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Estimulación eléctrica neuromuscular para la prevención de la tromboembolia venosa

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References

Bostrom 1986 {published data only}

Bostrom S, Holmgren E, Jonsson O, Lindberg S, Lindstrom B, Winso I, et al. Post‐operative thromboembolism in neurosurgery. Acta Neurochirurgica 1986;80:83‐9. CENTRAL

Goyal 2012 {published data only}

Goyal A, Arora S, Batra S, Sharma R, Mittal MK, Sharma VK. Role of calf muscle stimulation in the prevention of DVT in Indian patients undergoing surgeries for fractures around the hip. Indian Journal of Orthopaedics 2012;46:542‐7. CENTRAL

Hou 2013 {published data only}

Hou L, Chen C, Xu L, Yin P, Peng W. Electrical stimulation of acupoint combinations against deep venous thrombosis in elderly bedridden patients after major surgery. Journal of Traditional Chinese Medicine 2013;33(2):187‐93. CENTRAL

Kiudelis 2002 {published data only}

Kiudelis M, Endzinas Z, Mickevicius A, Pundzius J. Venous stasis and deep vein thrombosis prophylaxis during laparoscopic fundoplication. Zentralblatt fur Chirurgie 2002;127(11):944‐9. CENTRAL

Lindstrom 1982 {published data only}

Lindström B, Holmdahl C, Jonsson O, Korsan‐Bengtsen K, Lindberg S, Petrusson B, et al. Prediction and prophylaxis of postoperative thromboembolism ‐ a comparison between peroperative calf muscle stimulation with groups of impulses and dextran 40. British Journal of Surgery 1982;69(11):633‐7. CENTRAL

Merli 1988 {published data only}

Merli GJ, Herbison GJ, Ditunno JF, Weitz HH, Henzes JH, Park CH, et al. Deep vein thrombosis: prophylaxis in acute spinal cord injured patients. Archives of Physical Medicine and Rehabilitation 1988;69(9):661‐4. CENTRAL

Rosenberg 1975 {published data only}

Rosenberg LL, Evans M, Pollock AV. Prophylaxis of postoperative leg vein thrombosis by low dose subcutaneous heparin or peroperative calf muscle stimulation: a controlled clinical trial. British Medical Journal 1975;1:649‐51. CENTRAL

Velmahos 2005 {published data only}

Velmahos GC, Petrone P, Chan LS, Hanks SE, Brown CV, Demetriades D. Electrostimulation for the prevention of deep venous thrombosis in patients with major trauma: a prospective randomized study. Surgery 2005;137(5):493‐8. CENTRAL

Browse 1970 {published data only}

Browse NL, Negus D. The effect of intra‐operative calf muscle stimulation on the prevention of postoperative deep‐vein thrombosis. British Journal of Surgery1970; Vol. 57, issue 11:861. CENTRAL

Czyrny 2010 {published data only}

Czyrny JJ, Kaplan RE, Wilding GE, Purdy CH, Hirsh J. Electrical foot stimulation: a potential new method of deep venous thrombosis prophylaxis. Vascular 2010;18(1):20‐7. CENTRAL
NCT00114608. Venous blood flow velocity: electrical foot stimulation compared to intermittent pneumatic compression of the foot. www.clinicaltrials.gov/ct2/show/NCT00114608 (date first received 15 June 2005). CENTRAL

Doran 1967 {published data only}

Doran FS, White HM. A demonstration that the risk of postoperative deep venous thrombosis is reduced by stimulating the calf muscles electrically during the operation. British Journal of Surgery 1967;54(8):686‐9. CENTRAL

Doran 1970 {published data only}

Doran FS, White M, Drury M. A clinical trial designed to test the relative value of two simple methods of reducing the risk of venous stasis in the lower limbs during surgical operations, the danger of thrombosis, and a subsequent pulmonary embolus, with a survey of the problem. British Journal of Surgery 1970;57:20‐30. CENTRAL

Faghri 1998 {published data only}

Faghri PD. Evaluation of mechanical methods for prevention of deep venous thrombosis. Clinical Kinesiology 1998;52(1):4‐11. CENTRAL

Hou 2014 {published data only}

Hou LL, Yao LW, Niu QM, Xu L, Yu QH, Sun WQ, et al. Preventive effect of electrical acupoint stimulation on lower‐limb thrombosis: a prospective study of elderly patients after malignant gastrointestinal tumor surgery. Cancer Nursing 2014;36:139‐44. CENTRAL

Izumi 2014 {published data only}

Izumi M, Ikeuchi M, Aso K, Sugimura N, Kamimoto Y, Mitani T, et al. Less deep vein thrombosis due to transcutaneous fibular nerve stimulation in total knee arthroplasty: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy 2015;23(11):3317‐23. CENTRAL

Jansen 1972 {published data only}

Jansen H. Postoperative thromboembolism and its prevention with 500 ml dextran given during operation ‐ with a special study of the venous flow pattern in the lower extremities. Acta Chirurgica Scandinavica 1972;Suppl 427:1‐73. CENTRAL

Kaplan 2002 {published data only}

Kaplan RE, Czyrny JJ, Fung TS, Unsworth JD, Hirsh J. Electrical foot stimulation and implications for the prevention of venous thromboembolic disease. Thrombosis and Haemostasis 2002;88(2):200‐4. CENTRAL

Lobastov 2014 {published data only}

Lobastov K, Barinov V, Laberko L, Obolensky V, Boyarintsev V, Rodoman G. Electrical calf muscle stimulation with Veinoplus device in postoperative venous thromboembolism prevention. International Angiology 2014;33(1):42‐9. CENTRAL
Lobastov K, Barinov V, Obolensky V, Laberko L, Rodoman G. Electrical calf muscle stimulation combined with low dose unfractionated heparin (LDUH) and elastic compression (EC) versus LDUH with EC alone in the prevention of postoperative DVT. Scientific Programme and Book of Abstracts of the 14th Annual Meeting of the European Venous Forum. Belgrade, Serbia, 27‐30 June 2013; Vol. 5. CENTRAL

Morita 2006 {published data only}

Morita H, Abe C, Tanaka K, Shiratori M, Oguri M, Shiga T, et al. Neuromuscular electrical stimulation and an ottoman‐type seat effectively improve popliteal venous flow in a sitting position. Journal of Physiological Sciences 2006;56(2):183‐6. CENTRAL

NCT02425917 {published data only}

NCT02425917. IPC‐CALF versus GEKO in post‐op total hip patients. www.clinicaltrials.gov/ct2/show/NCT02425917 (date first received 14 April 2015). CENTRAL

Nicolaides 1983 {published data only}

Nicolaides AN, Miles C, Hoare M, Jury P, Helmis E, Venniker R. Intermittent sequential pneumatic compression of the legs and thromboembolism‐deterrent stockings in the prevention of postoperative deep venous thrombosis. Surgery 1983;94:21‐5. CENTRAL

Ojima 2017 {published data only}

Ojima M, Takegawa R, Hirose T, Ohnishi M, Shiozaki T, Shimazu T. Hemodynamic effects of electrical muscle stimulation in the prophylaxis of deep vein thrombosis for intensive care unit patients: a randomized trial. Journal of Intensive Care 2017;5:9. CENTRAL

Pambianco 1995 {published data only}

Pambianco G, Orchard T, Landau P. Deep vein thrombosis: prevention in stroke patients during rehabilitation. Archives of Physical Medicine and Rehabilitation 1995;76(4):324‐30. CENTRAL

