Post-operative electrical muscle stimulation attenuates loss of muscle mass and function following major abdominal surgery in older adults: a split body randomised control trial

Edward J Hardy, Jacob Hatt, Brett Doleman, Thomas F Smart, Matthew Piasecki, Jonathan N Lund, Bethan E Phillips, Edward J Hardy, Jacob Hatt, Brett Doleman, Thomas F Smart, Matthew Piasecki, Jonathan N Lund, Bethan E Phillips

Abstract

Introduction: Significant losses of muscle mass and function occur after major abdominal surgery. Neuromuscular electrical stimulation (NMES) has been shown to reduce muscle atrophy in some patient groups, but evidence in post-operative patients is limited. This study assesses the efficacy of NMES for attenuating muscle atrophy and functional declines following major abdominal surgery in older adults.

Methods: Fifteen patients undergoing open colorectal resection completed a split body randomised control trial. Patients' lower limbs were randomised to control (CON) or NMES (STIM). The STIM limb underwent 15 minutes of quadriceps NMES twice daily on post-operative days (PODs) 1-4. Ultrasound measurements of Vastus Lateralis cross-sectional area (CSA) and muscle thickness (MT) were made preoperatively and on POD 5, as was dynamometry to determine knee extensor strength (KES). Change in CSA was the primary outcome. All outcomes were statistically analysed using linear mixed models.

Results: NMES significantly reduced the loss of CSA (-2.52 versus -9.16%, P < 0.001), MT (-2.76 versus -8.145, P = 0.001) and KES (-10.35 versus -19.69%, P = 0.03) compared to CON. No adverse events occurred, and patients reported that NMES caused minimal or no discomfort and felt that ~90-minutes of NMES daily would be tolerable.

Discussion: NMES reduces losses of muscle mass and function following major abdominal surgery, and as such, may be the promising tool for post-operative recovery. This is important in preventing long-term post-operative dependency, especially in the increasingly frail older patients undergoing major abdominal surgery. Further studies should establish the efficacy of bilateral NMES for improving patient-centred outcomes.

Keywords: atrophy; muscle; neuromuscular electrical stimulation; older people; recovery; surgery.

© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Figures

Figure 1
Figure 1
CONSORT diagram.
Figure 2
Figure 2
Percentage change in VL muscle CSA from baseline to POD5 with and without NMES. * = P < 0.05. MD 1.18 (95% CI: 0.75–1.61; P < 0.001).
Figure 3
Figure 3
Percentage change in VL MT from baseline to POD5 with and without NMES. * = P < 0.05. MD 0.12 (95% CI: 0.04–0.2; P = 0.001).
Figure 4
Figure 4
Percentage change in KES from baseline to POD5 with and without NMES. * = P < 0.05. MD 4.48 (95% CI: 0.00–8.97; P = 0.03).

