Original research
Effects of Neuromuscular Electrical Stimulation During Hemodialysis on Peripheral Muscle Strength and Exercise Capacity: A Randomized Clinical Trial

https://doi.org/10.1016/j.apmr.2016.12.009Get rights and content

Abstract

Objective

To evaluate the effects of neuromuscular electrical stimulation of high and low frequency and intensity, performed during hemodialysis, on physical function and inflammation markers in patients with chronic kidney disease (CKD).

Setting

Hemodialysis clinic.

Participants

Patients with CKD (N=51) were randomized into blocks of 4 using opaque sealed envelopes. They were divided into a group of high frequency and intensity neuromuscular electrical stimulation and a group of low frequency and intensity neuromuscular electrical stimulation.

Interventions

The high frequency and intensity neuromuscular electrical stimulation group was submitted to neuromuscular electrical stimulation at a frequency of 50Hz and a medium intensity of 72.90mA, and the low frequency and intensity neuromuscular electrical stimulation group used a frequency of 5Hz and a medium intensity of 13.85mA, 3 times per week for 1 hour, during 12 sessions.

Main Outcome Measures

Peripheral muscle strength, exercise capacity, levels of muscle trophism marker (insulin growth factor 1) and levels of proinflammatory (tumor necrosis factor α) and anti-inflammatory (interleukin 10) cytokines.

Results

The high frequency and intensity neuromuscular electrical stimulation group showed a significant increase in right peripheral muscle strength (155.35±65.32Nm initial vs 161.60±68.73Nm final; P=.01) and left peripheral muscle strength (156.60±66.51Nm initial vs 164.10±69.76Nm final; P=.02) after the training, which did not occur in the low frequency and intensity neuromuscular electrical stimulation group for both right muscle strength (109.40±32.08Nm initial vs 112.65±38.44Nm final; P=.50) and left muscle strength (113.65±37.79Nm initial vs 116.15±43.01Nm final; P=.61). The 6-minute walk test distance (6MWTD) increased in both groups: high frequency and intensity neuromuscular electrical stimulation group (435.55±95.81m initial vs 457.25±90.64m final; P=.02) and low frequency and intensity neuromuscular electrical stimulation group (403.80±90.56m initial vs 428.90±87.42m final; P=.007). The groups did not differ in peripheral muscle strength and 6MWTD after the training protocol. In the high frequency and intensity neuromuscular electrical stimulation group, a correlation was observed between the initial and final values of 6MWTD and muscle strength. In the low frequency and intensity neuromuscular electrical stimulation group, correlations occurred only between the 6MWTD and the initial muscle strength. Only the low frequency and intensity neuromuscular electrical stimulation group increased levels of insulin growth factor 1 (252.38±156.35pg/mL initial vs 336.97±207.34pg/mL final; P=.03), and only the high frequency and intensity neuromuscular electrical stimulation group reduced levels of interleukin 10 (7.26±1.81pg/mL vs 6.32±1.54pg/mL; P=.03). The groups showed no differences in tumor necrosis factor α levels.

Conclusions

Patients with CKD on hemodialysis improve exercise capacity after peripheral neuromuscular electrical stimulation of high and low frequency and intensity. However, the benefits on muscle and inflammatory outcomes seem to be specific for the adopted electrical stimulation strategy.

Section snippets

Methods

This is a randomized, double-blind, controlled trial of patients with CKD who underwent HD. They were divided into 2 groups: patients who were submitted to high frequency and intensity neuromuscular electrical stimulation and patients who were submitted to low frequency and intensity neuromuscular electrical stimulation. Patients were blind to group allocation. Randomization was stratified according to sex, using a block size of 4, and performed using opaque sealed envelopes after the

Results

A total of 51 patients were eligible for the study: 26 patients (51%) were randomized for high frequency and intensity neuromuscular electrical stimulation and 25 (49%) for low frequency and intensity neuromuscular electrical stimulation. Six (23%) and 5 (20%) patients were excluded from the high the frequency and intensity neuromuscular electrical stimulation group and low frequency and intensity neuromuscular electrical stimulation group, respectively. Thus, 40 patients (78%) completed the

Discussion

This study demonstrated that patients with CKD on HD undergoing a high frequency and intensity neuromuscular electrical stimulation therapy as well as those submitted to low frequency and intensity therapy showed increased exercise capacity. However, only the high frequency and intensity neuromuscular electrical stimulation group showed improved peripheral muscle strength.

A relation was found between improved peripheral muscle strength and increased 6MWTD only in the high frequency and

Study limitations

Despite the pair analysis performed in this study, patients in the low frequency and intensity neuromuscular electrical stimulation group showed lower initial peripheral muscle strength than did patients in the high frequency and intensity neuromuscular electrical stimulation group. This chance error could not be controlled, but it has been corrected for the analysis between the groups. The high frequency and intensity neuromuscular electrical stimulation group showed a relation between age and

Conclusions

Patients with CKD on HD improve exercise capacity after peripheral neuromuscular electrical stimulation of high and low frequency and intensity. However, the benefits on muscle and inflammatory outcomes seem to be specific for the adopted electrical stimulation strategy.

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    GPower version 3.1.9.2; University of Kiel.

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References (46)

  • I. Vivodtzev et al.

    Functional and muscular effects of neuromuscular electrical stimulation in patients with severe COPD: a randomized clinical trial

    Chest

    (2012)
  • L.F. Fried et al.

    Kidney function as a predictor of loss of lean mass in older adults: health, aging and body composition Study

    J Am Geriatr Soc

    (2007)
  • P. Stenvinkel et al.

    Muscle wasting in end-stage renal disease promulgates premature death: established, emerging and potential novel treatment strategies

    Nephrol Dial Transplant

    (2016)
  • KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 update

    Am J Kidney Dis

    (2012)
  • T.A. Ikizler et al.

    Hemodialysis stimulates muscle and whole body protein loss and alters substrate oxidation

    Am J Physiol Endocrinol Metab

    (2002)
  • I.H. Fahal

    Uraemic sarcopenia: aetiology and implications

    Nephrol Dial Transplant

    (2014)
  • V.A. Souza et al.

    [Sarcopenia in chronic kidney disease] [Portuguese]

    J Bras Nefrol

    (2015)
  • M. Ruiz-Ortega et al.

    Proinflammatory actions of angiotensins

    Curr Opin Nephrol Hypertens

    (2001)
  • S.A. Greenwood et al.

    Intra-dialytic exercise training: a pragmatic approach

    J Renal Care

    (2014)
  • P. Dobsak et al.

    Intra-dialytic electrostimulation of leg extensors may improve exercise tolerance and quality of life in hemodialyzed patients

    Artif Organs

    (2012)
  • G. Bourjeily-Habr et al.

    Randomised controlled trial of transcutaneous electrical muscle stimulation of the lower extremities in patients with chronic obstructive pulmonary disease

    Thorax

    (2002)
  • M.E. Kho et al.

    Neuromuscular electrical stimulation for intensive care unit-acquired weakness: protocol and methodological implications for a randomized, sham-controlled, phase II trial

    Phys Ther

    (2012)
  • F. Van Buuren et al.

    Electrical myostimulation: improvement of quality of life, oxygen uptake and left ventricular function in chronic heart failure

    Rehabilitation (Stuttg)

    (2014)
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    Supported by Coordination of Improvement of Higher Level Personnel (CAPES).

    Clinical Trial Registration No.: NCT02786849.

    Disclosures: none.

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