Journal List > J Korean Med Assoc > v.60(7) > 1043206

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

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.

REFERENCES

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Figure 1.
Flow diagram of the study selection process. RCT, randomized controlled trial.
jkma-60-579f1.tif
Figure 2.
Results of metaanalysis for quadriceps indices. (A) Anterior cruciate ligament reconstruction (ACLR) and (B) Total knee arthroplasty (TKA).
jkma-60-579f2.tif
Figure 3.
Results of metaanalysis for knee function indices. (A) Anterior cruciate ligament reconstruction (ACLR) and (B) Total knee arthroplasty (TKA).
jkma-60-579f3.tif
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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