Neuromuscular electrical stimulation (NMES) for patellofemoral pain syndrome

Ana Luiza C Martimbianco; Maria Regina Torloni; Brenda NG Andriolo; Gustavo JM Porfírio; Rachel Riera

doi:10.1002/14651858.CD011289.pub2

Cochrane Database of Systematic Reviews

Estimulación eléctrica neuromuscular (EENM) para el síndrome de dolor patelofemoral

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DOI:

https://doi.org/10.1002/14651858.CD011289.pub2 Copiar DOI

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Cochrane Database of Systematic Reviews

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12 diciembre 2017see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Lesiones óseas, articulares y musculares

Copyright:

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Ana Luiza C Martimbianco

Correspondencia a: Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil

[email protected]
Maria Regina Torloni

Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
Brenda NG Andriolo

Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
Gustavo JM Porfírio

Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
Rachel Riera

Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil

Contributions of authors

Ana Luiza C Martimbianco: drafted the protocol and review, methodological and content issues
Maria R Torloni: drafted the protocol and review, content issues, language (English) issues
Brenda NG Andriolo: drafted the protocol and review, methodological and content issues
Gustavo Porfirio: drafted the protocol and review, content issues
Rachel Riera: drafted the protocol and review, methodological issues

Sources of support

Internal sources

Brazilian Cochrane Centre, Brazil.

External sources

No sources of support supplied, Other.

Declarations of interest

Ana Luiza C Martimbianco: none known
Maria R Torloni: none known
Brenda NG Andriolo: none known
Gustavo Porfirio: none known
Rachel Riera: none known

Acknowledgements

We thank Lindsey Elstub and Laura MacDonald for their assistance in the preparation of this review, Joanne Elliott for her advice on developing the search strategies, and the Brazilian Cochrane Centre team for their methodological support. We also thank Helen Handoll, Zipporah Iheozor‐ejiofor, Catherine Sherrington, Toby Smith, and Martin Underwood for their feedback and suggestions on the protocol and review.

This project was supported by the National Institute for Health Research (NIHR) via Cochrane Infrastructure funding to the Cochrane Bone, Joint and Muscle Trauma Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service (NHS), or the Department of Health.

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Published

Title

Stage

Authors

Version

2017 Dec 12

Neuromuscular electrical stimulation (NMES) for patellofemoral pain syndrome

Review

Ana Luiza C Martimbianco, Maria Regina Torloni, Brenda NG Andriolo, Gustavo JM Porfírio, Rachel Riera

https://doi.org/10.1002/14651858.CD011289.pub2

2014 Sep 02

Neuromuscular electrical stimulation (NMES) for patellofemoral pain syndrome

Protocol

Ana Luiza C Martimbianco, Maria R Torloni, Brenda NG Andriolo, Gustavo Porfirio, Rachel Riera

https://doi.org/10.1002/14651858.CD011289

Differences between protocol and review

Consistent with the International Patellofemoral Pain consensus statements published in 2014, we replaced the terminology 'patellofemoral pain syndrome' with 'patellofemoral pain' in the written text.

As noted by the external referee, PFP is a multifactorial condition, and people with PFP can take several months of treatment to gain sustained improvement in outcomes. We therefore adjusted the 'Timing of outcome measurement' section from: at the end of the treatment, up to three months after treatment (short term), and over three months after treatment (long term) to: up to three months (short term), three to up to 12 months (medium term), and 12 months or above (long term). We adjusted the start point for follow‐up to the start of treatment (postrandomisation) and note that the timing of the short‐term follow‐up usually coincided with the end of treatment.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adult; Female; Humans; Male;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Analysis 1.1

Comparison 1 NMES versus placebo (sham device), Outcome 1 Knee pain during activities (end of the treatment, single 15‐minute NMES session): VAS scale: 0 to 10; higher score = worse pain.

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Analysis 2.1

Comparison 2 NMES (+ other intervention) versus no NMES (+ same other intervention), Outcome 1 Knee pain (end of the treatment, 3 to 12 weeks): VAS scale: 0 to 10; higher score = worse pain.

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Analysis 2.2

Comparison 2 NMES (+ other intervention) versus no NMES (+ same other intervention), Outcome 2 Knee pain during activities (end of the treatment, 6 weeks): VAS scale: 0 to 10; higher score = worse pain.