Rosengarten 1975 {published data only}

Rosengarten DS, McNeur JC. Prophylaxis of deep vein thrombosis after total hip replacement. Journal of Bone and Joint Surgery. British Volume1975; Vol. 57:249. CENTRAL
Rosengarten DS, McNeur JC. Prophylaxis of deep vein thrombosis after total hip replacement. Thrombosis et Diathesis Haemorrhagica 1975;34(3):885‐6. CENTRAL

Yilmaz 2016 {published data only}

Yilmaz S, Calbiyik M, Yilmaz BK, Aksoy E. Potential role of electrostimulation in augmentation of venous blood flow after total knee replacement: a pilot study. Phlebology / Venous Forum of the Royal Society of Medicine 2016;31(4):251‐6. CENTRAL

NCT01835990 {published data only}

NCT01835990. Feasibility study of Geko vs. IPCs in trauma (GIFT Pilot). www.clinicaltrials.gov/ct2/show/NCT01835990 (date first received 17 December 2012). CENTRAL

ISRCTN95441725 {published data only}

ISRCTN95441725. A randomised controlled trial investigating the effect of the Geko nerve stimulator to reduce DVT rates and improve healing in ankle fractures. www.isrctn.com/ISRCTN95441725 (date first received 17 July 2012). CENTRAL

NCT01935414 {published data only}

NCT01935414. Geko neuromuscular stimulator vs thromboembolism deterrent stockings (TEDS): DVT prevention study. www.clinicaltrials.gov/ct2/results?term=NCT01935414 (date first received 28 August 2013). CENTRAL

Anderson 1992

Anderson FA, Wheeler HB, Goldberg RJ, Hosmer DW, Forcier A. The prevalence of risk factors for venous thromboembolism among hospital patients. Archives of Internal Medicine 1992;152(8):1660–4.

Anderson 2003

Anderson FA, Spencer FA. Risk factors for venous thromboembolism. Circulation 2003;107:I9‐16.

Arnold 2001

Arnold DM, Kahn SR, Shrier I. Missed opportunities for prevention of venous thromboembolism. Chest 2001;120(6):1964–71.

Atkins 2004

Atkins D, Best D, Briss PA, Eccles M, Falck‐Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. British Medical Journal 2004;328(7454):1490‐4.

Baker 1993

Baker LL, McNeal DR, Benton LA, Bowman BR, Waters RL. Neuromuscular Electrical Stimulation – A Practical Guide. 3rd Edition. Downey, California, USA: Rancho Los Amigos Research and Education Institute, 1993.

Breen 2012

Breen PP, Galvin O, Quondamatteo F, Grace PA, Ó Laighin G. Comparison of single‐ and two‐channel neuromuscular electrical stimulation sites for enhancing venous return. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2012;20:389‐94.

Broderick 2010

Broderick BJ, O'Briain DE, Breen PP, Kearns SR, Ó Laighin G. A pilot evaluation of a neuromuscular electrical stimulation (NMES) based methodology for the prevention of venous stasis during bed rest. Medical Engineering and Physics 2010;32(4):349‐55.

Broderick 2013

Broderick BJ, Breathnach O, Condon F, Masterson E, Ó Laighin G. Haemodynamic performance of neuromuscular electrical stimulation (NMES) during recovery from total hip arthroplasty. Journal of Orthopaedic Surgery and Research 2013;8:3.

Cushman 2007

Cushman M. Epidemiology and risk factors for venous thrombosis. Seminars in Hematology 2007;44:62‐9.

Doucet 2012

Doucet BM, Lam A, Griffin L. Neuromuscular electrical stimulation for skeletal muscle function. Yale Journal of Biology and Medicine 2012;85(2):201‐15.

Faghri 1997

Faghri PD, Van Meerdervort HF, Glaser RM, Figoni SF. Electrical stimulation‐induced contraction to reduce blood stasis during arthroplasty. IEEE Transactions on Neural Systems and Rehabilitation Engineering 1997;5(1):62–9.

Firstkind 2013

Firstkind Ltd. The gekoTM device for venous thromboembolism (VTE) prophylaxis. http://www.nice.org.uk/guidance/mtg19/documents/the‐geko‐device‐for‐venous‐thromboembolism‐prophylaxis‐scope2 2013 (accessed 2 December 2015).

Froimson 2009

Froimson MI, Murray TG, Fazekas AF. Venous thromboembolic disease reduction with a portable pneumatic compression device. Journal of Arthroplasty 2009;24(2):310–6.

Gorgey 2009

Gorgey AS, Black CD, Elder CP, Dudley GA. Effects of electrical stimulation parameters on fatigue in skeletal muscle. Journal of Orthopaedic and Sports Physical Therapy 2009;39(9):684‐92.

GRADEproGDT [Computer program]

McMaster University (developed by Evidence Prime). GRADEproGDT. Version accessed 22 October 2016. Hamilton (ON): McMaster University (developed by Evidence Prime), 2015.

Griffin 2010

Griffin M, Nicolaides AN, Bond D, Geroulakos G, Kalodiki E. The efficacy of a new stimulation technology to increase venous flow and prevent venous stasis. European Journal of Vascular and Endovascular Surgery 2010;40(6):766‐71.

Guyatt 2012

Guyatt GH, Aki EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th edition: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines. Chest 2012;141:7S‐47S.

Hajibandeh 2015

Hajibandeh S, Hajibandeh S, Antoniou G, Scurr J, Torella F. Neuromuscular electrical stimulation for thromboprophylaxis: a systematic review. Phlebology 6 Jan 2015;Epub ahead of print:1‐14. [DOI: 10.1177/0268355514567731]

Higgins 2011

Higgins JP, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.

Izumi 2010

Izumi M, Ikeuchi M, Mitani T, Taniguchi S, Tani T. Prevention of venous stasis in the lower limb by transcutaneous electrical nerve stimulation. European Journal of Vascular and Endovascular Surgery 2010;39(5):642‐5.

Kahn 2002

Kahn SR, Ginsberg JS. The post‐thrombotic syndrome: current knowledge, controversies, and directions for future research. Blood Reviews 2002;16(3):155‐65.

Laverick 1990

Laverick MD, McGivern RC, Crone MD, Mollan RAB. A comparison of the effects of electrical calf muscle stimulation and the venous foot pump on venous blood flow in the lower leg. Phlebology 1990;5(4):285‐90.

Lyons 2002

Lyons GM, Leane GE, Grace PA. The effect of electrical stimulation of the calf muscle and compression stocking on venous bloodflow velocity. European Journal of Vascular and Endovascular Surgery 2002;23(6):564‐6.

Masri 2004

Masri B, Dunlop D, McEwen J, Garbuz D, Duncan C. Can a new design of pneumatic compression device reduce variations in delivered therapy for the mechanical prophylaxis of thromboembolic disease after total hip arthroplasty?. Canadian Journal of Surgery 2004;47(4):263–9.

Mehran 2011

Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 2011;123(23):2736‐47.

Moloney 2006

Clarke Moloney M, Lyons GM, Breen P, Burke PE, Grace PA. Haemodynamic study examining the response of venous blood flow to electrical stimulation of the gastrocnemius muscle in patients with chronic venous disease. European Journal of Vascular and Endovascular Surgery 2006;31(3):300‐5.

Morris 2004

Morris RJ, Woodcock JP. Evidence‐based compression: prevention of stasis and deep vein thrombosis. Annals of Surgery 2004;239(2):162–71.

NICE 2011

National Institute for Health and Clinical Excellence Medical Technologies Evaluation Programme (MTEP), 2011. http://www.nice.org.uk/guidance/mtg19/documents/the‐geko‐device‐for‐venous‐thromboembolism‐prophylaxis‐sponsors‐submission2 (accessed 2 December 2015).

