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Limb muscle dysfunction is a key systemic consequence of COPD that impacts patients' physical activity, exercise tolerance, quality of life and survival. Deconditioning is the main mechanism underlying the development of limb muscle dysfunction in COPD, which can be partially improved with exercise. However, some patients may not be able to tolerate exercise because of incapacitating breathlessness or unwillingness to undertake whole-body exercise. Alternative training modalities that do not give rise to dyspnoea, such as neuromuscular electrical stimulation (NMES), are urged. Over the past 20\u2005years, NMES in COPD has presented conflicting conclusions in meta-analysis. In this review, we try to understand the reason for this result by analysing possible biases and factors that brought conflicting conclusions. We discuss the population (the intervention group, but also the control group), the outcome measures, the frequency of stimulation, the rehabilitation protocol (<jats:italic>i.e.<\/jats:italic>NMES alone<jats:italic>versus<\/jats:italic>standard care\/rehabilitation or NMES plus conventional exercise training<jats:italic>versus<\/jats:italic>conventional exercise training alone or NMES<jats:italic>versus<\/jats:italic>sham treatment) and the trial design. The main reason for this discrepancy is the lack of dedicated guidelines for NMES. Further research is urged to determine the optimal parameters for an NMES programme. Despite this, NMES appears to be an effective means of enhancing quadriceps strength and exercise capacity in COPD with the potential to break the vicious circle induced by the disease and COPD patients\u2019 lifestyle.<\/jats:p>","DOI":"10.1183\/16000617.0247-2022","type":"journal-article","created":{"date-parts":[[2024,3,20]],"date-time":"2024-03-20T09:30:12Z","timestamp":1710927012000},"page":"220247","update-policy":"https:\/\/doi.org\/10.1183\/ers-crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["20 years of neuromuscular electrical stimulation in COPD"],"prefix":"10.1183","volume":"33","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1408-6971","authenticated-orcid":false,"given":"Antonella","family":"LoMauro","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fabrizio","family":"Gervasoni","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"81","published-online":{"date-parts":[[2024,3,20]]},"reference":[{"key":"2024102404172492000_33.171.220247.1","unstructured":"World Health Organization (WHO) . 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