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Analysis 2.3

Comparison 2 NMES (+ other intervention) versus no NMES (+ same other intervention), Outcome 3 Knee function (end of the treatment, 3 and 6 weeks): Cincinnati Knee Rating System and LEFS; higher score = better function.

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Analysis 2.4

Comparison 2 NMES (+ other intervention) versus no NMES (+ same other intervention), Outcome 4 Change score for KPS (end of treatment, 12 weeks) (0 to 100; higher score = better function).

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Analysis 2.5

Comparison 2 NMES (+ other intervention) versus no NMES (+ same other intervention), Outcome 5 Good or normal muscle strength (end of the treatment, 6 weeks): grades 4 to 5 Lovett’s manual muscle scale.

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Analysis 2.6

Comparison 2 NMES (+ other intervention) versus no NMES (+ same other intervention), Outcome 6 Muscle strength (end of the treatment, 12 weeks): isokinetic dynamometer (N).

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Analysis 3.1

Comparison 3 NMES versus exercise, Outcome 1 Knee function (end of the treatment, 4 weeks): Arpège function scale: 0 to 18; higher score = better function.

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Analysis 3.2

Comparison 3 NMES versus exercise, Outcome 2 Muscle strength (end of the treatment, 4 weeks): isokinetic dynamometer (Nm).

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Analysis 4.1

Comparison 4 NMES (simultaneous frequencies) versus control NMES (sequential or fixed frequencies), Outcome 1 Knee pain (end of the treatment, 6 weeks): VAS scale: 0 to 10; higher score = worse pain.

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Analysis 4.2

Comparison 4 NMES (simultaneous frequencies) versus control NMES (sequential or fixed frequencies), Outcome 2 Knee function (end of the treatment, 6 weeks): KPS: 0 to 100 scale; higher score = better function.

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Analysis 4.3

Comparison 4 NMES (simultaneous frequencies) versus control NMES (sequential or fixed frequencies), Outcome 3 Functional performance (end of the treatment, 6 weeks): number of steps up and down until pain.

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Analysis 4.4

Comparison 4 NMES (simultaneous frequencies) versus control NMES (sequential or fixed frequencies), Outcome 4 Quadriceps isometric muscle strength (end of the treatment, 6 weeks): dynamometer at 90°/s (Nm).

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Analysis 4.5

Comparison 4 NMES (simultaneous frequencies) versus control NMES (sequential or fixed frequencies), Outcome 5 Quadriceps isokinetic muscle strength (end of the treatment, 6 weeks): dynamometer at 90°/s (Nm).

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Summary of findings for the main comparison. Neuromuscular electrical stimulation + other intervention (e.g. exercise) versus same other intervention only for patellofemoral pain syndrome

