Effects of Electrical Muscle Stimulation in Subjects Undergoing

Prolonged Mechanical Ventilation

Yen-Huey Chen, Hsiu-Feng Hsiao, Li-Fu Li, Ning-Hung Chen, and Chung-Chi Huang

BACKGROUND: Muscle atrophy and deconditioning are common complications in patients on

prolonged mechanical ventilation (PMV). There are few studies that reviewed the effects of elec-
trical muscle stimulation in this population. The purpose of this study was to examine the effects of
electrical muscle stimulation on muscle function and hospitalization outcomes in subjects with
PMV. METHODS: Subjects on mechanical ventilation for >21 d were randomly assigned to the
electrical muscle stimulation group (n ⴝ 16) or the control group (n ⴝ 17). The electrical muscle
stimulation group received daily muscle electrical stimulation for 30 min/session for 10 d. The
measurement of muscle strength (by medical research council [MRC] scale), leg circumference, and
physical functional status (by Functional Independence Measure [FIM] scores) were performed
before and after completion of the study. The length of stay in respiratory care center of subjects
were recorded. RESULTS: After electrical muscle stimulation, there was no difference in pulmo-
nary function between the electrical muscle stimulation and control groups. Significantly increased
in MRC points was found in the electrical muscle stimulation group after intervention (2 [1-7]
points vs 2 [1-3.5] points, respectively, P ⴝ .034). No difference in MRC points was found between
baseline and post-measurement in the control group (1[1-2] points vs 1[1-2.5] points, respectively,
P > .99). At the end of the study, leg circumference in control group significantly decreased when
compared with baseline (47.5 ⴞ 8.3 cm vs 44.6 ⴞ 5.7 cm, respectively, P ⴝ .004) and remained
unchanged in the EMS group. However, no significant differences were found between the electrical
muscle stimulation and control groups. There was no difference in physical functional status and
hospital stay between the electrical muscle stimulation and control groups. CONCLUSIONS: Elec-
trical muscle stimulation enhanced muscle strength in subjects who received PMV. Electrical
muscle stimulation can be considered a preventive strategy for muscle weakness in patients who
receive PMV. (ClinicalTrials.gov registration NCT02227810.) Key words: electrical stimulation; mus-
cle weakness; critical illness; hospitalization outcomes; mechanical ventilation; physical function. [Respir
Care 2019;64(3):262–271. © 2019 Daedalus Enterprises]

Introduction acute illness, some may experience weaning difficulties

and require prolonged mechanical ventilation (PMV). Pa-
Invasive ventilation is a necessary treatment for patients tients who require PMV are often transferred to subacute
with respiratory failure in ICUs. As patients recover from

This study was supported by Chang Gung Memorial Hospital

Mr YH Chen and Dr Huang are affiliated with the Department of Re- (CMRPD1C0331).
spiratory Therapy, College of Medicine, Chang Gung University, Taoyuan,
Taiwan. Mr YH Chen, Dr Li, Dr NH Chen, and Dr Huang are affiliated The authors have disclosed no conflicts of interest.
with the Department of Pulmonary and Critical Care Medicine, Chang
Gung Memorial Hospital, Taoyuan, Taiwan. Mr YH Chen is affiliated Correspondence: Chung-Chi Huang MD, Department of Respiratory Care,
with the Department of Respiratory Care, Chang Gung University of College of Medicine, Chang Gung University, 259 Wen-Hwa 1st Rd, Gweis-
Science and Technology, Taiwan. Ms Hsiu-Feng Hsiao and Dr Huang are han, Taoyuan City, Taiwan 33302. E-mail: cch4848@adm.cgmh.org.tw.
affiliated with the Department of Respiratory Therapy, Chang Gung Me-
morial Hospital, Taoyuan, Taiwan. DOI: 10.4187/respcare.05921

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 ELECTRICAL MUSCLE STIMULATION IN PMV

