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

Abstract

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.

Effects of acute phase intensive electrical muscle stimulation in COVID-19 patients requiring invasive mechanical ventilation: an observational case-control study

“…Consistent with previous studies in critically ill patients, EMS was initiated a mean of 3.2 ± 1.4 days after ICU admission for COVID-19 patients with IMV, ECMO, and/or placement in the prone position, and was accompanied by neither effects on vital signs nor adverse events in the present study 13 , suggesting that acute-phase intensive EMS therapy is safe for use in critically ill COVID-19 patients admitted to the ICU. However, our findings were inconsistent with a previous meta-analysis indicating that EMS reduces ICU-acquired weakness and increases muscle strength during ICU admission 13 . As these previous studies did not discuss administration of EMS to patients with COVID-19, it was not possible to perform direct comparisons of the effects of EMS with the present study.…”

The Omission of Double-Zero Events Has the Potential to Introduce Bias Into the Outcomes of a Meta-Analysis

“…In this instance, a continuity correction of 0.5 was employed for randomized controlled trials that yielded zero events, resulting in a combined effect size risk ratio and 95% CI of 2.67 (0.87–8.20) ( Fig. 1 ), which was notably lower than the findings reported by Nakanishi et al (1).…”

“…The recently published meta-analysis by Nakanishi et al (1) regarding the efficacy of neuromuscular electrical stimulation (NMES) in preventing ICU-acquired weakness has piqued our academic interest. We extend our congratulations to the authors for conducting a comprehensive systematic review that contributes to the existing body of evidence supporting the use of NMES in intensive rehabilitation.…”

“…It was observed that a majority of the “double-zero studies” (i.e., studies with zero events in both groups) (2) were present in the “adverse events” dataset, and the authors employed the Mantel-Haenszel method to construct a random-effects model based on two studies. Consequently, Nakanishi et al (1) inferred that the utilization of NMES may have minimal or no impact on tingling in critically ill patients (eight trials; risk ratio = 6.87; 95% CI, 0.84–56.50; I 2 = 0%). However, excluding double-zero event studies in the meta-analysis of sparse data may lead to bias in estimating the overall effect size (3).…”

Effects of Vibration Therapy on the Physical Function of Critically Ill Adults Trial: A Randomized Controlled Trial

“…Various devices can be used in the ICU. Electrical muscle stimulation helps prevent physical impairments in the ICU; however, the pricking sensation hampers its use in conscious patients (11). Cycling has been reported as a strenuous activity for critically ill patients, necessitating careful application (12,13).…”