WHO Collaborating Centre for Palliative Care and Older People Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease Matthew Maddocks MCSP PhD NIHR Post-Doctoral Research Fellow Specialist Physiotherapist
Background muscle wasting and weakness common in advanced disease adverse impact on: exercise capacity physical function service utilisation quality of life can be addressed with exercise training Issues in uptake and compliance Donaldson et al. 2013, Man et al. 2009. Dodson et al, 2011
Preferences for type of exercise advanced cancer, palliative chemo (n=200) tendency for NMES to be preferred by older, male, sedentary patients with co-morbidities. Maddocks et al. Psycho-Oncology 2011;20:173-8
Neuromuscular electrical stimulation exercise; fulfils ACSM criteria strengthening effects: > no exercise < resistance exercise may be more pragmatic option: in presence of severe symptoms home-based, less supervision Thompson et al. ASCM 2009; Bax et al. Sports Med 2005;35:191-212
Strengthening improves exercise capacity sedentary adults (n=15) cross-over RCT NMES 60min, 5x/wk, 6wk Baseline Postcontrol Post- NMES Quads strength (Nm) 361 (108) 386 (135) 448 (123) <0.01 6MWT distance (m) 493 (36) 505 (27) 530 (40) <0.01 Treadmill time (min) 15.6 (1.4) 15.5 (1.8) 17.1 (1.9) <0.01 Peak VO 2 (l/min) 2.5 (0.6) 2.5 (0.7) 2.7 (0.6) 0.03 P Banerjee P et al. J Appl Physiol 2005;99:2307-11
Objectives primary: effectiveness of NMES for improving muscle strength secondary: acceptability and safety of NMES and changes in: muscle mass and function (strength, endurance) exercise capacity breathlessness health-related quality of life.
Methodology Selection criteria: RCTs and CCTs comparing NMES (alone or as an adjunct) to control, sham or exercise in adults with advanced disease (>50% study sample) Search criteria: databases (CENTRAL, MEDLINE, EMBASE, CINAHL), reference and citation search, expert contact Outcomes: quadriceps strength, muscle strength or endurance, muscle mass, maximal and submaximal exercise capacity, breathlessness, health-related quality of life Analysis: random effects meta-analysis, mean-differences with inverse variance, narrative synthesis where data limited
Study retrieval 11 RCTs (n=218) COPD, CHF, cancer 2/3 male, age 53 70yrs quadriceps ± hamstrings / calves / glutei Median (range) prog. 60 (30 240) minutes 5 (4 7) times weekly 6 (4 10) weeks.
Methodological quality Main limitations: small heterogeneous samples, lack of blinding, lack of follow-up
Findings: compliance and safety rates of adherence high; mean 80 100% pts with COPD continued use during acute exacerbations no serious adverse events reported twelve pts (6%) reported muscle discomfort following use during initial few days of use
Findings: muscle improved mid-thigh CSA 2 of 4 studies (both using CT) single fibre size and type, oxidative:gylcolytic enzyme activity equivocal improved markers of protein oxidation and anabolic / catabolic balance (single studies only)
Meta-analysis: analysis: muscle strength SMD of 0.9 [95%CI 0.3, 1.5] favouring NMES About 25Nm [95% CI 9 to 41]
Meta-analysis: analysis: exercise performance VO 2 max during CPET improved in 2 of 3 studies.
Findings: daily living improved domain specific and overall QoL physical functioning, emotional role and social functioning (SF-36) dyspnoea (CRQ ) dyspnea in daily tasks (Maugeri Resp Failure) breathlessness at isotime during walk test reduced in 1 of 2 studies
Overall conclusions NMES appears an effective intervention for muscle weakness in advanced disease further research is required to clarify its place in clinical practice. existing forms of exercise should be favoured as a first-choice NMES should be reserved for those unwilling or unable to undertake existing exercise programmes
Research recommendations Further work should help determine: the optimal parameters for a NMES programme patients most likely to benefit impact on morbidity and service use Situations where NMES may be of value: patients unable or unwilling to undertake existing programmes as an adjunct to traditional exercise programmes as a prophylactic intervention for hospitalised patients with acute illness
Acknowledgements co-authors Prof Irene Higginson, Dr Gao Wei, Dr Andrew Wilcock National Institute for Health Research Cochrane PaPaS Review Group Dr Hristina Petkova for help with translations of Russian publication matthew.maddocks@kcl.ac.uk www.kcl.ac.uk/palliative