Nicolaides 2013

Nicolaides AN, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, et al. Prevention and treatment of venous thromboembolism ‐ international consensus statement. International Angiology 2013;32(2):111–260.

Pavon 2016

Pavon JM, Adam SS, Razouki ZA, McDuffie JR, Lachiewicz PF, Kosinski AS, et al. Effectiveness of intermittent pneumatic compression devices for venous thromboembolism prophylaxis in high‐risk surgical patients: a systematic review. Journal of Arthroplasty 2016;31(2):524‐32. [DOI: 10.1016/j.arth.2015.09.043]

RevMan 2014 [Computer program]

The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan 5). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Roderick 2005

Roderick P, Ferris G, Wilson K, Halls H, Jackson D, Collins R, et al. Towards evidence‐based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis. Health Technology Assessment Programme 2005;9(49):iii‐iv, ix‐x, 1‐78.

Sachdeva 2014

Sachdeva A, Dalton M, Amaragiri SV, Lees T. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database of Systematic Reviews 2014, Issue 12. [DOI: 10.1002/14651858.CD001484.pub3]

Stefanou 2016

Stefanou C. Electrical muscle stimulation in thromboprophylaxis: review and a derived hypothesis about thrombogenesis ‐ the 4th factor. Springerplus 2016;5(1):884. [DOI: 10.1186/s40064‐016‐2521‐x]

Summers 2015

Summers JA, Clinch J, Radhakrishnan M, Healy A, McMillan V, Morris E, et al. The geko electro‐stimulation device for venous thromboembolism prophylaxis: a NICE medical technology guidance. Applied Health Economics and Health Policy 2015;13:135‐47.

Tucker 2010

Tucker AT, Maass A, Bain DS, Chen LH, Azzam M, Dawson H, et al. Augmentation of venous, arterial and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. International Journal of Angiology 2010;19(1):e31‐7.

Virchow 1856

Virchow RLK. Thrombosis and emboli (1846–1856) [Thrombose und Embolie. Gefässentzündung und septische Infektion]. Gesammelte Abhandlungen zur wissenschaftlichen Medicin1856:219‐732.

Warwick 2013

Warwick DJ, Shaikh A, Gadola S, Stokes M, Worsley P, Bain D, et al. Neuromuscular electrostimulation via the common peroneal nerve promotes lower limb blood flow in a below‐knee cast: a potential for thromboprophylaxis. Bone and Joint Research 2013;2(9):179‐85.

White 2003

White RH. The epidemiology of venous thromboembolism. Circulation 2003;107(23 Suppl 1):I4‐8.

References to other published versions of this review

Hajibandeh 2015b

Hajibandeh S, Hajibandeh S, Antoniou GA, Scurr JRH, Torella F. Neuromuscular electrical stimulation for the prevention of venous thromboembolism. Cochrane Database of Systematic Reviews 2015, Issue 6. [DOI: 10.1002/14651858.CD011764]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Bostrom 1986

Methods

Quasi‐randomised case‐controlled trial

Participants

Number of participants: 104 (NMES: 46; low‐dose heparin: 58)

Inclusion criteria: neurosurgical patients aged 40 years or older with normal laboratory coagulation values and operated on under general anaesthesia

Interventions

NMES group: preoperative calf muscle stimulation with groups of impulses, followed by Dextran 70 administered postoperatively. Stimulation characteristics included stimulus strength 40 to 50 mA; impulse duration 50 ms; number of impulses per group 6; impulse frequency within groups 8 per second; group frequency 8 per minute.

Low‐dose heparin group: Heparin (sodium heparin, Heparin, Lrvens, 5000 IU × 2 subcutaneously) was administered 2 hours preoperatively and was continued daily for 1 week postoperatively.

Outcomes

DVT (Participants were screened by fibrinogen uptake test; whenever possible, a phlebography was performed.)

Notes

Of 122 participants who entered the study, 18 were excluded during the course of the study. The most common reason for not completing the prophylaxis for the intended full week was early discharge from the hospital. One participant died 5 days after clipping of a ruptured intracranial aneurysm.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

The participant's year of birth was chosen as a method for randomisation.

Allocation concealment (selection bias)

High risk

The study was quasi‐randomised, and allocation was not adequately concealed.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding of participants and personnel was reported.

Blinding of outcome assessment (detection bias)
All outcomes

High risk

US or CT operator/radiologist was not blinded to patient allocation.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Of 122 participants who entered the study, 18 were excluded during the course of the study. However, the missing outcome data were balanced in numbers across intervention groups, and reasons for missing data were similar across groups.

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

Low risk

None was identified.

Goyal 2012

Methods

Quasi‐randomised case‐controlled trial

Participants

Number of participants: 200 (NMES: 100; no prophylaxis: 100)

Inclusion criteria: patients > 25 years of age requiring surgery around the hip joint who underwent surgery within 2 weeks of sustaining trauma and were operated on under spinal anaesthesia

Exclusion criteria: established cases of DVT; taking antithrombotic medication; open fractures; pacemakers; other serious life‐threatening conditions, pathological fractures, and associated vascular injuries

Interventions

NMES group: VeinoPlus (Ad Rem Technology, Paris, France) stimulator device for electrostimulation of the calf muscles during surgery. The stimulator device delivered low‐voltage (peak value usually around 15 to 25 V) and small‐energy impulses (below 25 μC per impulse) to calf muscles.

Control group: no prophylaxis

Outcomes

DVT (diagnosed by Doppler ultrasound 7 days after surgery)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Participants were randomised into 2 groups of 100 participants each by odd–even number.

Allocation concealment (selection bias)

High risk

The study was quasi‐randomised, and allocation was not adequately concealed.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding was reported.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

The radiologist was blinded about the study and groups of participants.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No outcome data were missing.

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

Low risk

None was identified.

Hou 2013

Methods

Four‐arm randomised controlled trial

Participants

Number of participants: 160 (conventional care group 40; invigorating and promoting Qi group 40; blood‐activating and damp‐eliminating group 40; acupoint‐combination stimulation group 40)

Inclusion criteria: age > 60 years; patients who underwent major surgery, including general surgeries, major gynaecological surgeries, limb fracture repairs, etc.; operative duration > 2 hours; patients on postoperative bed rest who could not get out of bed; and patients who signed the informed consent form

Exclusion criteria: inability to implement care measures in non‐compliant patients; patients who dropped out halfway for various reasons; inability to implement interventions in patients with lower limb infection; and inability to implement interventions among patients in critical condition

Interventions

Invigorating and promoting Qi group: postoperative routine care plus bilateral transcutaneous electrical stimulation at Taichong (LR 3) and Zusanli (ST 36) in two 20‐minute sessions per day (morning and afternoon) for 1 week

Blood‐activating and damp‐eliminating group: postoperative routine care plus bilateral transcutaneous electrical stimulation at Yinlingquan (SP 9) and Sanyinjiao (SP 6) in two 20‐minute sessions per day (morning and afternoon) for 1 week

Acupoint‐combination stimulation group: postoperative routine care plus bilateral transcutaneous electrical stimulation at a combination of 4 acupoints: Taichong (LR 3), Zusanli (ST 36), Yinlingquan (SP 9), and Sanyinjiao (SP 6), in two 20‐minute sessions per day (morning and afternoon) for 1 week

Conventional care group: postoperative routine care, including observation, basic care, catheter care, prevention and care of complications, and health education. In addition, participants received help with raising the lower extremities and were given postoperative symptomatic care.

