The goal of this clinical trial study: is to determine the effectiveness of neuromuscular electrical stimulation in critically ill patients undergoing extracorporeal membrane oxygenation.

The main questions it aims to answer are:

• Does NMES has an effect when added to conventional protocol for ECMO patients?
• Does NMES will help in preserve muscle mass?
• Patients will recieve the treatment untill discharge.
• Assesment will be done before and after treatement

1. Subjects:

   Fifty Patients from both genders with pulmonary or cardiac disease receiving extracorporeal membrane oxygenation will participate in this study. They will randomly have divided into two groups equal in numb.Their ages will be ranged from 20 to 50 years.

2. Design of the study:

In this study the patients will be randomly assigned into two equal groups (25 patients for each group):

1. Group A (Study group):

   This group includes 25 patients who will receive VMS current of NMES on quadriceps muscle bilateral for 30 min daily for one week in addition to conventional physiotherapy program (Range of motion exercises, Positioning,Strengthening exercises and Stretching exercises).

2. Group B (Control group):

This group will include 25 patients. The participants will receive conventional physiotherapy program (Range of motion exercises, Positioning,Strengthening exercises and Stretching exercises) two times per day for one week.

- Equipments:

Measurement equipments:

A-Evaluating muscle strength The Medical Research Council (MRC) Scale for Muscle Strength B-Evaluating muscle mass Ultrasonography for assessing quadriceps muscle mass applied by ACUSON P500 manufactured by SEIMENS made in USA C-Evaluating level of activity ICU Mobility scale (IMS): IMS provides a sensitive 11-point ordinal scale, ranging from nothing (lying/passive exercises in bed, score of 0) to independent ambulation (score of 10).

D- Hospital length of stay (LOS) days E-Discharge destination Discharge destination was ranked on an ordinal scale: 0 = mortality; 1 = discharge to inpatient hospice; 2 = discharge to long-term acute care facility equivalent to ventilator weaning and skilled nursing facilities; 3 = discharge to acute and subacute care rehabilitation facilities; 4 = discharge to home with home health rehabilitation services; and 5 = discharge to home with no services.

F- Incidence and type of ECMO complication

- Treatmenet Procedures: NMES will be applied by using DJO/ Chattanooga - USA 2023 Patients on ECMO will receive daily 30-minute of neuromuscular electrical stimulation VMS current / on the quadriceps femoris muscles (rectus femoris and vastus intermedius) bilaterally as long as they were on ECMO to preserve muscle mass. Patients will be supine lying with knee slight flexion 40 degree by billow. 2 rectangular carbon electrodes (6×8 cm) on the muscle motor point, Frequency 50 pps , with a 1000 usec phase duration, ramp 5 sec, duty cycle 1:5.

The conventional program for both groups:

(Early mobilization started passively and progressed to be active, and progressed from in bed mobility to out of bed mobility, Mobilization activities, Passive- and active-assisted movements of extremities, Sitting on a chair, Bedside standing, Walking with support).

Inclusion Criteria:

• Adult patients of both sexes aged 20 to 50 years
• Patients receiving extracorporeal membrane oxygenation (ECMO) (veno-venous or veno- arterial)
• Patients admitted to the ECMO unit for at least 72 hours
• Hemodynamically stable patients as determined by the treating medical team
• Patients medically eligible for participation in physiotherapy and neuromuscular electrical stimulation (NMES)

Exclusion Criteria:

• Hemodynamic instability
• Patients requiring ECMO support for less than 72 hours
• Unstable cardiac arrhythmias
• Hemorrhagic shock
• Deep venous thrombosis or pulmonary embolism
• Lower limb open wounds or acute skin burns at electrode placement sites
• Pregnant patients
• Patients receiving intra-aortic balloon pump (IABP) support
• Any contraindication to NMES application