Neuromuscular electrical stimulation therapy after knee surgery: a systematic review

Jin Hee Yoon; Sunyoung Jo; Seok-Hyun Kim

doi:10.5124/jkma.2017.60.7.579

J Korean Med Assoc > Volume 60(7); 2017 > Article

Yoon, Jo, and Kim: Neuromuscular electrical stimulation therapy after knee surgery: a systematic review

Health Technologies

J Korean Med Assoc 2017; 60(7): 579-587.

Published online: July 17, 2017

DOI: http://dx.doi.org/10.5124/jkma.2017.60.7.579

Neuromuscular electrical stimulation therapy after knee surgery: a systematic review

Jin Hee Yoon, MS, Sunyoung Jo, MS, Seok-Hyun Kim, MD

Division for New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea

Corresponding author:> Seok-Hyun Kim E-mail: shkim@neca.re.kr

Received May 03, 2017 Accepted May 19, 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The recovery of quadriceps muscle strength and knee function after knee surgery is important. Recently, neuromuscular electrical stimulation (NMES), which is a method in which an electrical current is applied to the surrounding targeted muscle, has been incorporated into muscle-strengthening programs. The objective of this review was to evaluate the safety and effectiveness of NMES in patients who have undergone knee surgery. A database search was performed in 8 Korean databases, Medline, Embase, and the Cochrane Library. Article selection and quality assessment were performed by 2 reviewers. Of the 580 articles selected, 14 papers (randomized controlled trials) were included in the final assessment. In the results of the metaanalysis, NMES combined with rehabilitation demonstrated a significant improvement in the enhancement of quadriceps muscle strength after anterior cruciate ligament reconstruction. On the basis of the currently available data, NMES with rehabilitation is associated with favorable outcomes, and should be considered a safe and effective procedure for enhancing quadriceps muscle strength.

Key words: Electrical stimulation therapy; Anterior cruciate ligament reconstruction; Quadriceps muscle

Figure 1.

Flow diagram of the study selection process. RCT, randomized controlled trial.

Figure 2.

Results of metaanalysis for quadriceps indices. (A) Anterior cruciate ligament reconstruction (ACLR) and (B) Total knee arthroplasty (TKA).

Figure 3.

Results of metaanalysis for knee function indices. (A) Anterior cruciate ligament reconstruction (ACLR) and (B) Total knee arthroplasty (TKA).

Table 1.

SIGN criteria for assignment of levels of evidence

Level	Description
1++	High quality metaanalyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+	Well conducted metaanalyses, systematic reviews, or RCTs with a low risk of bias
1-	Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++	High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causa
2+	Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-	Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causa
3	Non-analytic studies, e.g. case reports, case series
4	Expert opinion

SIGN, Scottish Intercollegiate Guideline Network; RCT, randomized controlled trial.

Table 2.

SIGN criteria for assignment of grades of recommendation

Level	Description
A	At least one metaanalysis, systematic review, or randomized controlled trial rated as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B	A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+
C	A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; Extrapolated evidence from studies rated as 2++
D	Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

SIGN, Scottish Intercollegiate Guideline Network.

Table 3.

Study characteristics of included studies

Author (year)	Operation type (n)	Intervention	Comparator
Asakawa et al. (2014) [1]	Total knee arthroplasty (20)	NMES+rehab	Rehab
Taradaj et al. (2013) [7]	Anterior cruciate ligament reconstruction (80)	NMES+exercise program	Exercise program
Stevens-Lapsley et al. (2012) [8]	Total knee arthroplasty (66)	NMES+rehab	Rehab
Avramidis et al. (2011) [9]	Total knee arthroplasty (70)	NMES+physical therapy	Physical therapy
Feil et al. (2011) [3]	Anterior cruciate ligament reconstruction (131)	NMES+rehab	Rehab
Boucher et al. (2009) [10]	Knee arthroscopic surgery (25)	NMES+exercise	Exercise
Petterson et al. (2009) [11]	Total knee arthroplasty (200)	NMES+exercise	Exercise
Avramidis et al. (2003) [12]	Total knee arthroplasty (30)	NMES+physical therapy	Physical therapy
Fitzgerald et al. (2003) [13]	Anterior cruciate ligament reconstruction (43)	NMES+rehab	Rehab
Ross (2000) [14]	Anterior cruciate ligament reconstruction (20)	NMES+CKch exercise	CKCh exercise
Paternostro-Sluga et al. (1999) [6]	Anterior cruciate ligament reconstruction (49)	NMES+exercise therapy	TENS+exercise therapy/exercise therapy only
Synder-Mackler et al. (1995) [15]	Anterior cruciate ligament reconstruction (110)	High intensity NMES+rehab/Low intensity	High level volitional exercise
		NMES+rehab/combined high and low rehab	intensity+
Synder-Mackler et al. (1991) [16]	Anterior cruciate ligament reconstruction (10)	NMES+volitional exercise	Volitional exercise
Sisk et al. (1987) [17]	Anterior cruciate ligament reconstruction (22)	NMES+exercise program	Exercise program

NMES, neuromuscular electrical stimulation; CKCh, closed kinetic chain; TENS, transcutaneous electrical nerve stimulation.