Outcomes

DVT (diagnosed by Doppler ultrasound 7 days after surgery)

D‐dimer levels

Changes in haemorheology: blood viscosity (including whole blood viscosity and plasma viscosity)

Notes

Data for the 3 NMES groups were combined in analyses.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

A random numbers table was used.

Allocation concealment (selection bias)

Unclear risk

This was not reported.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding was reported.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

This was not reported.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No outcome data were missing.

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

High risk

The study was Industry sponsored.

Kiudelis 2002

Methods

Three‐arm randomised controlled trial

Participants

Number of participants: 54 (NMES group 18; GCS group 18; IPCD group 18)

Inclusion criteria: adult patients undergoing elective laparoscopic fundoplication

Exclusion criteria: not reported

Interventions

NMES group: intermittent electrical calf muscle stimulation during operation

GCS group: GCS during operation

IPCD group: IPCD during operation

Outcomes

Lower extremity venous blood velocity (measured by Doppler ultrasonography during operation)

DVT (1 day after operation using venous occlusion plethysmography)

PE (1 day after operation using lung perfusion scintigraphy)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

This was not reported.

Allocation concealment (selection bias)

Unclear risk

This was not reported.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding was reported.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

This was not reported.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No outcome data were missing.

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

Low risk

None was identified.

Lindstrom 1982

Methods

Three‐arm randomised controlled trial

Participants

Number of participants: 112 (stimulation group 37; control group 40; Dextran 40 group 35)

Inclusion criteria: patients who underwent major abdominal surgery

Interventions

Stimulation group: optimised bilateral calf muscle stimulation with groups of impulses during the entire operation.(strength 40 to 50 mA, impulse duration 50 ms; number of impulses per group 6; impulse frequency within group 8 amp/s; group frequency 8 groups/min)

Control group: standard routine of the ward. Plasma and whole blood were given to replace blood lost.

Dextran 40 group: 500 mL Dextran 40 was given perioperatively and during the first and third postoperative days.

Outcomes

DVT (Participants were screened by fibrinogen uptake test; whenever possible, a phlebography was performed.)

PE (diagnosed by pulmonary perfusion scintigraphy)

Total VTE

PE with DVT

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

This was not reported.

Allocation concealment (selection bias)

Unclear risk

This was not reported.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding was reported.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

This was not reported.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No outcome data were missing.

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

Low risk

None was identified.

Merli 1988

Methods

Three‐arm randomised controlled trial

Participants

Number of participants: 48 (NMES + low‐dose heparin group 15; low‐dose heparin group 16; saline placebo group 17)

Inclusion criteria: patients with C2 to T11 motor complete and incomplete, preserved motor, non‐functional spinal cord injuries

Interventions

NMES + low‐dose heparin group: Tibialis anterior and gastrocnemius‐soleus muscle groups were stimulated bilaterally via 50‐microsecond pulses given at 10 Hz with a 4‐second "on" and 8‐second "off" cycle for 23 hours daily over a 28‐day period + 5000 IU heparin, given subcutaneously every 8 hours.

Low‐dose heparin group: 5000 IU heparin, given subcutaneously every 8 hours

Placebo: saline

Outcomes

DVT (Venography was performed to confirm positive impedance plethysmography and/or fibrinogen uptake tests.)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Data about randomisation were not reported.

Allocation concealment (selection bias)

Unclear risk

This was not reported.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Participants in control group received placebo saline.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

This was not reported.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All outcomes were reported.

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

Low risk

None was identified.

Rosenberg 1975

Methods

Quasi‐randomised case‐controlled trial

Participants

Number of participants: 194 (NMES group 50; no prophylaxis group 89; low‐dose heparin group 55)

Inclusion criteria: Patients older than 40 years undergoing a major general surgical operation for which they were expected to be in hospital for at least a week were eligible to enter the trial.

Exclusion criteria: No exclusions were made on the grounds of pre‐existing cardiorespiratory disease, peripheral vascular disease, or varicose veins; or previous history of thrombosis; but for technical reasons patients undergoing thyroidectomy, left mastectomy, and peripheral arterial reconstruction were not studied.

Interventions

NMES group: intermittent electrical calf muscle stimulation during surgery, use of Thrombophylactor (Rank Precision Industries Ltd., Maidenhead, Berkshire, UK), which delivers an interrupted direct current of 50 milliseconds duration every 5 seconds

Low‐dose heparin group: heparin calcium administered subcutaneously 5000 IU, the first dose 2 hours before operation, then every 8 hours until the end of the sixth postoperative day, or until the participant was fully mobile, whichever was longer

No prophylaxis group: leg exercises only

Outcomes

DVT (The fibrinogen uptake test was performed on all participants for diagnosis.)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Randomisation into 3 groups was by month of birth.

Allocation concealment (selection bias)

High risk

The study was a quasi‐randomised trial, and allocation was not adequately concealed.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding was reported.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

This was not reported.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No outcome data were missing.

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

High risk

This study was industry sponsored.

Velmahos 2005

Methods

Two‐arm randomised controlled trial

Participants

Number of participants: 47 (NMES group 26; non‐NMES group 21)

Inclusion criteria: trauma patients with Injury Severity Score > 9 who were admitted to the intensive care unit and had a contraindication for prophylactic heparin; significant head injury; operation for extensive organ injury; major retroperitoneal haematoma; liver, spleen, or kidney injury higher than Grade II, managed non‐operatively; other injuries that at the discretion of the trauma surgeon were deemed to be associated with a high likelihood for bleeding; anticipated survival for longer than 7 days; anticipated hospital stay longer than 7 days; and randomisation within 24 hours of injury

Exclusion criteria: younger than 18 years; known allergy to contrast material, precluding use of venography, cardiac demand pacemakers, or other implanted stimulators or implants containing metal parts within the area of treatment; spastic paralysis; local infection at the site of application; and history or present evidence of venous thrombosis. Trauma to the extremity was not an exclusion criterion.

Interventions

NMES group: two 30‐minute sessions daily, 1 in the morning and 1 in the evening, using the Lymphavision stimulator (Physiomed Elektromedizin AG, Schnaittach, Germany). Voltage was applied gradually (0 to 120 V) to obtain a slightly visible twitch of the muscles. Stimuli 3 milliseconds long were used at a frequency of 1.75 Hz (105/min) with inversion of polarity every 5 seconds.

Non‐NMES group: managed according to standard of care with no thromboprophylaxis for as long as contraindications existed

Participants in both groups were allowed to have standard prophylaxis with subcutaneous unfractionated or LMWH when the contraindication for its use was no longer present.

Outcomes

DVT (diagnosed by venography or Doppler ultrasound)

Venous blood flow velocity

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Type and method of randomisation are not clearly described.

Allocation concealment (selection bias)

Unclear risk

Type and method of randomisation are not clearly described, and allocation concealment cannot be judged confidently.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding was reported.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

This was not reported.

Incomplete outcome data (attrition bias)
All outcomes

High risk

Missing outcome data were not balanced in numbers across intervention groups: 4 NMES and 9 control participants were excluded from analysis because of lack of outcome evaluation (2 control participants died, 7 control participants and 1 NMES participant were transferred to another hospital, and 2 NMES participants refused to continue the study despite initial consent).

Selective reporting (reporting bias)

Low risk

The study protocol was not available, but it is clear that published reports include all expected outcomes.

Other bias

High risk

The study was industry sponsored.

