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Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery

Abstract

Purpose

Reduced ability to contract the quadriceps muscles is often found immediately following anterior cruciate ligament (ACL) surgery. This can lead to muscle atrophy and decreased function. Application of neuromuscular electrical stimulation (NMES) may be a useful adjunct intervention to ameliorate these deficits following ACL surgery. The purpose of this review was to determine whether NMES in addition to standard physical therapy is superior to standard physical therapy alone in improving quadriceps strength or physical function following ACL surgery.

Methods

A computer-assisted literature search was conducted utilizing PubMed, CINAHL, PEDro and Cochrane Library databases for randomized clinical trials where patients after ACL surgery received NMES with the outcome of muscle strength and/or physical function. Random effect models were used to pool summary estimates using standardized mean differences (SMD) for strength outcomes. Physical function outcomes were assessed qualitatively. Methodological quality was assessed from the Physiotherapy Evidence Database (PEDro)-score.

Results

Eleven studies met our inclusion criteria; results from six of these were pooled in the meta-analysis showing a statistically significant short-term effect of NMES (4–12 weeks) after surgery compared to standard physical therapy [SMD = 0.73 (95% CI 0.29, 1.16)]. Physical function also improved significantly more in the NMES groups. PEDro scores ranged from 3/10 to 7/10 points.

Conclusion

NMES in addition to standard physical therapy appears to significantly improve quadriceps strength and physical function in the early post-operative period compared to standard physical therapy alone.

Level of evidence

I.

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References

  1. 1.

    Agel J, Arendt EA, Bershadsky B (2005) Anterior cruciate ligament injury in National Collegiate Athletic Association basketball and soccer a 13-year review. Am J Sports Med 33(4):524–531

    Article  PubMed  Google Scholar 

  2. 2.

    Ardern CL, Taylor NF, Feller JA, Webster KE (2014) Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med 33(21):1543–1552

    Article  Google Scholar 

  3. 3.

    Arvidsson I, Arvidsson H, Eriksson E, Jansson E (1986) Prevention of quadriceps wasting after immobilization: an evaluation of the effect of electrical stimulation. Orthopedics 9(11):1519–1528

    CAS  PubMed  Google Scholar 

  4. 4.

    Barber-Westin SD, Noyes FR (2011) Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy 27(12):1697–1705

    Article  PubMed  Google Scholar 

  5. 5.

    Currier DP, Ray JM, Nyland J, Rooney JG, Noteboom JT, Kellogg R (1993) Effects of electrical and electromagnetic stimulation after anterior cruciate ligament reconstruction. JOSPT J Orthop Sports Phys Ther 17(4):177–184

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    de Morton NA (2009) The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 55(2):129–133

    Article  PubMed  Google Scholar 

  7. 7.

    Delitto A, Rose SJ, McKowen JM, Lehman RC, Thomas JA, Shively RA (1988) Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament surgery. Phys Ther 68(5):660–663

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Draper V, Ballard L (1991) Electrical stimulation versus electromyographic biofeedback in the recovery of quadriceps femoris muscle function following anterior cruciate ligament surgery. Phys Ther 71(6):455–461

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Draper V, Lyle L, Seymour T (1997) From the Field-EMG biofeedback versus electrical stimulation in the recovery of quadriceps surface EMG. Clin Kinesiol 51:28–32

    Google Scholar 

  11. 11.

    Ediz L, Ceylan MF, Turktas U, Yanmis I, Hiz O (2012) A randomized controlled trial of electrostimulation effects on effussion, swelling and pain recovery after anterior cruciate ligament reconstruction: a pilot study. Clin Rehabil 26(5):413–422

    Article  PubMed  Google Scholar 

  12. 12.

    Eriksson E, Häggmark T (1979) Comparison of isometric muscle training and electrical stimulation supplementing isometric muscle training in the recovery after major knee ligament surgery: a preliminary report. Am J Sports Med 7(3):169–171

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Feil S, Newell J, Minogue C, Paessler HH (2011) The effectiveness of supplementing a standard rehabilitation program with superimposed neuromuscular electrical stimulation after anterior cruciate ligament reconstruction: a prospective, randomized, single-blind study. Am J Sports Med 39(6):1238–1247

    Article  PubMed  Google Scholar 

  14. 14.

    Fitzgerald GK, Piva SR, Irrgang JJ (2003) A modified neuromuscular electrical stimulation protocol for quadriceps strength training following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 33(9):492–501

    Article  PubMed  Google Scholar 

  15. 15.

    Hart JM, Pietrosimone B, Hertel J, Ingersoll CD (2010) Quadriceps activation following knee injuries: a systematic review. J Athl Train 45(1):87–97

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Hasegawa S, Kobayashi M, Arai R, Tamaki A, Nakamura T, Moritani T (2011) Effect of early implementation of electrical muscle stimulation to prevent muscle atrophy and weakness in patients after anterior cruciate ligament reconstruction. J Electromyogr Kinesiol 21(4):622–630

    Article  PubMed  Google Scholar 

  17. 17.

    Higgins J, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21(11):1539–1558

    Article  PubMed  Google Scholar 

  18. 18.

    Hopkins JT, Ingersoll CD (2000) Arthrogenic muscle inhibition: a limiting factor in joint rehabilitation. J Sport Rehabil 9(2):135–159

    Article  Google Scholar 

  19. 19.

    Imoto AM, Peccin S, Almeida GJM, Saconato H, Atallah ÁN (2011) Effectiveness of electrical stimulation on rehabilitation after ligament and meniscal injuries: a systematic review. Sao Paulo Med J 129(6):414–423

    Article  PubMed  Google Scholar 

  20. 20.