Neuromuscular electrical stimulation (NMES) plus other intervention (e.g. exercise) versus no NMES plus same other intervention for patellofemoral pain syndrome
Patient or population: people with patellofemoral pain syndrome¹ Settings: outpatient rehabilitation and home‐based therapy Intervention: NMES² plus other active intervention (e.g. exercise)³ Comparison: no NMES control plus same other active intervention
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	No NMES plus same other intervention	NMES plus other intervention (e.g. exercise)
Knee pain (short term) VAS scale: 0 to 10; higher score = worse pain. Follow‐up: 3 to 12 weeks (all were at the end of the treatment programme²)	The mean knee pain ranged across control groups from 2.36 to 2.70 points.	The mean knee pain in the intervention groups was 1.63 lower (2.23 to 1.02 lower).	MD ‐1.63 (‐2.23 to ‐1.02)	118 (3 studies)	⊕⊝⊝⊝ very low⁴	This difference may not be clinically important since the MCID for VAS (1.5 to 2.0, out of 10 points)⁵ lies within the 95% CI.
Knee pain (long term) VAS scale: 0 to 10; higher score = worse pain. Follow‐up: 1 year	The median pain score in the study control group was 0.4 points (IQR 0.2 to 3.4).	The median pain score in the NMES group was 1.8 points (IQR 0.1 to 3.6).	See comment	29 (1 study)	⊕⊝⊝⊝ very low⁶	The difference was reported as not statistically significant.
Knee function (short term) 2 tools used: Cincinnati Knee Rating System (6 to 100; higher scores = better function) and Lower Extremity Functional Scale (LEFS) scale (0 to 80; higher scores = better function). Follow‐up: 3 to 6 weeks (at the end of the treatment programme)	The mean knee function in the study control groups was 72.4 (LEFS scale) and 83.3 (Cincinnati score).	The mean difference in knee function in the intervention groups was 0.37 SDs higher (0.11 lower to 0.84 higher).	SMD 0.37 (‐0.11 to 0.84)	70 (2 studies)	⊕⊝⊝⊝ very low⁷	0.2 SD represents a small difference, 0.5 SD a moderate difference, and 0.8 SD a large difference. However, the mean differences in the 2 trials were small and unlikely to be clinically important (LEFS scale: MD 0.73; Cincinnati score: MD 4.65).
Knee function (long term) Kujala Patellofemoral Score (KPS) (0 to 100; higher score = better function). Follow‐up: 1 year	The median KPS in the study control group was 95 (IQR 85 to 96).	The median KPS in the NMES group was 94 (IQR 88 to 96).	See comment	29 (1 study)	⊕⊝⊝⊝ very low⁶	The very small difference was reported as not statistically significant.
Adverse events ‐ not measured	See comment	See comment	Not estimable	‐	See comment	Not measured
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; IQR: interquartile range; MCID: minimal clinically important difference; MD: mean difference; SD: standard deviation; SMD: standardised mean difference; VAS: visual analogue scale
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Where reported, there was a higher percentage of females (63% to 100%). The mean ages of the participants in the four trials ranged from 25 to 39 years. There was a wide duration of symptoms, with the minimum duration of symptoms for trial inclusion ranging from one to six months. ²The format of the NMES varied among the four trials. Sessions of NMES lasted between 10 to 20 minutes, applied 2 to 5 times a week, for between 3 and 12 weeks. ³The co‐intervention in all four trials was exercise. Patellar taping was also applied to all participants in two trials, and ice was applied in one trial. ⁴We downgraded the evidence two levels due to very serious risk of bias (performance bias), one level for imprecision reflecting small sample size, and one level for indirectness (time point of pain assessment was very far from the end of the intervention). ⁵The minimal clinically important difference for visual analogue scale usual pain was set at 1.5 to 2.0 (out of 10) points (Crossley et al. Archives of Physical Medicine and Rehabilitation 2004;85(5):815‐22). ⁶We downgraded the evidence two levels due to very serious risk of bias (performance, detection, and attrition biases) and two levels for imprecision reflecting single‐trial data and small sample size. ⁷We downgraded the evidence two levels due to very serious risk of bias (performance bias) and one level for imprecision reflecting small sample size.

Summary of findings for the main comparison. Neuromuscular electrical stimulation + other intervention (e.g. exercise) versus same other intervention only for patellofemoral pain syndrome

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Summary of findings 2. Neuromuscular electrical stimulation versus exercise for patellofemoral pain syndrome

Neuromuscular electrical stimulation (NMES) versus exercise for patellofemoral pain syndrome
Patient or population: people with patellofemoral pain syndrome Settings: at home Intervention: NMES (2‐hour session, twice a day, every day for 4 weeks)¹ Comparison: exercise (either isokinetic or isometric; data combined in the analyses)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Exercise	NMES
Knee pain (short term: < 3 months)	See comment	See comment	Not estimable	‐	See comment	Not estimable
Knee pain (longer term: > 3 months)	See comment	See comment	Not estimable	‐	See comment	Not estimable
Knee function (short term) Arpège function scale (0 to 18; higher score = better function). Follow‐up: 4 weeks (at end of treatment)	The mean knee function in the study control group was 15.34 points.	The mean knee function in the intervention groups was 0.94 lower (2.1 lower to 0.22 higher).	MD ‐0.94 (‐2.10 to 0.22)	94 (1 study)	⊕⊝⊝⊝ very low²
Knee function (longer term: > 3 months)	See comment	See comment	Not estimable	‐	See comment	Not estimable
Adverse events	See comment	See comment	Not estimable	‐	See comment	Not measured
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; MD: mean difference
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹This very demanding schedule is unlikely to be found in clinical practice. ²We downgraded the evidence two levels for very serious risk of bias (including high risk of performance bias and attrition bias), one level for imprecision (low numbers and wide 95% confidence interval), and one level for indirectness (the scheme used for NMES (during 4 hours/day) does not correspond to that used in clinical practice).