CT: computed tomography.
DVT: deep vein thrombosis.
GCS: graduated compression stockings.
IPCD: intermittent pneumatic compression devices.
LMWH: low molecular weight heparin.
ms: milliseconds.
NMES: neuromuscular electrical stimulation.
PE: pulmonary embolism.
US: ultrasound.
VTE: venous thromboembolism.

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Browse 1970

Randomised legs instead of participants

Czyrny 2010

Included healthy individuals

Doran 1967

Randomised legs instead of participants

Doran 1970

Randomised legs instead of participants

Faghri 1998

Non‐randomised, non‐clinical study

Hou 2014

Study did not report outcomes defined in our review paper. Study authors were contacted to clarify if any of our review outcomes had been measured, but no reply was received.

Izumi 2014

Only 1 leg received NMES; the other leg received other methods of thromboprophylaxis.

Jansen 1972

Investigated non‐mechanical methods of prophylaxis

Kaplan 2002

Included healthy individuals

Lobastov 2014

Non‐randomised study

Morita 2006

Included healthy individuals

NCT02425917

Trial was withdrawn before enrolment.

Nicolaides 1983

Randomised legs instead of participants

Ojima 2017

Investigated haemodynamic outcomes and was powered for these outcomes only

Pambianco 1995

NMES arm was terminated early in the pilot phase.

Rosengarten 1975

Investigated non‐mechanical methods of prophylaxis

Yilmaz 2016

Investigated haemodynamic outcomes only

NMES: neuromuscular electrical stimulation.

Characteristics of studies awaiting assessment [ordered by study ID]

NCT01835990

Methods

Two‐arm randomised controlled trial

Participants

Inclusion criteria: diagnosis of trauma; age 18 years or older; contraindication to anticoagulation expected to last longer than 3 days; projected hospitalisation longer than 3 days; and informed consent

Exclusion criteria: inability to wear either IPCs or geko™ (Sky Medical Technology Ltd, Newport, Vermont, USA) on both legs; diagnosis of DVT within 1 month before assessment for enrolment; use of anticoagulant medication within 24 hours of enrolment; leg circumference greater than 24 inches at the location where the geko™ device would be secured to the leg; or presence of cardiac demand pacemaker

Interventions

Intervention group: geko™

Comparator group: IPCs

Outcomes

Incidence of DVT

Compliance

VTE

Tolerability

Venous and arterial physiological flow

Notes

Study has been completed. Results of this study are not yet available.

DVT: deep vein thrombosis.
IPC: intermittent pneumatic compression device.
VTE: venous thromboembolism.

Characteristics of ongoing studies [ordered by study ID]

ISRCTN95441725

Trial name or title

Does the Geko™ nerve stimulator reduce deep vein thrombosis (DVT) and improve healing in ankle fractures?

Methods

Randomised controlled trial

Participants

Adults aged 18 years or older, either sex, with closed ankle fractures that have required open reduction and internal fixation; able to consent for themselves

Interventions

Each participant randomised into 1 of 2 groups, i.e. those who receive the stimulator for a 2‐week period postoperatively and those who do not

Outcomes

DVT rate; time to union

Starting date

01/11/2012

Contact information

Wirral University Teaching Hospital

Notes

The study has been completed, but results have not yet been published. Study authors contacted, but no reply

NCT01935414

Trial name or title

Geko™ neuromuscular stimulator vs thromboembolism deterrent stockings (TEDS): DVT prevention study

Methods

Open‐label randomised controlled trial

Participants

Inclusion criteria: aged 18 years or older; free of significant abnormal findings as determined by medical history (specifically, absence of DVT or haematological disorders); no reported use of medications (prescribed or over‐the‐counter, including herbal remedies) judged to be significant by the principal investigator during the ten (10) days preceding enrolment; able to understand the patient information sheet and willing to sign the written informed consent form; and able and willing to follow the protocol requirements

Interventions

Intervention: continual Geko™ use post surgery for 48 hours, then for a minimum of 4 hours/d until discharge

Control: continual use of TEDS stockings post surgery for 48 hours, then for a minimum of 4 hours/d until discharge

Outcomes

Presence of asymptomatic DVT assessed by duplex ultrasound

Starting date

August 2013

Contact information

[email protected]

Notes

DVT: deep vein thrombosis.
NMES: neuromuscular electrical stimulation.
TEDS: thromboembolism deterrent stockings.

Data and analyses

Open in table viewer
Comparison 1. NMES versus alternative prophylaxis

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

6

415

Odds Ratio (M‐H, Fixed, 95% CI)

1.01 [0.60, 1.70]

Analysis 1.1

Comparison 1 NMES versus alternative prophylaxis, Outcome 1 Total DVT.

Comparison 1 NMES versus alternative prophylaxis, Outcome 1 Total DVT.

2 Asymptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.2

Comparison 1 NMES versus alternative prophylaxis, Outcome 2 Asymptomatic DVT.

Comparison 1 NMES versus alternative prophylaxis, Outcome 2 Asymptomatic DVT.

3 Symptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.3

Comparison 1 NMES versus alternative prophylaxis, Outcome 3 Symptomatic DVT.

Comparison 1 NMES versus alternative prophylaxis, Outcome 3 Symptomatic DVT.

4 PE Show forest plot

2

126

Odds Ratio (M‐H, Fixed, 95% CI)

1.31 [0.38, 4.48]

Analysis 1.4

Comparison 1 NMES versus alternative prophylaxis, Outcome 4 PE.

Comparison 1 NMES versus alternative prophylaxis, Outcome 4 PE.

5 Total VTE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.5

Comparison 1 NMES versus alternative prophylaxis, Outcome 5 Total VTE.

Comparison 1 NMES versus alternative prophylaxis, Outcome 5 Total VTE.

Open in table viewer
Comparison 2. NMES versus no prophylaxis

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

4

576

Odds Ratio (M‐H, Fixed, 95% CI)

0.40 [0.23, 0.70]

Analysis 2.1

Comparison 2 NMES versus no prophylaxis, Outcome 1 Total DVT.

Comparison 2 NMES versus no prophylaxis, Outcome 1 Total DVT.

2 Asymptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 2.2

Comparison 2 NMES versus no prophylaxis, Outcome 2 Asymptomatic DVT.

Comparison 2 NMES versus no prophylaxis, Outcome 2 Asymptomatic DVT.

3 Symptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 2.3

Comparison 2 NMES versus no prophylaxis, Outcome 3 Symptomatic DVT.

Comparison 2 NMES versus no prophylaxis, Outcome 3 Symptomatic DVT.

4 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 2.4

Comparison 2 NMES versus no prophylaxis, Outcome 4 PE.

Comparison 2 NMES versus no prophylaxis, Outcome 4 PE.

5 Total VTE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 2.5

Comparison 2 NMES versus no prophylaxis, Outcome 5 Total VTE.

Comparison 2 NMES versus no prophylaxis, Outcome 5 Total VTE.

Open in table viewer
Comparison 3. NMES versus low‐dose heparin

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

2

194

Odds Ratio (M‐H, Fixed, 95% CI)

2.78 [1.19, 6.48]

Analysis 3.1

Comparison 3 NMES versus low‐dose heparin, Outcome 1 Total DVT.

Comparison 3 NMES versus low‐dose heparin, Outcome 1 Total DVT.

2 Asymptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 3.2

Comparison 3 NMES versus low‐dose heparin, Outcome 2 Asymptomatic DVT.

Comparison 3 NMES versus low‐dose heparin, Outcome 2 Asymptomatic DVT.

3 Symptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 3.3

Comparison 3 NMES versus low‐dose heparin, Outcome 3 Symptomatic DVT.