care units, such as respiratory care centers, for continued

care and further weaning. According to the National As- QUICK LOOK
sociation for Medical Direction of Respiratory Care in the Current knowledge
United States, it is estimated that, by 2020, there will be
As the population of prolonged mechanical ventilation
600,000 cases per year of PMV in the United States, de-
(PMV) increases with decreased ICU mortality, there
fined as at least 6 h of mechanical ventilation per day for
will be a growing number of survivors at risk of de-
⬎21 consecutive days,1 at a cost of approximately $50
conditioning and muscle wasting. Comprehensive pul-
billion.2 Improving the weaning rate and hospitalization
monary rehabilitation plays an important role in im-
outcomes for patients who receive PMV has become in-
proving patients’ muscle strength and functional
creasingly important.3
independence. However, patients with PMV are often
Various complications can occur during PMV and af-
too fragile to collaborate in active exercise or muscle
fect patient outcomes. Scheinhorn et al4 reported that 98.7%
training.
of subjects were bedridden on admission to weaning cen-
ters and that 69% of subjects were still bedridden on dis- What this paper contributes to our knowledge
charge. Even 12 months after discharge, only 19% of sub-
jects who received PMV were fully active during daily This study showed that the subjects who received PMV
life.4 Prolonged bed rest can reduce knee extensor strength had significant reductions in leg circumference after
by approximately 0.6% per day and muscle mass by 0.4% 2 weeks of hospitalization. A 2-week daily electrical
per day.5 Individuals who receive PMV are commonly muscle stimulation program resulted in the prevention
immobilized and experience complications, including mus- of muscle atrophy and an increase of muscle strength in
cle wasting, pneumonia, atelectasis, and deconditioning. the subjects with PMV. The results were comparable
Muscle weakness and general deconditioning were reported with those of subjects in the ICU.
to be associated with poor hospitalization outcomes, such
as increased service use, longer hospital length of stay, and
higher mortality rates.6 Moreover, skeletal muscle dys-
function is a major source of exercise intolerance and im- muscle through the circulation system.12 However, the ef-
paired capability to perform activities of daily living. Mus- fects of electrical muscle stimulation on the PMV popu-
cle-strengthening interventions can break this negative lation remain unclear. Our primary aim was to evaluate the
cycle and improve patients’ prognosis. potential effects of electrical muscle stimulation on muscle
There is compelling evidence that pulmonary rehabili- function and physical function in subjects with PMV. We
tation can improve functional capacity and daily indepen- also evaluated the effects of electrical muscle stimulation
dence in patients with chronic pulmonary dysfunction.7 on secondary measures of hospitalization outcomes.
Muscle-strengthening exercises, a component of pulmo-
nary rehabilitation programs, can help patients translate Methods
gains in muscle strength into physical capacity. The en-
hancement in muscle strength was associated with im- This prospective study was performed in a 24-bed re-
provement of hospitalization outcomes by shortening the spiratory care center at Chang Gung Memorial Hospital,
number of days from bed to chair and by reducing the risks Taiwan. Patients in the respiratory care center receive med-
of complications that arise from long-term confinement to ical care related to treatment of their primary disease, un-
the bed.8 However, patients who receive PMV may be too derlying causes of respiratory failure, ventilator support,
fragile to initiate exercise, given their severely impaired ventilator weaning, and pulmonary rehabilitation. Inclu-
cardiopulmonary function and muscle weakness. Conse- sion criteria for this study were as follows: (1) age ⭌ 20 y;
quently, there is growing interest in the use of nonvoli- (2) mechanical ventilation for ⬎ 6 h/d for ⬎ 21 d; (3)
tional assistive technologies that facilitate early exercise, failure to be weaned in the ICU; and (4) medical stability
for example, electrical muscle stimulation. (arterial blood gas pH ⫽ 7.35–7.45, PaO2 ⭌ 60 mm Hg at
Electrical muscle stimulation involves applying a series 40% FIO2, absence of signs and symptoms of infection, and
of stimuli to skeletal muscle, primarily to trigger muscle hemodynamic stability). Exclusion criteria were cancer,
contraction,9 and it can be used for the recovery of muscle acute lung or systemic infection, hemodynamic instability,
mass and muscle strength after prolonged immobilization.10 previous or ongoing neuromuscular disease (eg, myasthe-
Electrical muscle stimulation may also improve circula- nia gravis, Guillain–Barré disease), or conditions that could
tion and exercise capacity in both chronic heart failure and interfere with evaluation of strength, skin lesions, or obe-
COPD populations.11 Electrical muscle stimulation is re- sity (body mass index of ⬎35 kg/m2). The study was
ported to enhance growth factors of localized muscle, and approved by the hospital’s institutional review board and
this may also act as an anabolic stimulus to the respiratory registered with clinicaltrials.gov (NCT02227810). The

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 ELECTRICAL MUSCLE STIMULATION IN PMV

