (GBS) with preserved deep tendon reflexes allowing for stimulation via nerve. This single case report documents the results of an FES-supported, task-oriented grasp training to regain hand closure and pinch grip.

STUDY DESIGN

Single-subject repeated measures study.

SETTING

International FES Centre®, Swiss Paraplegic Centre Nottwil.

METHODS

Three individually defined goals were formulated and scored by using the goal attainment scale. With a focus on these goals, FES was applied bilaterally to improve hand closure and pinch grip. Based on principles of motor learning FES was executed together with task-oriented movements. The hand closure distance (cm) between the tip of the middle finger and the palmar side of the hand was measured and the achievement of personal, predefined goals evaluated.

RESULTS

After 16 weeks of daily stimulation, hand closure could be voluntarily performed. Regained opposition of the thumb to the index finger enabled improved individually defined fine motor control. Restored function remained unchanged in the follow-up at 6 months without stimulation.

CONCLUSION

Improving fine motor skills in chronic GBS with intact deep tendon reflexes was possible utilizing FES combined with task-oriented grasp training. These improvements were maintained over time indicating the combination was effective in promoting functionally meaningful motor gains.

Comparative study of the effect of neuromuscular electrical stimulation and oral administration of branched-chain amino acid on preventing sarcopenia in patients after living-donor liver transplantation: study protocol for an open-label randomized controlled trial

Background

Liver cirrhosis is the irreversible fibrosis of the liver and causes refractory ascites and hepatic encephalopathy, which might not respond to treatment. Living donor liver transplantation (LDLT) is an effective treatment for patients with cirrhosis. However, post-LDLT patients are prone to muscle atrophy and sarcopenia. Therefore, physiotherapy of post-LDLT patients is essential for preventing the progression of sarcopenia. Recently, rehabilitation using neuromuscular electrical stimulation (NMES) has been reported to be useful for preventing the progression of sarcopenia. Similarly, nutrition therapy is essential for post-LDLT patients because these patients frequently experience malnutrition. However, the effects of combined NMES and nutrition therapy on post-LDLT patients remain unknown.

Methods/design

This open-label, randomized, parallel-group study will compare the effects of combined therapy with NMES and branched-chain amino acids (BCAA) with those of NMES alone in patients with decompensated cirrhosis after LDLT. After LDLT, 50 patients with decompensated cirrhosis will be randomly assigned to receive NMES with BCAA or NMES without BCAA. The duration of the intervention will be 3 months. To analyze the change in skeletal muscle mass, InBody 770 body composition and body water analysis and ultrasonography will be performed before LDLT and 4 weeks and 12 weeks post-LDLT. The primary endpoint is changes in the skeletal muscle mass from baseline to 3 months. Important secondary endpoints are the changes in the skeletal muscle mass from baseline to 1 month and changes in the quadriceps strength from baseline to 1 month.

Discussion

The results of this study are expected to provide evidence regarding the effect of NMES combined with BCAA therapy on the skeletal muscle of post-LDLT patients.

Trial registration

Japan Registry of Clinical Research jRCTs071190051. Registered on February 26, 2020.

Is transcutaneous electrical muscle stimulation an alternative for preventing acquired muscle weakness in the pediatric intensive care unit? A scoping review

BACKGROUND

Transcutaneous electrical muscle stimulation (TEMS) has been progressively used as add-on therapy to reduce muscle atrophy in adults unable to carry out active mobilization in the intensive care unit (ICU). There are no studies addressing TEMS in the pediatric ICU. Therefore, we decided to develop a scoping review, a type of knowledge synthesis, which unlike systematic review, identify gaps in the literature to aid the planning and commissioning of future research.

OBJECTIVE

To provide current perspectives on the application of TEMS for combating pediatric intensive care unit acquired weakness (PICUAW).

METHODS

Online databases were used to identify papers published 2006-2016, from which we selected those used musculoskeletal and cardiorespiratory performance as a primary or secondary outcome variable in participants under 18 years.

RESULTS

The publications reported six clinical trials from 218 outpatients with 9.5 ± 8 years old. There were differences in current modulation and duration of TEMS sessions, with a predominance of high intensity and short duration in which a muscle contraction is triggered. The main use of TEMS was in pediatric neurological disorders. TEMS was more effective when compared with SHAM on spasticity, bone mineral density, disability, and gait. One study regarding spine injury showed improvement in VO₂ (P = 0.035) when combined cycling with TEMS.

CONCLUSION

TEMS was an effective and safe treatment for musculoskeletal impairments and cardiorespiratory performance in children with neurological disorders. Although the physiopathology is different in outpatients, an individualized protocol with TEMS might be promising for preventing PICUAW. Its effectiveness, however, deserves further investigation.