Comparison 3 NMES versus low‐dose heparin, Outcome 3 Symptomatic DVT.

Open in table viewer
Comparison 4. NMES versus Dextran 40

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 4.1

Comparison 4 NMES versus Dextran 40, Outcome 1 Total DVT.

Comparison 4 NMES versus Dextran 40, Outcome 1 Total DVT.

2 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 4.2

Comparison 4 NMES versus Dextran 40, Outcome 2 PE.

Comparison 4 NMES versus Dextran 40, Outcome 2 PE.

3 Total VTE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 4.3

Comparison 4 NMES versus Dextran 40, Outcome 3 Total VTE.

Comparison 4 NMES versus Dextran 40, Outcome 3 Total VTE.

Open in table viewer
Comparison 5. Combined NMES and low‐dose heparin versus no prophylaxis

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 5.1

Comparison 5 Combined NMES and low‐dose heparin versus no prophylaxis, Outcome 1 Total DVT.

Comparison 5 Combined NMES and low‐dose heparin versus no prophylaxis, Outcome 1 Total DVT.

Open in table viewer
Comparison 6. Combined NMES and low‐dose heparin versus low‐dose heparin

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 6.1

Comparison 6 Combined NMES and low‐dose heparin versus low‐dose heparin, Outcome 1 Total DVT.

Comparison 6 Combined NMES and low‐dose heparin versus low‐dose heparin, Outcome 1 Total DVT.

Open in table viewer
Comparison 7. NMES versus GCS

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 7.1

Comparison 7 NMES versus GCS, Outcome 1 Total DVT.

Comparison 7 NMES versus GCS, Outcome 1 Total DVT.

2 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 7.2

Comparison 7 NMES versus GCS, Outcome 2 PE.

Comparison 7 NMES versus GCS, Outcome 2 PE.

Open in table viewer
Comparison 8. NMES versus IPCD

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 8.1

Comparison 8 NMES versus IPCD, Outcome 1 Total DVT.

Comparison 8 NMES versus IPCD, Outcome 1 Total DVT.

2 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 8.2

Comparison 8 NMES versus IPCD, Outcome 2 PE.

Comparison 8 NMES versus IPCD, Outcome 2 PE.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 NMES versus alternative prophylaxis, outcome: 1.1 Total DVT.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 NMES versus alternative prophylaxis, outcome: 1.1 Total DVT.

Forest plot of comparison: 2 NMES versus no prophylaxis, outcome: 2.1 Total DVT.
Figures and Tables -
Figure 5

Forest plot of comparison: 2 NMES versus no prophylaxis, outcome: 2.1 Total DVT.

Comparison 1 NMES versus alternative prophylaxis, Outcome 1 Total DVT.
Figures and Tables -
Analysis 1.1

Comparison 1 NMES versus alternative prophylaxis, Outcome 1 Total DVT.

Comparison 1 NMES versus alternative prophylaxis, Outcome 2 Asymptomatic DVT.
Figures and Tables -
Analysis 1.2

Comparison 1 NMES versus alternative prophylaxis, Outcome 2 Asymptomatic DVT.

Comparison 1 NMES versus alternative prophylaxis, Outcome 3 Symptomatic DVT.
Figures and Tables -
Analysis 1.3

Comparison 1 NMES versus alternative prophylaxis, Outcome 3 Symptomatic DVT.

Comparison 1 NMES versus alternative prophylaxis, Outcome 4 PE.
Figures and Tables -
Analysis 1.4

Comparison 1 NMES versus alternative prophylaxis, Outcome 4 PE.

Comparison 1 NMES versus alternative prophylaxis, Outcome 5 Total VTE.
Figures and Tables -
Analysis 1.5

Comparison 1 NMES versus alternative prophylaxis, Outcome 5 Total VTE.

Comparison 2 NMES versus no prophylaxis, Outcome 1 Total DVT.
Figures and Tables -
Analysis 2.1

Comparison 2 NMES versus no prophylaxis, Outcome 1 Total DVT.

Comparison 2 NMES versus no prophylaxis, Outcome 2 Asymptomatic DVT.
Figures and Tables -
Analysis 2.2

Comparison 2 NMES versus no prophylaxis, Outcome 2 Asymptomatic DVT.

Comparison 2 NMES versus no prophylaxis, Outcome 3 Symptomatic DVT.
Figures and Tables -
Analysis 2.3

Comparison 2 NMES versus no prophylaxis, Outcome 3 Symptomatic DVT.

Comparison 2 NMES versus no prophylaxis, Outcome 4 PE.
Figures and Tables -
Analysis 2.4

Comparison 2 NMES versus no prophylaxis, Outcome 4 PE.

Comparison 2 NMES versus no prophylaxis, Outcome 5 Total VTE.
Figures and Tables -
Analysis 2.5

Comparison 2 NMES versus no prophylaxis, Outcome 5 Total VTE.

Comparison 3 NMES versus low‐dose heparin, Outcome 1 Total DVT.
Figures and Tables -
Analysis 3.1

Comparison 3 NMES versus low‐dose heparin, Outcome 1 Total DVT.

Comparison 3 NMES versus low‐dose heparin, Outcome 2 Asymptomatic DVT.
Figures and Tables -
Analysis 3.2

Comparison 3 NMES versus low‐dose heparin, Outcome 2 Asymptomatic DVT.

Comparison 3 NMES versus low‐dose heparin, Outcome 3 Symptomatic DVT.
Figures and Tables -
Analysis 3.3

Comparison 3 NMES versus low‐dose heparin, Outcome 3 Symptomatic DVT.

Comparison 4 NMES versus Dextran 40, Outcome 1 Total DVT.
Figures and Tables -
Analysis 4.1

Comparison 4 NMES versus Dextran 40, Outcome 1 Total DVT.

Comparison 4 NMES versus Dextran 40, Outcome 2 PE.
Figures and Tables -
Analysis 4.2

Comparison 4 NMES versus Dextran 40, Outcome 2 PE.

Comparison 4 NMES versus Dextran 40, Outcome 3 Total VTE.
Figures and Tables -
Analysis 4.3

Comparison 4 NMES versus Dextran 40, Outcome 3 Total VTE.

Comparison 5 Combined NMES and low‐dose heparin versus no prophylaxis, Outcome 1 Total DVT.
Figures and Tables -
Analysis 5.1

Comparison 5 Combined NMES and low‐dose heparin versus no prophylaxis, Outcome 1 Total DVT.

Comparison 6 Combined NMES and low‐dose heparin versus low‐dose heparin, Outcome 1 Total DVT.
Figures and Tables -
Analysis 6.1

Comparison 6 Combined NMES and low‐dose heparin versus low‐dose heparin, Outcome 1 Total DVT.

Comparison 7 NMES versus GCS, Outcome 1 Total DVT.
Figures and Tables -
Analysis 7.1

Comparison 7 NMES versus GCS, Outcome 1 Total DVT.

Comparison 7 NMES versus GCS, Outcome 2 PE.
Figures and Tables -
Analysis 7.2

Comparison 7 NMES versus GCS, Outcome 2 PE.

Comparison 8 NMES versus IPCD, Outcome 1 Total DVT.
Figures and Tables -
Analysis 8.1

Comparison 8 NMES versus IPCD, Outcome 1 Total DVT.

Comparison 8 NMES versus IPCD, Outcome 2 PE.
Figures and Tables -
Analysis 8.2

Comparison 8 NMES versus IPCD, Outcome 2 PE.

