Neuromuscular electrical stimulation for muscle strengthening in elderly with knee osteoarthritis – A systematic review
Introduction
Knee osteoarthritis (OA) is a painful and chronic degenerative joint disease that affects nearly 27 million people in the United States.1 Pathologic changes in OA involve progressive hyaline joint cartilage loss with concomitant changes in the subchondral bone and the development of osteophytes.2, 3, 4, 5 The clinical symptoms of OA often include muscle weakness, disability, stiffness, joint deformity, decreased range of motion and chronic pain.5, 6
According to Slemenda et al.,7 quadriceps muscle weakness is evident in subjects with symptomatic knee OA. In these cases, a dilemma is faced by physiotherapists when deciding the best treatment. While pharmacological treatments (paracetamol, nonsteroidal antiinflammatory drugs, and topical agents) cause numerous adverse affects,4, 8 pain can decrease the adherence to non-pharmacological therapy, such as regular quadriceps strengthening exercise. This, in turn, could lead to an increase in knee pain and a decrease in muscle strength and function.9, 10 Due to this vicious cycle (pain-weakness-pain), other non-pharmacological strategies and physical therapies have been used in the clinical practice with the aim of recovering joint function and reducing pain.
Among the therapeutic modalities, neuromuscular electrical stimulation (NMES) is presented as a non-invasive technique used by physical therapists (1) to promote muscle strengthening, (2) to minimize muscle hypotrophy, (3) to reduce muscle spasm and spasticity and (4) to increase range of motion in the joint.11, 12, 13 Particularly, with respect to knee OA treatment, NMES has been suggested as an alternative therapy for quadriceps muscle strengthening, mainly when elderly present chronic pain and joint stiffness, which prevent them from engaging in voluntary exercises.4, 9
Despite the importance of muscle strength loss attributed to disuse and/or muscular inhibition as an important factor involved in the etiology and progression of OA,14 to the best of our knowledge, no systematic review has summarized the results of using NMES to achieve quadriceps strengthening in the elderly with knee OA. Considering that this information might be of use in clinical practice, the purpose of this study was to identify if there is evidence to support the use of NMES to strengthen the quadriceps muscle in elderly patients with knee OA.
Section snippets
Data sources and search strategy
Manuscripts were identified from the following database sources: Pubmed/Medline, PEDro and The Cochrane Library. Key words used were knee, osteoarthritis (or arthritis, or arthrosis), muscle strength (or muscle strengthening) and electrical stimulation (or NMES, or neuromuscular electrical stimulation). In PEDro database, the terms were adapted according to the criteria of the search platform (electrotherapy, knee, osteoarthritis, clinical trial and muscle weakness).
Study selection
Two authors independently
Study selection
The literature search identified 48 relevant studies from PubMed/Medline, 24 from PEDro, and 4 from the Cochrane Library. After abstracts screening and removal of duplicate studies, 29 studies were retrieved in full text. Finally, 6 studies that met the inclusion criteria were selected for this review. The main reason for exclusion of other relevant studies was that the outcome of interest was not examined. Characteristics and results of included studies are presented in Table 1.
Quality assessment
The included
Quadriceps strength results
The best-evidence analysis showed moderate evidence in favor of NMES alone or combined with exercise for isometric quadriceps strengthening in elderly with knee OA.8, 19, 20 However, there is limited evidence that NMES is more effective than other intervention programs at increasing isometric strength (Table 1). Similarly, there is limited evidence to show that NMES intervention as an adjunct therapy effects isokinetic strength at different angular velocities.10
Considering the methodological
Conclusion
Best-evidence synthesis showed that there is moderate evidence in favor of NMES alone or combined with exercise for isometric quadriceps strengthening in elderly with knee OA. However, there is limited evidence that NMES is more effective than other intervention programs at increasing isometric strength.
In addition, limited evidence was found in favor or against the use of NMES as an adjunct therapy for isokinetic strength at different angular velocities. No or insufficient evidence was found
Conflict of interest statement
The authors have no conflicts of interest to disclose.
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