study was performed in accordance with the Declaration Table 1. Medical Research Council Scale Score
of Helsinki. Written informed consent was obtained from
Point Description
the subjects or their relatives before inclusion.
0 No muscular contraction detected
Electrical Muscle Stimulation Intervention 1 Barely detectable flicker or trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
The electrical muscle stimulation intervention involved 4 Active movement against gravity and some resistance
two 30-min electrical muscle stimulation sessions per day, 5 Active movement against gravity and full resistance
5 d/wk for 2 wk. During each session, rectangular elec-
trodes were placed on motor points of the vastus lateralis
and rectus femoris of both legs. Electrical muscle stimu-
lation was performed by using a commercial stimulator Primary Outcomes Measurement
(Omnistm 500, ZMI, Taipei, Taiwan) with biphasic waves
at a simulation frequency of 50 Hz and pulse width of Pulmonary Function Measurement. The subjects were
400 ␮s, cycling 2 s on and 4 s off. Electrical muscle required to maintain the semi-Fowler position during mea-
stimulation intensity was gradually increased until a visi- surement of weaning profiles. During measurement, sub-
ble muscle contraction was observed. The subjects in the jects’ endotracheal or tracheostomy tubes were temporar-
control group received similar electrode placement and ily disconnected from the ventilator and connected to a
intervention duration, except that the stimulator power was spirometer (Respiradyne II, Sherwood, St. Louis, Mis-
off. souri). Once the subjects were stable, the investigator
(HSF) activated the spirometer and measured minute
volume and breathing frequency. To measure the mouth’s
Study Procedure
maximum inspiratory pressure, the investigator con-
nected the endotracheal or tracheostomy tube with a T
This study followed a prospective and randomized de- tube and placed a manometer (Boehringer Ingelheim,
sign. Before subject recruitment, sequential sealed enve- Norristown, Pennsylvania) to one end of the T tube by
lopes were prepared by an independent investigator (CYH), using a nipple adapter and a 1-way valve. After the
with one chosen randomly by another investigator for each inspiratory port was manually occluded, the investigator
subject. The subjects were then assigned to an electrical coached the subject to inhale actively against the oc-
muscle stimulation group or a control group according to cluded airway during breathing cycles for 20 to 25 s; the
the label in the envelope. Age, sex, body weight, height, most negative value was recorded as the maximum in-
and diagnosis at respiratory care center admission were spiratory pressure.
recorded for each subject. Disease severity was assessed
within 24 h of respiratory care center admission by using Muscle Function Measurement. Muscle function was
the APACHE (Acute Physiology and Chronic Health Eval- assessed by skin-fold thickness, leg circumference, and
uation) II score. The subjects assigned to the electrical quadriceps muscle strength. To measure skin-fold thick-
muscle stimulation group received daily electrical muscle ness, the investigator pinched the skin at the middle of the
stimulation starting from the day after completion of base- bilateral thigh and pulled the skin fold away from the
line data collection. The subjects in the control group re- underlying muscle; therefore, only skin and fat tissue were
ceived similar medical treatment except for the electrical held. Lange calipers (Cambridge Scientific Industries,
muscle stimulation therapy. Cambridge, Maryland) were used to measure the skin-fold
thickness (in mm). Two measurements were recorded and
Primary and Secondary Outcomes averaged. Leg circumference was measured at the level of
the middle thigh. Quadriceps muscle strength, an indicator
Primary outcomes, which included pulmonary function, of knee extension, was assessed according to modified
muscle function, and physical function, were measured on procedures of manual muscle testing. In brief, the subjects
the day before the intervention (day 0) and the day after maintained a semi-Fowler position with the knee bent and
completion of the intervention (day 11). After completing were asked to perform a knee extension. The strength was
the intervention program, the subjects were followed up scored according to the Medical Research Council (MRC)
until they were discharged from the respiratory care cen- scoring system (Table 1).12 These scores are widely used
ter. Secondary outcomes were defined as the subject’s to evaluate ICU-acquired paresis.13,14
hospitalization outcomes, which included survival status,
weaning outcomes, duration of ventilation in the respira- Physical Functional Status Measurement. Physical
tory care center, and respiratory care center length of stay. functional status was assessed before and after the study

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 ELECTRICAL MUSCLE STIMULATION IN PMV

Assessed for eligibility

103

Excluded
66
Did not meet inclusion criteria: 43
Declined to participate: 23

Subjects enrolled
37

Electrical muscle stimulation Control

18 19

Discontinued intervention: 2 Lost to follow-up: 2

Analyzed Analyzed
16 17

Fig. 1. Flow chart.