Summary of findings for the main comparison. NMES compared to alternative prophylaxis for the prevention of venous thromboembolism

NMES compared to alternative prophylaxis for the prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: NMES
Comparison: alternative prophylaxis

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with alternative prophylaxis

Risk with NMES

Total DVT
Follow‐up: mean 11 days

Study population

OR 1.01
(0.60 to 1.70)

415
(6 RCTs)

⊕⊕⊝⊝
LOWa,b

170 per 1000

172 per 1000
(110 to 259)

Asymptomatic DVT
Follow‐up: 8 days

Study population

OR 1.61
(0.40 to 6.43)

89
(1 RCT)

⊕⊕⊝⊝
LOWa,c

82 per 1000

125 per 1000
(34 to 364)

Symptomatic DVT
Follow‐up: 8 days

Study population

OR 0.40
(0.02 to 10.07)

89
(1 RCT)

⊕⊕⊝⊝
LOWa,c

20 per 1000

8 per 1000
(0 to 173)

PE
Follow‐up: mean 4 days

Study population

OR 1.31
(0.38 to 4.48)

126
(2 RCTs)

⊕⊕⊝⊝
LOWa,c

70 per 1000

90 per 1000
(28 to 253)

Total VTE
Follow‐up: 6 days

Study population

OR 0.92
(0.34 to 2.52)

72
(1 RCT)

⊕⊕⊝⊝
LOWa,c

314 per 1000

297 per 1000
(135 to 536)

Bleeding (major and minor)

see comment

see comment

not estimable

415
(6 RCTs)

None of the studies in this comparison reported this outcome.

*Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aHigh or unclear risk of selection bias, performance bias, and detection bias ‐ downgraded by one level.
bModerate level of between‐study heterogeneity ‐ downgraded by one level.
cFew participants and few events and thus wide confidence intervals ‐ downgraded by one level.

Figures and Tables -
Summary of findings for the main comparison. NMES compared to alternative prophylaxis for the prevention of venous thromboembolism
Summary of findings 2. NMES compared to no prophylaxis for prevention of venous thromboembolism

NMES compared to no prophylaxis for prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: NMES
Comparison: no prophylaxis

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with no prophylaxis

Risk with NMES

Total DVT
Follow‐up: mean 7 days

Study population

OR 0.40
(0.23 to 0.70)

576
(4 RCTs)

⊕⊕⊕⊝
MODERATEa

219 per 1000

101 per 1000
(61 to 164)

Asymptomatic DVT

Follow‐up: 7 days

Study population

OR 0.32
(0.06 to 1.62)

200
(1 RCT)

⊕⊕⊝⊝
LOWa,b

60 per 1000

20 per 1000
(4 to 94)

Symptomatic DVT

Follow‐up: 7 days

Study population

OR 0.06
(0.00 to 1.36)

160
(1 RCT)

⊕⊕⊝⊝
LOWa,b

50 per 1000

3 per 1000
(0 to 67)

PE

Follow‐up: 6 days

Study population

OR 0.36
(0.12 to 1.07)

77
(1 RCT)

⊕⊕⊝⊝
LOWa,b

350 per 1000

162 per 1000
(61 to 366)

Total VTE

Follow‐up: 6 days

Study population

OR 0.23
(0.09 to 0.59)

77
(1 RCT)

⊕⊕⊝⊝
LOWa,b

650 per 1000

299 per 1000
(143 to 523)

Bleeding (major and minor)

see comment

see comment

not estimable

576

(4 RCTs)

None of the studies in this comparison reported this outcome.

*Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aHigh or unclear risk of selection bias, performance bias, and detection bias ‐ downgraded by one level.
bFew participants and few events and thus wide confidence intervals ‐ downgraded by one level.

Figures and Tables -
Summary of findings 2. NMES compared to no prophylaxis for prevention of venous thromboembolism
Summary of findings 3. NMES compared to low‐dose heparin for the prevention of venous thromboembolism

NMES compared to low‐dose heparin for the prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: NMES
Comparison: low‐dose heparin

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with low‐dose heparin

Risk with NMES

Total DVT
Follow‐up: mean 7 days

Study population

OR 2.78
(1.19 to 6.48)

194
(2 RCTs)

⊕⊕⊝⊝
LOWa,b

87 per 1000

208 per 1000
(101 to 380)

Asymptomatic DVT

Follow‐up: 8 days

Study population

OR 1.61
(0.40 to 6.43)

89
(1 RCT)

⊕⊕⊝⊝
LOWb,c

82 per 1000

125 per 1000
(34 to 364)

Symptomatic DVT

Follow‐up: 8 days

Study population

OR 0.40
(0.02 to 10.07)

89
(1 RCT)

⊕⊕⊝⊝
LOWb,c

20 per 1000

8 per 1000
(0 to 173)

PE

see comment

see comment

not estimable

194

(2 RCTs)

None of the studies in this comparison reported this outcome.

Total VTE

see comment

see comment

not estimable

194

(2 RCTs)

None of the studies in this comparison reported this outcome.

Bleeding (major and minor)

see comment

see comment

not estimable

194

(2 RCTs)

None of the studies in this comparison reported this outcome.

*Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aHigh or unclear risk of selection bias, performance bias, and detection bias ‐ downgraded by one level.
bFew participants and few events and thus wide confidence intervals ‐ downgraded by one level.
cHigh or unclear risk of selection bias and detection bias ‐ downgraded by one level.

Figures and Tables -
Summary of findings 3. NMES compared to low‐dose heparin for the prevention of venous thromboembolism
Summary of findings 4. NMES compared to Dextran 40 for the prevention of venous thromboembolism

NMES compared to Dextran 40 for the prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: NMES
Comparison: Dextran 40

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with Dextran 40

Risk with NMES

Total DVT
Follow‐up: 6 days

Study population

OR 0.63
(0.18 to 2.19)

72
(1 RCT)

⊕⊕⊝⊝
LOWa,b

200 per 1000

136 per 1000
(43 to 354)

Asymptomatic DVT

see comment

see comment

not estimable

72

(1 RCT)

The single study in this comparison did not report this outcome.

Symptomatic DVT

see comment

see comment

not estimable

72

(1 RCT)

The single study in this comparison did not report this outcome.

PE

Follow‐up: 6 days

Study population

OR 1.50
(0.39 to 5.84)

72
(1 RCT)

⊕⊕⊝⊝
LOWa,b

114 per 1000

162 per 1000
(48 to 430)

Total VTE

Follow‐up: 6 days

Study population

OR 0.92
(0.34 to 2.52)

72
(1 RCT)

⊕⊕⊝⊝
LOWa,b

314 per 1000

297 per 1000
(135 to 536)

Bleeding (major and minor)

see comment

see comment

not estimable

72

(1 RCT)

The single study in this comparison did not report this outcome.

Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect,

aHigh or unclear risk of selection bias, performance bias, and detection bias ‐ downgraded by one level.
bSingle study, few participants, and few events and thus wide confidence intervals ‐ downgraded by one level.

Figures and Tables -
Summary of findings 4. NMES compared to Dextran 40 for the prevention of venous thromboembolism
Summary of findings 5. Combined NMES and low‐dose heparin compared to no prophylaxis for the prevention of venous thromboembolism

Combined NMES and low‐dose heparin compared to no prophylaxis for the prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: combined NMES and low‐dose heparin
Comparison: no prophylaxis

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with no prophylaxis

Risk with combined NMES and low‐dose heparin

Total DVT
Follow‐up: 28 days

Study population

OR 0.08
(0.01 to 0.76)

32
(1 RCT)

⊕⊕⊝⊝
LOWa,b

471 per 1000

66 per 1000
(9 to 403)

Asymptomatic DVT

see comment

see comment

not estimable

32

(1 RCT)

The single study in this comparison did not report this outcome.