References

    1. Farhan H, Moreno-Duarte I, Latronico N, Zafonte R, Eikermann M. Acquired muscle weakness in the surgical intensive care unit. Anesthesiology 2016; 124: 207–34.
    1. van Wijk L, van Duinhoven S, Liem MSL, Bouman DE, Viddeleer AR, Klaase JM. Risk factors for surgery-related muscle quantity and muscle quality loss and their impact on outcome. Eur J Med Res 2021; 26: 36. 10.1186/s40001-021-00507-9.
    1. Carli F. Physiologic considerations of Enhanced Recovery After Surgery (ERAS) programs: implications of the stress response. Can J Anaesth 2015; 62: 110–9.
    1. Aoyama T, Kawabe T, Hirohito F et al. Body composition analysis within 1 month after gastrectomy for gastric cancer. Gastric Cancer 2016; 19: 645–50.
    1. Vinge O, Edvardsen L, Jensen F, Jensen FG, Wernerman J, Kehlet H. Effect of transcutaneous electrical muscle stimulation on postoperative muscle mass and protein synthesis. Br J Surg 1996; 83: 360–3.
    1. Shimoda Y, Ogata T, Nagasawa S et al. The impact of muscle mass loss after esophagectomy for esophageal cancer on prognosis. J Clin Oncol 2019; 37: 107–7.
    1. Puthucheary ZA, Rawal J, McPhail M et al. Acute skeletal muscle wasting in critical illness. JAMA 2013; 310: 1591. 10.1001/jama.2013.278481.
    1. Kobayashi A, Kaido T, Hamaguchi Y et al. Impact of postoperative changes in sarcopenic factors on outcomes after hepatectomy for hepatocellular carcinoma. J Hepatobiliary Pancreat Sci 2016; 23: 57–64.
    1. National Bowel Cancer Audit . 2020. (14 October 2022, date last accessed).
    1. British Geriatrics Society . BGS Position Statement: Older Patients Undergoing Emergency Laparotomy. BGS Position Statements. 2020. (24 September 2021, date last accessed).
    1. Watters JM, Clancey SM, Moulton SB, Briere KM, Zhu JM. Impaired recovery of strength in older patients after major abdominal surgery. Ann Surg 1993; 218: 380. 10.1097/00000658-199309000-00017.
    1. Dronkers J, Witteman B, van Meeteren N. Surgery and functional mobility: doing the right thing at the right time. Tech Coloproctol 2016; 20: 339–41.
    1. Wall BT, Dirks ML, van Loon LJC. Skeletal muscle atrophy during short-term disuse: Implications for age-related sarcopenia. Ageing Res Rev 2013; 12: 898–906.
    1. Clark BC, Manini TM. Functional consequences of sarcopenia and dynapenia in the elderly. Curr Opin Clin Nutr Metab Care 2010; 13: 271–6.
    1. Deschenes MR. Effects of aging on muscle fibre type and size. Sport Med 2004; 34: 809–24.
    1. Wall BT, Dirks ML, Snijders T, Senden JMG, Dolmans J, van Loon LJC. Substantial skeletal muscle loss occurs during only 5 days of disuse. Acta Physiol 2014; 210: 600–11.
    1. Noro H, Yoshikawa M, Nomura M et al. Is laparoscopic colorectal surgery less invasive than classical open surgery? Quantitation of physical activity using an accelerometer to assess postoperative convalescence. Surg Endosc 2003; 17: 1269–73.
    1. Hussey JM, Yang T, Dowds J, O’Connor L, Reynolds JV, Guinan EM. Quantifying postoperative mobilisation following oesophagectomy. Physiotherapy 2019; 105: 126–33.
    1. Henriksen M, Jensen M, Hansen H, Jespersen T, Hessov I. Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery. Nutrition 2002; 18: 147–52.
    1. Fiore JF, Castelino T, Pecorelli N et al. Ensuring early mobilization within an enhanced recovery program for colorectal surgery. Ann Surg 2017; 266: 223–31.
    1. Low DE, Allum W, De Manzoni G et al. Guidelines for perioperative care in esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2019; 43: 299–330.
    1. Arentson-Lantz E, Galvan E, Wacher A, Fry CS, Paddon-Jones D. 2,000 steps/day does not fully protect skeletal muscle health in older adults during bed rest. J Aging Phys Act 2019; 27: 191–7.
    1. Dirks ML, Hansen D, Van Assche A, Dendale P, Van Loon LJC. Neuromuscular electrical stimulation prevents muscle wasting in critically ill comatose patients. Clin Sci (Lond) 2015; 128: 357–65.
    1. Strasser EM, Stättner S, Karner J et al. Neuromuscular electrical stimulation reduces skeletal muscle protein degradation and stimulates insulin-like growth factors in an age- and current-dependent manner: a randomized, controlled clinical trial in major abdominal surgical patients. Ann Surg 2009; 249: 738–43.
    1. Dirks ML, Wall BT, Snijders T, Ottenbros CLP, Verdijk LB, van Loon LJC. Neuromuscular electrical stimulation prevents muscle disuse atrophy during leg immobilization in humans. Acta Physiol 2014; 210: 628–41.
    1. Gibson JNA, Smith K, Rennie MJ. Prevention of disuse muscle atrophy by means of electrical stimulation: maintenance of protein synthesis. Lancet 1988; 332: 767–70.
    1. Erika Scremin AM, Kurta L, Gentili A et al. Increasing muscle mass in spinal cord injured persons with a functional electrical stimulation exercise program. Arch Phys Med Rehabil 1999; 80: 1531–6.