period by using the Functional Independence Measure. pital mortality and 30 – 40% dropouts, the sample size was
The subjects were scored from totally dependent to com- increased to 19 subjects. Analysis was conducted by using
pletely independent, with lower scores representing greater SPSS v.17 (SPSS, Chicago, Illinois). The normality of
disability. The reliability and validity of these question- distribution was examined by using the Shapiro-Wilk test.
naires have been demonstrated.13 The results were expressed as the mean ⫾ SD for nom-
inal distributions, and as median and interquartile range
Secondary Outcomes Measurement (25th-75th percentiles) for nonparametric distributions.
Baseline characteristics, pre-intervention and post-inter-
Respiratory Care Center (RCC) Hospitalization Out- vention measurements, and continuous-variable hospital-
comes. RCC hospitalization outcomes were followed up ization outcomes of the electrical muscle stimulation group
until the subjects were discharged from the respiratory and the control group were compared by using an unpaired
care center to ward or home. Survival status, weaning Student t test or Mann–Whitney U test in case of nonpara-
outcomes, duration of ventilation in the respiratory care metric distribution. A paired t test or Wilcoxon signed-
center, and respiratory care center stay were recorded from rank test was used to examine intervention effects on pul-
the subjects’ medical records. Weaning off the mechanical monary function and muscle function within groups.
ventilator was considered successful if the subject was Pearson and Spearman correlation coefficients were used
continuously free of the mechanical ventilator for ⬎5 con- to examine the relationship between baseline variables and
secutive days. parametric or nonparametric distributions, respectively. A
chi-square test was used to analyze differences in the fre-
Statistical Analysis quency distributions of mechanical ventilator weaning and
survival rates between the groups. P ⬍ .05 indicated sta-
The main outcome was taken as quadriceps muscle power tistical significance.
measured in the subjects on the day after completion of
electrical muscle stimulation. The sample size was calcu- Results
lated according to a previous study,12 with assuming an
SD of ⫾1 and an ␣ error of .05, a sample size of 11 From August 2012 to July 2013, a total of 103 consec-
subjects would have 90% power to detect an increase of utive eligible patients were screened (Fig. 1). Sixty-six
1 MRC scale point on one of the stimulated muscles com- patients were excluded because they did not meet inclu-
pared with baseline. When allowing for 10 –20% in-hos- sion criteria (n ⫽ 43) or declined to participate (n ⫽ 23).

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Table 2. Baseline Characteristics of Study Participants

Variable Electrical Muscle Stimulation Group (n ⫽ 16) Control Group (n ⫽ 17) P

Age, mean ⫾ SD y 77.7 ⫾ 14.3 73.8 ⫾ 17.8 .49

Men/women, n 8/8 9/8 .64
APACHE score, mean ⫾ SD 20.8 ⫾ 7.4 20.3 ⫾ 6.3 .82
BMI, mean ⫾ SD kg/m2 22.9 ⫾ 5.6 23.1 ⫾ 3.9 .71
Body height, mean ⫾ SD cm 160.4 ⫾ 9.0 160.4 ⫾ 8.4 .84
Body weight, mean ⫾ SD kg 59.8 ⫾ 12.3 58.7 ⫾ 12.7 .81
Reasons for initiating mechanical ventilation, n (%) .70
Acute respiratory failure on chronic pulmonary diseases
COPD 5 (31.2) 3 (18.8)
Asthma 2 (12.5) 2 (12.5)
Chronic pulmonary diseases, non-COPD 3 (18.8) 4 (25.0)
Acute respiratory failure
Causes
Congestive heart failure 4 (25.0) 3 (18.8)
Postoperative respiratory failure 1 (6.3) 1 (6.3)
Sepsis ND 1 (6.3)
Burn ND 1 (6.3)
Others 1 (6.3) 2 (12.5)

APACHE ⫽ Acute Physiology and Chronic Health Evaluation

BMI ⫽ body mass index
ND ⫽ no data

Thus, 37 subjects were randomized into the electrical mus- Comparisons of Primary Outcomes Between the
cle stimulation group (n ⫽ 18) and the control group Electrical Muscle Stimulation and Control Groups
(n ⫽ 19). During the study period, 2 subjects in each group
had acute pulmonary infection and dropped out of the
In the measurements of pulmonary function, no signif-
study, which left 16 (electrical muscle stimulation group) icant difference existed in both pre-intervention and post-
and 17 (control group) for analysis. intervention measurements between the electrical muscle
stimulation and control groups (Table 3). In the measure-
Demographic Characteristics ments of muscle function, no significant differences in
skin-fold thickness or leg circumference were revealed
between the groups in pre-intervention and post-interven-
A summary of the demographic and clinical charac- tion measurements. The muscle strength was assessed by
teristics of the subjects is presented in Table 2. Prob- MRC scale. Subjects were scored from “0 point - no mus-
lems at admission to the respiratory care center were cular contraction”, “1 point -Barely detectable trace of
mostly diseases that involved the respiratory system. No contraction”, “2 points -active movement with elimination
significant differences existed between the electrical of gravity”, “3 points -active movement against gravity”,
muscle stimulation and control groups in terms of age “4 points - active movement against gravity and some
(mean ⫾ SD, 77.7 ⫾ 14.3 vs 73.8 ⫾ 17.8 years, re- resistance”, “5 points -active movement against gravity
spectively, P ⫽ .49), BMI (mean ⫾ SD, 22.9 ⫾ 5.6 vs and full resistance”.12 The MRC points of right quadri-
23.1 ⫾ 3.9 kg/m2, respectively, P ⫽ .71), severity ceps muscle in the electrical stimulation muscle group
(APACHE II score mean ⫾ SD, 20.8 ⫾ 7.4 vs 20.3 ⫾ 6.3, were significantly higher than those in the control group
respectively, P ⫽ .82), or diagnosis. In baseline mea- after the intervention (median [IQR], 2[1-4] points vs 1[1-2]
surements, muscle strength was significantly associated points, respectively, P ⫽ .024). The MRC points of left
with Functional Independence Measure scores (r ⫽ 0.79, quadriceps muscle in the electrical muscle stimulation
P ⫽ .001). The subjects who had higher muscle strength group increased by a median of 0.5 points (IQR, 0 –1
were associated with higher independence in daily ac- points) from the enrollment to the end of the program,
tivities. A significant inverse relationship also existed which were significantly higher than those in the control
between muscle strength and APACHE scores group (median [IQR], 0 [0-0] points) (P ⫽ .046) (Table 5).
(r ⫽ ⫺0.41, P ⫽ .031) at baseline. Physical functional status was assessed by using Func-