Table 4.

Summary of results - quadriceps muscle strength

Author (year)	No. of patients (intervention/ comparators)	Category	Intervention	Comparators	P-value
Isokinetic evaluation
	131 (intervention 1: 45/ intervention 2: 42/ comparator: 44)	After 6 weeks - initial value, 90 deg/s - Intervention 1		-0.58±0.35	<0.001 (intervention 2-comparator, intervention 2-intervention1)
	∗Intervention 1: traditional NMES+rehab	-0.65±0.38		-0.58±0.35
	∗Intervention 2: novel NMES (kneehab)+rehab	Intervention 2 -0.29±0.57
		Involved/uninvolved(%)	Intervention 1 -34.32±17.93	-26.94±17.12
			Intervention 2
			-14.98±26.11
		After 12 weeks	- initial value, 90 deg/s	s
		-	Intervention 1	-0.25±0.42
			-0.26±0.38
			Intervention 2
			0.17±0.62
		Involved/uninvolved(%)	Intervention 1 -16.67±19.30	-14.26±19.83
			Intervention 2
			3.07±27.75
		After 24 weeks	- initial value, 90 deg/s
		-	Intervention 1	0.11±0.35
			0.09±0.40
			Intervention 2
			0.49±0.68
		Involved/uninvolved(%)	Intervention 1 -4.86±16.45	-2.85±15.86
			Intervention 2
			12.82±28.04
Paternostro-Sluga et al. (1999) [6]	47 (intervention [NMES+rehab]: 16/	Normalized to health limb (%), 60 deg/s			NS
	comparator 1 [TENS+rehab]: 14/	After 6 weeks	51.2±5.4	Comparator 1 48.7±7.2
				Comparator 2
				47.8±4.4
		After 12 weeks	75.2±5.9	Comparator 1
				61.7±4.3
				Comparator 2
				68.8±6.1
		After 52 weeks	91.5±4.6	Comparator 1
				90.2±4.8
				Comparator 2
				88.8±3.3
Snyder-Mackler et al. (1991) [16]	10 (5/5)	Normalized to uninvolved extremity, afteer 4 weeks			∗<0.005
		90 deg/s	70.1±6.0∗	46.7±3.1
		210 deg/s	68.9±4.8∗	43.7±2.8
Isometric evaluation
Taradaj et al. (2013) [7]	80 (40/40)	Before	645.9±34.6	648.6±38.6	0.002
		After	893.4	669.8
		-	P=0.001	P=0.04
Stevens-Lapsley et al. (2012) [8]	66 (35/31)	Before	1.33±0.57	1.32±0.49	∗<0.05
		After 3.5 weeks∗	0.93±0.41	0.66±0.24
		After 6.5 weeks	1.20±0.47	1.04±0.35
		After 13weeks	1.42±0.52	1.20±0.42
		After 26 weeks	1.51±0.48	1.39±0.44
		After weeks∗	1.66±0.52	1.50±0.43
Boucher et al. (2009) [10]	25 (15/10)	Involved	83.7±37.3	91.9±54.3	NS
		Uninvolved	111.7±37.4	125.6±57.4
		Peak torque index	73.5±18.3	71.2±26.9
Petterson et al. (2009) [11]	200 (100/100)	0 month	10.42	10.58	NS
		3 month	19.05	17.35
		12 month	22.64	20.60
		0-3 month (%)	83	64
		3-12 month (%)	19	19
		0-12 month (%)	117	95
Fitzgerald et al. (2003) [13]	43 (21/22)	After 12 weeks	75.9±16.8∗	67.0±19.9	∗<0.05
		After 16 weeks	83.1±15.6∗	75.0±17.8
Snyder-Mackler et al. (1995) [15]	110(Intervention 1: High intensity	After 6 weeks	Intervention 1	Comparator	-
	NMES+rehab 31/ Intervention 2:Low intensity NMES+rehab 25/		70	57
	Intervention 3: High and Low intensity NMES + rehab 20/ Comparator: rehab 34)	Intervention 2 51
			70
Sisk et al. (1987) [17]	22 (11/11)	After 7 weeks	0.73±0.41		NS
		After 8 weeks	0.90±0.44
		After 9 weeks	1.11±0.63
Manual muscle testing
Asakawa et al.(2014) [1]	20 (10/10)	Before	87.93±8.62	91.9±11.41	<0.05
		After	114.1±19.71	96.49±17.44
		-	P=0.001	P=0.420

NMES, neuromuscular electrical stimulation; TENS, transcutaneous electrical nerve stimulation; NS, non-significant.

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