Summary of findings 2. Neuromuscular electrical stimulation versus exercise for patellofemoral pain syndrome

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Comparison 1. NMES versus placebo (sham device)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knee pain during activities (end of the treatment, single 15‐minute NMES session): VAS scale: 0 to 10; higher score = worse pain Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1 Pain during a single‐leg squat	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Pain during a lateral step‐down	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. NMES versus placebo (sham device)

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Comparison 2. NMES (+ other intervention) versus no NMES (+ same other intervention)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knee pain (end of the treatment, 3 to 12 weeks): VAS scale: 0 to 10; higher score = worse pain Show forest plot	3	118	Mean Difference (IV, Fixed, 95% CI)	‐1.63 [‐2.23, ‐1.02]

2 Knee pain during activities (end of the treatment, 6 weeks): VAS scale: 0 to 10; higher score = worse pain Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 Pain during step‐down	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Pain during step‐up	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Pain during squat	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Knee function (end of the treatment, 3 and 6 weeks): Cincinnati Knee Rating System and LEFS; higher score = better function Show forest plot	2	70	Std. Mean Difference (IV, Fixed, 95% CI)	0.37 [‐0.11, 0.84]

4 Change score for KPS (end of treatment, 12 weeks) (0 to 100; higher score = better function) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Good or normal muscle strength (end of the treatment, 6 weeks): grades 4 to 5 Lovett’s manual muscle scale Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 Muscle strength (end of the treatment, 12 weeks): isokinetic dynamometer (N) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 Isometric strength with 30° knee flexion	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Isometric strength with 60° knee flexion	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. NMES (+ other intervention) versus no NMES (+ same other intervention)

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Comparison 3. NMES versus exercise

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knee function (end of the treatment, 4 weeks): Arpège function scale: 0 to 18; higher score = better function Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Muscle strength (end of the treatment, 4 weeks): isokinetic dynamometer (Nm) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 Isokinetic dynamometer at 30°/s	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Isokinetic dynamometer at 300°/s	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. NMES versus exercise

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Comparison 4. NMES (simultaneous frequencies) versus control NMES (sequential or fixed frequencies)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knee pain (end of the treatment, 6 weeks): VAS scale: 0 to 10; higher score = worse pain Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1 Simultaneous versus sequential delivery	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Knee function (end of the treatment, 6 weeks): KPS: 0 to 100 scale; higher score = better function Show forest plot	2	88	Mean Difference (IV, Fixed, 95% CI)	‐1.16 [‐6.79, 4.47]

2.1 Simultaneous versus sequential delivery	1	14	Mean Difference (IV, Fixed, 95% CI)	‐5.90 [‐16.14, 4.34]
2.2 Simultaneous versus fixed delivery	1	74	Mean Difference (IV, Fixed, 95% CI)	0.90 [‐5.84, 7.64]
3 Functional performance (end of the treatment, 6 weeks): number of steps up and down until pain Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 Simultaneous versus sequential delivery	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Quadriceps isometric muscle strength (end of the treatment, 6 weeks): dynamometer at 90°/s (Nm) Show forest plot	2	88	Mean Difference (IV, Fixed, 95% CI)	‐1.15 [‐16.24, 13.94]

4.1 Simultaneous versus sequential delivery	1	14	Mean Difference (IV, Fixed, 95% CI)	3.40 [‐25.83, 32.63]
4.2 Simultaneous versus fixed delivery	1	74	Mean Difference (IV, Fixed, 95% CI)	‐2.80 [‐20.42, 14.82]
5 Quadriceps isokinetic muscle strength (end of the treatment, 6 weeks): dynamometer at 90°/s (Nm) Show forest plot	2	88	Mean Difference (IV, Fixed, 95% CI)	‐7.28 [‐24.45, 9.89]

5.1 Simultaneous versus sequential delivery	1	14	Mean Difference (IV, Fixed, 95% CI)	6.10 [‐30.70, 42.90]
5.2 Simultaneous versus fixed delivery	1	74	Mean Difference (IV, Fixed, 95% CI)	‐11.0 [‐30.41, 8.41]

Comparison 4. NMES (simultaneous frequencies) versus control NMES (sequential or fixed frequencies)

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Estimulación eléctrica neuromuscular (EENM) para el síndrome de dolor patelofemoral

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