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 ELECTRICAL MUSCLE STIMULATION IN PMV

Table 3. Comparisons of Pulmonary Function in Electrical Muscle Table 4. Comparisons of Quadriceps Skin-Fold Thickness, Leg
Stimulation and Control Groups Circumference, and Quadriceps Muscle Power in the
Electrical Muscle Stimulation and Control Groups
Electrical
Muscle Electrical
Variable Control Group P Muscle Control
Stimulation Variable P
Group Stimulation Group
Group
VT , median (25th–75th Skin-fold thickness, median
percentiles) mL (25th–75th
Pre 190 (170–220) 205 (150–250) .84 percentiles) mm
Post 210 (170–245) 180 (170–215) .38 Right side
Pre 10.2 (6–13.3) 13 (7–20) .19
P .07 .69
Post 8 (5.5–14.3) 14 (7.5–24.3) .02
f, mean ⫾ SD breaths/min
P .31 .78
Pre 24.6 ⫾ 7.8 23.6 ⫾ 8.6 .90 Left side
Post 23.6 ⫾ 8.2 25.9 ⫾ 8.0 .50 Pre 10.5 (6.8–15.8) 13.0 (6–19) .30
P .86 .49 Post 10.0 (5.8–14) 14.5 (8.5–19.3) .03
Minute volume, P .034* .92
mean ⫾ SD L Leg circumference,
Pre 5.3 ⫾ 2.0 4.9 ⫾ 2.4 .63 mean ⫾ SD cm
Right side
Post 4.7 ⫾ 0.9 5.3 ⫾ 1.8 .38
Pre 39.8 ⫾ 5.6 46.0 ⫾ 6.9 .71
P .80 .80
Post 39.3 ⫾ 5.5 45.1 ⫾ 5.6 .051
RSBI, mean ⫾ SD P .51 .13
Pre 133.7 ⫾ 64.6 115.4 ⫾ 68.5 .45 Left side
Post 126.8 ⫾ 81.5 135.9 ⫾ 59.1 .77 Pre 39.7 ⫾ 5.6 47.5 ⫾ 8.3 .99
P .24 .35 Post 38.8 ⫾ 5.1 44.6 ⫾ 5.7 .47
PIamx, mean ⫾ SD cm H2O P .38 .004*
Pre 35.0 ⫾ 9.6 36.0 ⫾ 14.9 .58 Quadriceps muscle strength,
MRC scale median
Post 38.3 ⫾ 15.1 35.0 ⫾ 17.7 .77 (25th–75th
P .33 .35 percentiles) point
Right side
VT ⫽ tidal volume Pre 2 (1–3.5) 1 (1–2) .09
Pre ⫽ pre-intervention Post 2 (1–4) 1 (1–2) .02
Post ⫽ post-intervention
f ⫽ breathing frequency
P .08 .56
RSBI ⫽ rapid shallow breathing index Left side
PIamx ⫽ maximal inspiratory pressure Pre 2 (1–3.5) 1 (1–2) .068
Post 2 (1–4) 1 (1–2.5) .53
P .034* ⬎.99

Medical Research Council scale score points are 0 point- no muscular contraction; 1 point-
tional Independence Measure scores. No significant dif- Barely detectable trace of contraction; 2 points-active movement with elimination of gravity; 3
ferences were found in pre- or post-measurements of Func- points-active movement against gravity; 4 points-active movement against gravity and some
resistance; 5 points-active movement against gravity and full resistance.12
tional Independence Measure scores between the electrical Pre ⫽ pre-intervention
muscle stimulation and control groups. Post ⫽ post-intervention