    Kim K-M, Croy T, Hertel J, Saliba S (2010) Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. J Orthop Sports Phys Ther 40(7):383–391

    Article  PubMed  Google Scholar 

  21. 21.

    Lentz TA, Zeppieri G Jr, Tillman SM, Indelicato PA, Moser MW, George SZ, Chmielewski TL (2012) Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment, and self-report measures. J Orthop Sports Phys Ther 42(11):893–901

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Lepley LK, Wojtys EM, Palmieri-Smith RM (2015) Combination of eccentric exercise and neuromuscular electrical stimulation to improve quadriceps function post-ACL reconstruction. Knee 22(3):270–277

    Article  PubMed  Google Scholar 

  23. 23.

    Lieber RL, Silva PD, Daniel DM (1996) Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery. J Orthop Res 14(1):131–138

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Littell JH, Corcoran J, Pillai V (2008) Systematic reviews and meta-analysis. Oxford University Press, Oxford, pp 60–71

    Book  Google Scholar 

  25. 25.

    Low J, Reen A (2000) Electrotherapy explained: principles and practice. Butterworth-Heinemann, Oxford, pp 70–76

    Google Scholar 

  26. 26.

    Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M (2003) Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 83(8):713–721

    PubMed  Google Scholar 

  27. 27.

    Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, Bach BR Jr, Paletta GA Jr (2014) Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med 42(10):2363–2370

    Article  PubMed  Google Scholar 

  28. 28.

    Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Stewart LA (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Sys Rev 4(1):1

    Article  Google Scholar 

  29. 29.

    Moksnes H, Risberg MA (2009) Performance-based functional evaluation of non-operative and operative treatment after anterior cruciate ligament injury. Scand J Med Sci Sports 19(3):345–355

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Morrissey MC, Brewster CE, Shields CL Jr, Brown M (1985) The effects of electrical stimulation on the quadriceps during postoperative knee immobilization. Am J Sports Med 13(1):40–45

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE (2014) Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med 42(7):1567–1573

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Paternostro-Sluga T, Fialka C, Alacamliogliu Y, Saradeth T, Fialka-Moser V (1999) Neuromuscular electrical stimulation after anterior cruciate ligament surgery. Clin Orthop Relat Res 368:166–175

    Article  Google Scholar 

  33. 33.

    PEDro. PEDro, Physiotherapy Evidence Database. 2016 04.04.2016 [cited 2016 04.22.2016]; http://www.pedro.org.au/english/faq/#question_five

  34. 34.

    Ross M (2000) The effect of neuromuscular electrical stimulation during closed kinetic chain exercise on lower extremity performance following anterior cruciate ligament reconstruction. Res Sports Med 9(4):239–251

    Google Scholar 

  35. 35.

    Saka T (2014) Principles of postoperative anterior cruciate ligament rehabilitation. World J Orthop 5(4):450–459

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Sisk TD, Stralka SW, Deering MB, Griffin JW (1987) Effect of electrical stimulation on quadriceps strength after reconstructive surgery of the anterior cruciate ligament. Am J Sports Med 15(3):215–220

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Snyder-Mackler L, Ladin Z, Schepsis AA, Young JC (1991) Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament. Effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles. J Bone Joint Surg Am 73(7):1025–1036

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW (1995) Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am 77(8):1166–1173

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Taradaj J, Halski T, Kucharzewski M, Walewicz K, Smykla A, Ozon M, Pasternok M (2013) The effect of neuromuscular electrical stimulation on quadriceps strength and knee function in professional soccer players: return to sport after ACL reconstruction. Biomed Res Int 2013:802534. doi:10.1155/2013/802534

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Thomeé R, Kvist J (2015) Structured Rehabilitation Model with Clinical Outcomes After Anterior Cruciate Ligament Reconstruction. In: Doral MN, Karlsson J (eds) Sports injuries. Springer, Berlin, pp 1439–1465

  41. 41.

    Urbach D, Nebelung W, Weiler HT, Awiszus F (1999) Bilateral deficit of voluntary quadriceps muscle activation after unilateral ACL tear. Med Sci Sports Exerc 31(12):1691–1696

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Wigerstad-Lossing I, Grimby G, Jonsson T, Morelli B, Peterson L, Renström P (1988) Effects of electrical muscle stimulation combined with voluntary contractions after knee ligament surgery. Med Sci Sports Exerc 20(1):93–98

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Wright RW, Preston E, Fleming B, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN (2008) A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg 21(3):225–234

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Young A (1993) Current issues in arthrogenous inhibition. Ann Rheum Dis 52(11):829–834

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Annette V. Hauger.

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The authors of this article have no conflicts of interest on the matter presented.

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The study has not recieved any outside funding.

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No ethical approval has been necessary since sensitive information has not been provided or utilized in this review.

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Appendix: Search strategies

Appendix: Search strategies

See Tables 5, 6, 7 and 8.

Table 5 Search strategy PubMed
Table 6 Search strategy Embase
Table 7 Search strategy CINAHL
Table 8 Search strategy Cochrane

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Hauger, A.V., Reiman, M.P., Bjordal, J.M. et al. Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery. Knee Surg Sports Traumatol Arthrosc 26, 399–410 (2018). https://doi.org/10.1007/s00167-017-4669-5

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Keywords

  • ACL
  • NMES
  • Physical therapy
  • Muscle strength
  • Quadriceps