title: Electrical muscle stimulation in thomboprophylaxis: review and a derived hypothesis about thrombogenesis-the 4th factor.
abstract: BACKGROUND
  Electrical muscle stimulation (EMS) is an FDA-approved thromboprophylactic method. Thrombus pathogenesis is considered to depend on factors related to components of the vessel wall, the velocity of blood, and blood consistency-collectively known as, the Virchow's triad.
  
  
  OBJECTIVE
  The testimony supporting the thromboprophylactic effects of the EMS is reviewed. An emphasis is placed on the fact that, EMS has demonstrated, in certain circumstances, an efficacy rate that cannot be fully explained by the Virchow's triad; also that, in reviewing relevant evidence and the theorized pathophysiological mechanisms, several findings collectively point to a potentially missed point. Remarkably, venous thromboembolic disease (VTE) is extremely more common in the lower versus the upper extremities even when the blood velocities equalize; EMS had synergistic effects with intermittent compressive devices, despite their presumed identical mechanism of action; sleep is not thrombogenic; non-peroperative EMS is meaningful only if applied ≥5 times daily; neural insult increases VTEs more than the degree expected by the hypomobility-related blood stasis; etc. These phenomena infer the presence of a 4th thrombogenetic factor: neural supply to the veins provides direct antithrombic effects, by inducing periodic vessel diameter changes and/or by neuro-humoral, chemically acting factors. EMS may stimulate or substitute the 4th factor. This evidence-based hypothesis is analyzed.
  
  
  CONCLUSIONS
  A novel pathophysiologic mechanism of thrombogenesis is supported; and, based on this, the role of EMS in thromboprophylaxis is expanded. Exploration of this mechanism may provide new targets for intervention.
authors.affiliation: ICU, Limassol General Hospital, Eptanisou 2, Agios Nicolaos, 3100 Limassol, Cyprus.
authors.forename: Christos
authors.identifier: 0000-0003-1258-857X
authors.initials: C
authors.lastname: Stefanou
keywords: DVT; Electrical muscle stimulation; Endothelium; NMES; Nervous system; Pathophysiology; Thrombogenesis; Thrombosis; VTE; Vasomotion