Comparisons of Primary Outcomes Between Pre-

intervention and Post-intervention Measurements in The subjects in the electrical muscle stimulation group
Electrical Muscle Stimulation and Control groups demonstrated a higher left quadriceps MRC points after
the intervention when compared with those in their pre-
After electrical muscle stimulation, the subjects demon- intervention measurements (median [IQR], 2 [1-4] points)
strated an increase in tidal volume (from 190 [170-220] mL vs 2 [1-3.5] points, respectively, P ⫽ .034 (Table 4). No
to 210 [170-245] mL; P ⫽ .07) and maximum inspiratory significant difference in muscle strength between pre-in-
pressure (from 35.0 ⫾ 9.6 cm H2O to 38.3 ⫾ 15.1 cm H2O; tervention and post-intervention measurements was found
P ⫽ .33). However, the difference did not reach statistic in the control group. In the electrical muscle stimulation
significantly (P ⬎ .05). In the control group, tidal volume group, the left-side leg circumference remained similar,
decreased, from 205 (150-250) mL to 180 (170-215) mL from 39.7 ⫾ 5.6 cm to 38.8 ⫾ 5.1 cm (P ⫽ .38). The
(P ⫽ .69), and maximum inspiratory pressure decreased electrical muscle stimulation group also had a significantly
from 36.0 ⫾ 14.9 cm H2O to 35.0 ⫾ 17.7 cm H2O (P ⫽ .35). lower skinfold thickness of left quadriceps muscle after
The results regarding muscle function at the pre- and completion the program (median [IQR],10.5 [6.8 –15.8]
post-measurements in the 2 groups are listed in Table 4. mm vs 10.0 [5.8 –14] mm; P ⫽ .034). In the control group,

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 ELECTRICAL MUSCLE STIMULATION IN PMV

Table 5. Comparison of Changes of Muscle Function Between the ference in respiratory care center length of stay (median
Groups [IQR], 25 [18-49] d vs 24 [18-47] d; P ⫽ .74) and the
Electrical
duration of ventilation in the respiratory care center (me-
Variable Muscle Control Group P dian [IQR], 21.5[11-42.8] d vs 20 [12.5-43] d; P ⫽ .89)
Stimulation
Group between the electrical muscle stimulation and control
groups (Table 6).
Skin-fold thickness,
median
(IQR) mm
Right side ⫺0.75 (⫺3–1) ⫺0.5 (⫺1–2.5) .71 Discussion
Left side ⫺1 (⫺3–0.25) 0 (0–4.5) .34
Leg circumference,
median This study examined the effects of electrical stimulation
(IQR) cm
Right side ⫺1 (⫺2.25–1.5) ⫺0.5 (⫺3.6–2.25) .92
on the muscle function and hospitalization outcomes in the
Left side ⫺1 (⫺2.5–0.25) ⫺1.75 (⫺2.75–1.75) .66 subjects who received PMV. We discovered that the elec-
Quadriceps MRC trical muscle stimulation program improved muscle func-
scale, median
(IQR) point tion in the subjects who received PMV by increasing mus-
Right side 0 (0–1) 0 (0–0) .033 cle strength, but no significant improvement was revealed
Left side 0.5 (0–1) 0 (0–0) .046 in pulmonary function or hospitalization outcomes. The
subjects in the control group had significant reductions in
leg circumference (from 47.5 cm to 44.6 cm, P ⫽ .004).
This indicated that the subjects who received PMV were at
Table 6. Comparison of Hospitalization Outcomes Between the risk of muscle atrophy. Prolonged bed rest leads to de-
Groups creased muscle protein synthesis, increased muscle catab-
olism, and decreased muscle mass, particularly in the lower
Electrical extremities,15,16 and interactions among critical illness, in-
Muscle Control
Variable
Stimulation Group
P vasive ventilation, and immobility may lead to further mus-
Group cle function impairment.
Weaning rate, n/N (%) 9/16 (56.3) 8/17 (47.0) .72
The majority of the subjects in the present study were
Mortality, n/N (%) 3/16 (18.8) 2/17 (11.8) .67 diagnosed with pneumonia, often associated with elevated
Length of stay in RCC, 25 (18–49) 24 (18–47) .74 inflammatory mediators, cytokines, an abnormal metabolic
median (IQR) d state, and increased oxidative stress. These factors induce
Ventilator days in RCC, 21.5 (11–42.8) 20 (12.5–43) .89 changes in microvascular permeability, and increased glu-
median (IQR) d cose uptake and subsequent reactive oxygen species gen-
RCC ⫽ respiratory care center
eration may result in decreased oxygen and nutrient de-
livery to muscles, protein catabolism upregulation, and
muscle-fiber structure alteration.17,18 In our study, the sub-
jects in the electrical muscle stimulation group demon-
the left leg circumference decreased, from 47.5 ⫾ 8.3 cm strated a significant increase in muscle strength, whereas
to 44.6 ⫾ 5.7 cm (P ⫽ .004). No change was found in no change was found in the control group. In addition, the
skin-fold thickness in the subjects in the control group subjects had a reduction in skin-fold thickness without
(from 13.0 [6-19] to 14.5 [8.5-19.3] cm; P ⫽ .92). In the changes in leg circumference after receiving electrical mus-
measurement of physical function, the Functional Inde- cle stimulation.
pendence Measure scores increased, from 29.0 ⫾ 14.5 to Electrical muscle stimulation creates passive (nonvoli-
32.0 ⫾ 18.6 (P ⫽ .12) in the electrical muscle stimulation tional) contraction of skeletal muscles through the use of
group. In the control group, the Functional Independence low-voltage electrical impulses delivered by using surface
Measure scores decreased, from 25.6 ⫾ 7.9 to 25.2 ⫾ 14.5 electrodes through the skin to the underlying muscles,19
(P ⫽ .65). which may enhance muscle-fiber recruitment and reduce
atrophy due to immobility or critical illness.20 Previous
Comparisons of Secondary Outcomes Between studies reported that the application of high-frequency neu-
the Groups romuscular electrical stimulation caused muscle contrac-
tion and resulted in an increase in the size and cross-
For weaning outcomes, neither the weaning rate (56.3% sectional area of muscle fibers in healthy individuals21 and
vs 47.0%, P ⫽ .72) nor the mortality rate (18.8% vs 11.8%, subjects in the ICU.22 Vieira et al23 also reported an in-
P ⫽ .67) was significantly different between the electrical crease in fat-free mass in subjects with COPD. Our study
muscle stimulation and control groups. There was no dif- findings were consistent with previous findings,20 –22 which

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 ELECTRICAL MUSCLE STIMULATION IN PMV

indicated the potential role of electrical muscle stimulation found in the control group. In addition, leg circumference
in improving muscle function in PMV populations. was significantly decreased in the control group, whereas
Studies reported that exercise training can increase pe- no changes in leg circumference were found in the elec-
ripheral muscle function and exercise tolerance, thereby trical muscle stimulation group. The above-mentioned data
improving physical function.7,8,24 electrical muscle stimu- indicated that the application of electrical muscle stimu-
lation can, not only improve muscle function, but also lation prevents the progression of muscle dysfunction in
provide systemic effects that are similar to exercise. Gero- patients with PMV. However, no significant difference
vasili et al25 reported that electrical muscle stimulation in was found in hospitalization outcomes.
subjects who are critically ill induced an acute systemic This study had several limitations. First, because muscle
effect on microcirculation, and Perez et al26 demonstrated strength was the primary outcome in this study, the sample
that electrical muscle stimulation in healthy individuals size was calculated based on detecting a difference in
improved oxygen-uptake kinetics and work efficiency. Cen- the MRC scale score. However, this sample size may have
tral command and activation of the metaboreflex during been insufficient to reveal a between-group difference in
electrical muscle stimulation may even increase sympa- other outcomes, for example, hospitalization. In addition,
thetic discharge and contribute to changes in heart rate, we did observe a slight but significant reduction in the
systolic blood pressure, blood volume, and cardiac output, limb circumference of the control group, which may indi-
which thereby affect skeletal muscle metabolism in a sys- cate that subjects with PMV had a high risk of muscle
temic manner that may include respiratory muscles. How- atrophy. Future studies with larger sample sizes are re-
ever, in the present study, no significant differences in quired to confirm this finding and the effects of electrical
physical function were found between the groups. The stimulation on hospitalization outcomes. Second, the tim-
primary reason for this discrepancy may relate to differ- ing and total duration of our study may have been con-
ences in subject characteristics and electrical muscle stim- founding factors that attenuated the results. In a previous
ulation protocol. In a previous study, subjects with mod- study of subjects in the ICU, electrical muscle stimulation
erate-to-severe COPD but capable of ambulation sessions were initiated early (on the second day of admis-
demonstrated significant improvements in muscle strength sion) to prevent possible complications associated with
and 6-min walking test distance after a 6-wk home-based being bedridden and were continued until the subjects were
electrical muscle stimulation program.27 In this study, the discharged from the ICU.23
subjects who received PMV who had been bedridden for However, to ensure subject safety in our study and elec-
⬎21 d demonstrated more-severe impairment in pulmo- trical muscle stimulation session consistency, we began
nary muscle function than subjects in previous studies. electrical muscle stimulation when the subjects were he-
Electrical muscle stimulation duration, which was shorter modynamically stable, and it was performed for only 10 d.
in our study than reported elsewhere, may also have a role The delay may have predisposed the subjects to a higher
in determining its effects. Our 2-wk electrical muscle stim- risk of deconditioning and muscle wasting; therefore, they
ulation session may have been too short to induce suffi- may have required longer interventions to produce signif-
cient muscle strength to achieve significant improvement icant improvement. Also, we did not include any mecha-
in physical function. In a study that involved subjects with nistic evaluation of the effects of electrical muscle stimula-
COPD who were bedridden and received mechanical ven- tion, electrophysiologic measures of muscle function, or
tilation, 4 wk of electrical muscle stimulation resulted in histologic muscle evaluations, which might have produced
an increase in muscle strength and the capability to trans- more objective results.33 Although it has been widely used
fer from bed to chair.28 Whether a longer duration would for evaluating muscle strength, the MRC scale remains a
produce greater improvement in physical function requires subjective measure and has been questioned for its interob-
further study. server variability. However, in our study, muscle strength
Muscle strength and muscle mass have been reported to was assessed by a single-blinded observer, and potential in-
be negatively correlated with the stay in the hospital.29-31 terobserver variability was reduced by performing muscle
The greater the muscle strength that patients regain during strength comparisons among subjects. Nevertheless, from a
their hospitalization, the shorter the days they stay in the clinical perspective, the MRC scale is a convenient and use-
hospital.29-31 In our study, we also found that the subjects ful measure in an respiratory care center setting.
who had greater muscle strength were associated with To the best of our knowledge, this was the first study
greater independence in daily activities. The increase in that examined the effects of electrical muscle stimulation
MRC scale has been reported to be associated with changes on subjects who received PMV. Electrical muscle stimu-
of mortality rate.32 For each 1 unit increase in muscle lation is a simple, noninvasive method of muscle strength-
strength, there was a 5% relative decrease in the odds of ening that is well tolerated, without adverse effects, as
mortality.32 In our study, electrical muscle stimulation in- previously described. It produces effects similar to exer-
duced more improvement in the MRC scale score than that cise and does not require cooperation from patients. Elec-

