A Comparison of Neuromuscular Electrical Stimulation Parameters for Postoperative Quadriceps Strength in Patients After Knee Surgery: A Systematic Review

Abstract

Context: Postoperative quadriceps strength weakness after knee surgery is a persistent issue patients and health care providers encounter. Objective: To investigate the effect of neuromuscular electrical stimulation (NMES) parameters on quadriceps strength after knee surgery. Data Sources: CINAHL, MEDLINE, SPORTDiscus, and PubMed were systematically searched in December 2018. Study Selection: Studies were excluded if they did not assess quadriceps strength or if they failed to report the NMES parameters or quadriceps strength values. Additionally, studies that applied NMES to numerous muscle groups or simultaneously with other modalities/treatments were excluded. Study quality was assessed with the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials. Study Design: Systematic review. Level of Evidence: Level 1. Data Extraction: Treatment parameters for each NMES treatment was extracted for comparison. Quadriceps strength means and standard deviations were extracted and utilized to calculate Hedge g effect sizes with 95% CIs. Results: Eight RCTs were included with an average Physiotherapy Evidence Database scale score of 5 ± 2. Hedge g effect sizes ranged from small (−0.37; 95% CI, −1.00 to 0.25) to large (1.13; 95% CI, 0.49 to 1.77). Based on the Strength of Recommendation Taxonomy Quality of Evidence table, the majority of the studies included were low quality RCTs categorized as level 2: limited quality patient-oriented evidence. Conclusion: Because of inconsistent evidence among studies, grade B evidence exists to support the use of NMES to aid in the recovery of quadriceps strength after knee surgery. Based on the parameters utilized by studies demonstrating optimal treatment effects, it is recommended to implement NMES treatment during the first 2 postoperative weeks at a frequency of ≥50 Hz, at maximum tolerable intensity, with a biphasic current, with large electrodes and a duty cycle ratio of 1:2 to 1:3 (2- to 3-second ramp).

Effect of Neuromuscular Electrical Stimulation After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…It was reported that 50–60% quadriceps muscle strength deficits might occur compared with the preoperative levels ( 23 ). Besides, quadriceps weakness has been found to increase joint loading and contribute to the progress of osteoarthritis ( 42 , 43 ). It is a crucial goal to restore quadriceps strength for postoperative rehabilitation.…”

“…They did not find direct evidence to prove the advantage of NMES on quadriceps muscle strength recovery following TKA by limited (only two) included RCTs ( 44 ). Conley et al conducted a systematic review involving eight RCTs to assess the effect of NMES on quadriceps strength after knee surgery, such as anterior cruciate ligament reconstruction ( n = 5), TKA ( n = 2), and meniscectomy ( n = 1) ( 43 ). They revealed that NMES improved the recovery of quadriceps strength after the knee surgery with grade B evidence ( 43 ).…”

“…Conley et al conducted a systematic review involving eight RCTs to assess the effect of NMES on quadriceps strength after knee surgery, such as anterior cruciate ligament reconstruction ( n = 5), TKA ( n = 2), and meniscectomy ( n = 1) ( 43 ). They revealed that NMES improved the recovery of quadriceps strength after the knee surgery with grade B evidence ( 43 ). Due to limited pieces of relevant literature published, some other reviews also failed to examine the effect of NMES on MVIC following TKA ( 45 , 46 ).…”

“…The evidence to prove the advantage of NMES in TKA was limited. Given the insufficiency of available data for comparison, some other reviews failed to explore the quantized effect of NMES on TKA ( 43 , 44 , 46 , 57 , 58 ). As far as we knew, this was the first systematic review and meta-analysis to comprehensively explore the effect of NMES on quadriceps muscle strength, pain, and function following TKA.…”

Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction

“…A 10 seconds on/20 seconds off duty cycle for a 15-minute intervention period to begin treatment sessions has been reported as an effective paradigm. 90 Position of application is another factor to consider. Recommendations are to begin NMES application in an extended position adding a prop for the heel to facilitate hyperextension ROM as tolerated.…”