Symptomatic DVT

see comment

see comment

not estimable

32

(1 RCT)

The single study in this comparison did not report this outcome.

PE

see comment

see comment

not estimable

32

(1 RCT)

The single study in this comparison did not report this outcome.

Total VTE

see comment

see comment

not estimable

32

(1 RCT)

The single study in this comparison did not report this outcome.

Bleeding (major and minor)

see comment

see comment

not estimable

32

(1 RCT)

The single study in this comparison did not report this outcome.

*Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aHigh or unclear risk of selection bias and detection bias ‐ downgraded by one level.
bSingle study, few participants, and few events and thus wide confidence intervals ‐ downgraded by one level.

Figures and Tables -
Summary of findings 5. Combined NMES and low‐dose heparin compared to no prophylaxis for the prevention of venous thromboembolism
Summary of findings 6. Combined NMES and low‐dose heparin compared to low‐dose heparin for the prevention of venous thromboembolism

Combined NMES and low‐dose heparin compared to low‐dose heparin for the prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: combined NMES and low‐dose heparin
Comparison: low‐dose heparin

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with low‐dose heparin

Risk with combined NMES and low‐dose heparin

Total DVT
Follow‐up: 28 days

Study population

OR 0.07
(0.01 to 0.68)

31
(1 RCT)

⊕⊕⊝⊝
LOWa,b

500 per 1000

65 per 1000
(10 to 405)

Asymptomatic DVT

see comment

see comment

not estimable

31

(1 RCT)

The single study in this comparison did not report this outcome.

Symptomatic DVT

see comment

see comment

not estimable

31

(1 RCT)

The single study in this comparison did not report this outcome.

PE

see comment

see comment

not estimable

31

(1 RCT)

The single study in this comparison did not report this outcome.

Total VTE

see comment

see comment

not estimable

31

(1 RCT)

The single study in this comparison did not report this outcome.

Bleeding (major and minor)

see comment

see comment

not estimable

31

(1 RCT)

The single study in this comparison did not report this outcome.

*Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aHigh or unclear risk of selection bias and detection bias ‐ downgraded by one level.
bSingle study, few participants, and few events and thus wide confidence intervals ‐ downgraded by one level.

Figures and Tables -
Summary of findings 6. Combined NMES and low‐dose heparin compared to low‐dose heparin for the prevention of venous thromboembolism
Summary of findings 7. NMES compared to GCS for the prevention of venous thromboembolism

NMES compared to GCS for the prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: NMES
Comparison: GCS

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with GCS

Risk with NMES

Total DVT
Follow‐up: 1 day

Study population

OR 0.32
(0.01 to 8.27)

36
(1 RCT)

⊕⊕⊝⊝
LOWa,b

56 per 1000

18 per 1000

(1 to 327)

Asymptomatic DVT

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

Symptomatic DVT

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

PE

Follow‐up: 1 day

Study population

OR 0.32
(0.01 to 8.27)

36
(1 RCT)

⊕⊕⊝⊝
LOWa,b

56 per 1000

18 per 1000
(1 to 327)

Total VTE

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

Bleeding (major and minor)

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

*Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; GCS: graduated compression stockings; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aHigh or unclear risk of selection bias, performance bias, and detection bias ‐ downgraded by one level.
bSingle study, few participants, and few events and thus wide confidence intervals ‐ downgraded by one level.

Figures and Tables -
Summary of findings 7. NMES compared to GCS for the prevention of venous thromboembolism
Summary of findings 8. NMES compared to IPCD for the prevention of venous thromboembolism

NMES compared to IPCD for the prevention of venous thromboembolism

Patient or population: participants at risk of venous thromboembolism
Setting: hospital, secondary care
Intervention: NMES
Comparison: IPCD

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with IPCD

Risk with NMES

Total DVT

Follow‐up: 1 day

Study population

not estimable

36
(1 RCT)

⊕⊕⊝⊝
LOWa,b

No DVT events were recorded.

see comment

see comment

Asymptomatic DVT

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

Symptomatic DVT

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

PE

Follow‐up: 1 day

Study population

not estimable

36
(1 RCT)

⊕⊕⊝⊝
LOWa,b

No PE events were recorded.

see comment

see comment

Total VTE

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

Bleeding (major and minor)

see comment

see comment

not estimable

36

(1 RCT)

None of the studies in this comparison reported this outcome.

*Assumed control intervention risks were calculated by the mean number of events in control groups of selected studies for each outcome. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DVT: deep vein thrombosis; IPCD: intermittent pneumatic compression devices; NMES: neuromuscular electrical stimulation; OR: odds ratio; PE: pulmonary embolism; RCT: randomised controlled trial; VTE: venous thromboembolism.

GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aHigh or unclear risk of selection bias, performance bias, and detection bias ‐ downgraded by one level.
bSingle study, few participants, and few events ‐ downgraded by one level.

Figures and Tables -
Summary of findings 8. NMES compared to IPCD for the prevention of venous thromboembolism
Table 1. Neuromuscular electrical stimulation delivery in the included studies

Study

Device

Frequency (Hz)

Pulse width

Charge (mA)

Voltage (V)

Duration

Hou 2013

G6805‐II

30‐100

NR

NR

6‐15

7 days

(20 minutes twice/d)

Goyal 2012

VEINOPLUS

NR

NR

NR

15–25

Only during surgery

Velmahos 2005

Lymphavision

1.75

3 ms

NR

0‐120

7‐14 days

(30 minutes twice/d)

Kiudelis 2002

Mioritm 021

NR

NR

50‐100

NR

Only during surgery

Merli 1988

NR

10

50 μs

NR

NR

28 days

(23 hours/d)

Bostrom 1986

NR

8

50 ms

40‐50

NR

7 days

Lindstrom 1982

NR

8

50 ms

40‐50

NR

Only during surgery

Rosenberg 1975

Thrombophylactor

NR

50 ms

NR

Adjustable

Only during surgery

NR: rot reported.

Figures and Tables -
Table 1. Neuromuscular electrical stimulation delivery in the included studies
Comparison 1. NMES versus alternative prophylaxis

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

6

415

Odds Ratio (M‐H, Fixed, 95% CI)

1.01 [0.60, 1.70]

2 Asymptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Symptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4 PE Show forest plot

2

126

Odds Ratio (M‐H, Fixed, 95% CI)

1.31 [0.38, 4.48]

5 Total VTE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 1. NMES versus alternative prophylaxis
Comparison 2. NMES versus no prophylaxis

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

4

576

Odds Ratio (M‐H, Fixed, 95% CI)

0.40 [0.23, 0.70]

2 Asymptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Symptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5 Total VTE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 2. NMES versus no prophylaxis
Comparison 3. NMES versus low‐dose heparin

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

2

194

Odds Ratio (M‐H, Fixed, 95% CI)

2.78 [1.19, 6.48]

2 Asymptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Symptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 3. NMES versus low‐dose heparin
Comparison 4. NMES versus Dextran 40

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Total VTE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 4. NMES versus Dextran 40
Comparison 5. Combined NMES and low‐dose heparin versus no prophylaxis

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 5. Combined NMES and low‐dose heparin versus no prophylaxis
Comparison 6. Combined NMES and low‐dose heparin versus low‐dose heparin

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 6. Combined NMES and low‐dose heparin versus low‐dose heparin
Comparison 7. NMES versus GCS

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 7. NMES versus GCS
Comparison 8. NMES versus IPCD

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2 PE Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 8. NMES versus IPCD