    1. Deley G, Kervio G, Verges B et al. Comparison of low-frequency electrical myostimulation and conventional aerobic exercise training in patients with chronic heart failure. Eur J Cardiovasc Prev Rehabil 2005; 12: 226–33.
    1. Dobsák P, Nováková M, Fiser B et al. Electrical stimulation of skeletal muscles. An alternative to aerobic exercise training in patients with chronic heart failure? Int Heart J 2006; 47: 441–53.
    1. Karavidas A, Arapi SM, Pyrgakis V, Adamopoulos S. Functional electrical stimulation of lower limbs in patients with chronic heart failure. Heart Fail Rev 2010; 15: 563–79.
    1. Sarto F, Spörri J, Fitze DP, Quinlan JI, Narici MV, Franchi MV. Implementing ultrasound imaging for the assessment of muscle and tendon properties in elite sports: practical aspects, methodological considerations and future directions. Sports Med 2021; 51: 1151–70.
    1. Bass JJ, Hardy EJO, Inns TB et al. Atrophy resistant vs. atrophy susceptible skeletal muscles: ‘aRaS’ as a novel experimental paradigm to study the mechanisms of human disuse atrophy. Front Physiol 2021; 12: 545. 10.3389/fphys.2021.653060.
    1. Burnfield J, Powers C. Normal and pathologic gait. In: Placzek J, Boyce D, eds. Orthopaedic Physical Therapy Secrets. Second St. Louis, MO: MOSBY ELSEVIER, 2006; 119–25. 10.1016/B978-156053708-3.50018-0.
    1. Silva PE, de Cássia MR, Livino-de-Carvalho K et al. Neuromuscular electrical stimulation in critically ill traumatic brain injury patients attenuates muscle atrophy, neurophysiological disorders, and weakness: a randomized controlled trial. J Intensive Care 2019; 7: 59. 10.1186/s40560-019-0417-x.
    1. Liu M, Luo J, Zhou J, Zhu X. Intervention effect of neuromuscular electrical stimulation on ICU acquired weakness: a meta-analysis. Int J Nurs Sci 2020; 7: 228–37.
    1. Sumin AN, Oleinik PA, Bezdenezhnykh AV, Ivanova AV. Neuromuscular electrical stimulation in early rehabilitation of patients with postoperative complications after cardiovascular surgery: a randomized controlled trial. Medicine (Baltimore) 2020; 99: e22769. 10.1097/MD.0000000000022769.
    1. Conley CEW, Mattacola CG, Jochimsen KN, Dressler EV, Lattermann C, Howard JS. A comparison of neuromuscular electrical stimulation parameters for postoperative quadriceps strength in patients after knee surgery: a systematic review. Sports Health 2021; 13: 116–27.
    1. Edwards J, McWilliams D, Thomas M, Shah S. Electrical muscle stimulation in the intensive care unit: an integrative review. J Intensive Care Soc 2014; 15: 142–9.
    1. Arpin DJ, Ugiliweneza B, Forrest G, Harkema SJ, Rejc E. Optimizing neuromuscular electrical stimulation pulse width and amplitude to promote central activation in individuals with severe spinal cord injury. Front Physiol 2019; 10: 1310. 10.3389/fphys.2019.01310.
    1. Inns TB, McCormick D, Greig CA, Atherton PJ, Phillips BE, Piasecki M. Factors associated with electrical stimulation-induced performance fatigability are dependent upon stimulation location. Exp Physiol 2021; 106: 828–36.
    1. Otsuji H, Yokoyama Y, Ebata T et al. Surgery-related muscle loss and its association with postoperative complications after major hepatectomy with extrahepatic bile duct resection. World J Surg 2017; 41: 498–507.
    1. Suetta C. Plasticity and function of human skeletal muscle in relation to disuse and rehabilitation: influence of ageing and surgery - PubMed. Dan Med J 2017; 64: B5377.
    1. Goodpaster BH, Park SW, Harris TB et al. The loss of skeletal muscle strength, mass, and quality in older adults: the Health, Aging and Body Composition study. Journals Gerontol Ser A Biol Sci Med Sci 2006; 61: 1059–64.
    1. Cruz-Jentoft AJ, Bahat G, Bauer J et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019; 48: 16–31.
    1. Correa-de-Araujo R, Addison O, Miljkovic I et al. Myosteatosis in the context of skeletal muscle function deficit: an interdisciplinary workshop at the National Institute on Aging. Front Physiol 2020; 11: 963. 10.3389/fphys.2020.00963.
    1. Guo Y, E Phillips B, Atherton PJ, Piasecki M. Molecular and neural adaptations to neuromuscular electrical stimulation; implications for ageing muscle. Mech Ageing Dev 2021; 193: 111402. 10.1016/j.mad.2020.111402.
    1. Gustafsson UO, Scott MJ, Hubner M et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018. World J Surg 2019; 43: 659–95.
    1. Kings College Hospital NHS trust . Enhanced Recovery after Colorectal Surgery (ERAS). 2021. (19 July 2021, date last accessed).
    1. Haines KJ, Skinner EH, Berney S, Austin Health POST Study Investigators . Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy 2013; 99: 119–25.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe