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L. C. Burgess et al
outcomes from many individual NMES and oedema stu-
dies remain inconclusive. Thus, the current systematic
review assessed studies that evaluated NMES devices
for patients presenting with oedema. The results of this
review could help the development of rehabilitation
programmes focused on helping patients with oedema.
METHODS
Data sources
A systematic review was conducted to examine current publis-
hed evidence regarding the use of NMES for treatment of oede-
ma. The methodology of this review was developed according
to the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement (www.prismastatement.
org/PRISMAStatement) (6). A computer-based search was
completed in July 2018, and the electronic database sourced
was PubMed (https://www.ncbi.nlm.nih.gov/pubmed/). The
search reviewed all fields of the available literature, published
in the English language (or those for which a translation was
available) to the earliest record on file. A secondary search was
also conducted, whereby the reference lists of articles, review
papers and textbooks were scanned for additional papers. There
are 2 categories of this type of stimulation, one type of device
(named NMES) is used to treat muscle atrophy when the muscle
is in a resting state, and the other, named functional electrical
stimulation (FES), used to enhance functionality of neurologi-
cally impaired individuals. Therefore, FES search terms were
also included. Other devices delivering electrical stimulation
were excluded. Studies were considered eligible for inclusion
within the synthesis if they met the specified inclusion and
exclusion criteria listed in Table I.
Quality assessment
The Downs and Black checklist (8) was used to assess the risk
of bias within the studies sourced. The 27-item methodological
quality checklist has been shown to have good intra-rater (r.
0.88) and inter-rater (r. 0.75) reliability (8) It has been used
previously in systematic reviews with various study designs,
and has also been amended to suit the structure of the review
in which it was utilized (9, 10). Similarly, a modified version
of the Downs and Black checklist was employed with the items
that were not suitable to the review removed (items 5, 8, 14, 15,
21–27). The adapted version of the tool consisted of 16 items
(Appendix 1), including items 1–4, 6, 7, 9–13 and 16–20 from
the original list, with a maximum possible score of 16. The
higher scores indicated superior quality. The first 8 items on the
scale relate to reporting and include aims, outcome measures
and results. Items 11–13 relate to external validity and consider
whether results from the study can be generalized to a wider
population. Items 16–20 relate to internal validity. Risk of bias
was assessed by 2 independent assessors (LB and TI) and any
discrepancies were resolved through discussion.
Study selection Statistical analysis
In order to capture studies published across all rehabilitation
disciplines; a broad search strategy was adopted (Table II). All of the studies within this review compared pre- and post-
intervention values for oedema size. The majority of the data
were not normally distributed and, therefore, non-parametric
testing was used to compare means and variation. Six studies
also compared between-group changes when electrical stimula-
tion was compared with the following factors: no stimulation,
placebo stimulation, compression stockings, limb elevation,
and a whirlpool bath.
Table I. Inclusion and exclusion criteria
Inclusion criteria
Exclusion criteria
Population
Any patient population in a rehabilitation
setting where oedema was treated.
Intervention
Neuromuscular electrical stimulation
Functional electrical stimulation
Outcome measure
Oedema size, or swelling of limb
Methodology
Randomized clinical trials
Non-randomized clinical trials of good
methodological quality
Studies on animals
Functional electrical stimulation
cycling
Electromyographic biofeedback
Transcutaneous electrical nerve
stimulation
Calf muscle pump stimulation
Implanted peripheral nerve
electrodes
Neuromuscular monitoring
High-voltage pulsed current
Publication
Published in English
Access to full text
www.medicaljournals.se/jrm
Table II. Search strategy
Search strategy Search terms
1
2
Review articles
Case studies
Historical studies
All titles and abstracts were initially checked for relevance
and duplicates by 2 independent reviewers (LB and TW). The
remaining results then underwent a full-text appraisal to ensure
that the studies were of good methodological quality, that their
findings were significant, that they were evaluating a NMES
device, and that they were examining the effectiveness of the
device to treat oedema. Study design was assessed using the
PICO (Patient, Intervention, Comparison and Outcome) fram-
ework to ensure the study was relevant (7). Secondary searching
was also undertaken, whereby reference lists of the selected
articles were reviewed for additional studies not identified in
the primary search.
Unpublished studies
Study protocols
Cross-sectional studies
Historical studies
3
4
((neuromuscular[All Fields] AND (”electric stimulation”[MeSH
Terms] OR (”electric”[All Fields] AND ”stimulation”[All Fields])
OR ”electric stimulation”[All Fields] OR (”electrical”[All Fields]
AND ”stimulation”[All Fields]) OR ”electrical stimulation”[All
Fields])) AND (”oedema”[All Fields] OR ”edema”[MeSH
Terms] OR ”edema”[All Fields])) OR (electrostimulation[All
Fields] AND (”oedema”[All Fields] OR ”edema”[MeSH Terms]
OR ”edema”[All Fields]))
(neuromuscular[All Fields] AND stimulation[All Fields]
AND (”oedema”[All Fields] OR ”edema”[MeSH Terms] OR
”edema”[All Fields]))
(electrostimulation[All Fields] AND (”oedema”[All Fields] OR
”edema”[MeSH Terms] OR ”edema”[All Fields]))
(functional[All Fields] AND (”electric stimulation”[MeSH
Terms] OR (”electric”[All Fields] AND ”stimulation”[All Fields])
OR ”electric stimulation”[All Fields] OR (”electrical”[All Fields]
AND ”stimulation”[All Fields]) OR ”electrical stimulation”[All
Fields]) AND (”oedema”[All Fields] OR ”edema”[MeSH
Terms] OR ”edema”[All Fields]))