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 ELECTRICAL MUSCLE STIMULATION IN PMV

trical muscle stimulation could be easily implemented in 6. Topp R, Ditmyer M, King K, Doherty K, Hornyak J III. The effect
patients who receive PMV without major interference to of bed rest and potential of prerehabilitation on patients in the in-
tensive care unit. AACN Clin Issues 2002;13(2):263-276.
the routine care in respiratory care centers and with no
7. Casaburi R, ZuWallack R. Pulmonary rehabilitation for management
apparent increase to staff work load. Because a previous of chronic obstructive pulmonary disease. N Engl J Med 2009;
study observed slight skin injury in some subjects,34 elec- 360(13):1329-1335.
trical muscle stimulation should be performed with care by 8. Nici L, Raskin J, Rochester CL, Bourbeau JC, Carlin BW, Casaburi
trained personnel. R, et al. Pulmonary rehabilitation: what we know and what we need
to know. J Cardiopulm Rehabil Prev 2009;29(3):141-151.
The strength of our study was that all the subjects re-
9. Maffiuletti NA. Physiological and methodological considerations for
ceived the same number of electrical muscle stimulation the use of neuromuscular electrical stimulation. Eur J Appl Physiol
sessions before primary outcome measurements; thus, in- 2010;110(2):223-234.
terference due to different electrical muscle stimulation 10. Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the
sessions could be ruled out. In other studies, subjects re- quadriceps femoris muscle and functional recovery after reconstruc-
ceived electrical muscle stimulation sessions until discharge tion of the anterior cruciate ligament. A prospective, randomized
clinical trial of electrical stimulation. J Bone Joint Surg Am 1995;
from the clinical setting; consequently, electrical muscle 77(8):1166-1173.
stimulation duration and time to primary outcome varied 11. Sillen MJH, Speksnijder CM, Eterman RA, Janssen PP, Wagers SS,
among subjects and may have affected the objectiveness Wouters EFM5, et al. Effects of neuromuscular electrical stimulation
of outcome comparisons.27,30 We further ensured objec- of muscles of ambulation in patients with chronic heart failure or
tiveness by using a control group and concealed treatment COPD: a systematic review of the English-language literature. Chest
2009;136(1):44-61.
allocation, and we blinded the caregivers.
12. Rodriguez PO, Setten M, Maskin LP, Bonelli I, Vidomlansky SR,
Attie S, et al. Muscle weakness in septic patients requiring mechan-
Conclusions ical ventilation: Protective effect of transcutaneous neuromuscular
electrical stimulation. J Crit Care 2012;27(3):319.e1-e8.
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ment, electrical muscle stimulation increased muscle strength G, Mittermaier C, et al. Reliability and validity of the medical research
council (MRC) scale and a modified scale for testing muscle strength in
in the subjects who received PMV, but it was ineffective in patients with radial palsy. J Rehabil Med 2008;40(8):665-671.
improving physical function and hospitalization outcomes. 14. Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the
Because our trial involved only 2 weeks of electrical muscle functional independence measurement and its performance among re-
stimulation sessions, the beneficial effects may have been habilitation inpatients. Arch Phys Med Rehabil 1993;74(5):531-536.
underestimated. electrical muscle stimulation was well toler- 15. Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ. Effect of
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ated and seemed to be promising as a preventive strategy for 2007;297(16):1772-1774.
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Nerve 2005;32(2):140-163.
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