Abstract Objective This study aimed to comparatively evaluate the efficacy of different neuromuscular electrical stimulation (NMES)-based combination protocols for improving lower limb dysfunction in patients with stroke, in order to provide evidence-based support for clinical rehabilitation practice. Methods Randomized controlled trials (RCTs) investigating NMES-based combination interventions for lower limb dysfunction in patients with stroke published up to September 2, 2025 were systematically identified through searches of PubMed, Embase, the Cochrane Library, and Web of Science. The risk of bias of eligible studies was evaluated using the Cochrane Risk of Bias 2.0 (ROB 2.0) tool. Network meta-analysis (NMA) and subgroup analyses were conducted using R software (version 4.5.1) and Stata (version 15.0). Results In total, 37 RCTs were incorporated into the present NMA, involving 1,764 patients with stroke and encompassing nine distinct NMES-based combination intervention protocols. Regarding balance ability, core stability training (CST) combined with NMES (SMD = 0.99, 95% CrI: 0.33–1.67), gait training (GT) combined with NMES (SMD = 0.83, 95% CrI: 0.35–1.27), and NMES alone (SMD = 0.71, 95% CrI: 0.21–1.22) demonstrated significant therapeutic effects. CST+NMES (SUCRA = 76.02%) ranked highest among the NMES-based combined interventions for balance ability in patients with stroke. With respect to walking ability, no statistically significant differences were observed among the NMES-based intervention comparisons. Nevertheless, cycling exercise (CE) combined with NMES (SUCRA = 77.46%) received the highest ranking probability for walking ability, although this exploratory finding should be interpreted with caution given the absence of statistically significant differences among interventions and the lack of closed loops in the network. In terms of lower limb functional mobility, augmented reality technology (ART) combined with GT and NMES (SMD = 1.38, 95% CrI: 0.25–2.52), GT+NMES (SMD = 0.85, 95% CrI: 0.39–1.36), and NMES alone (SMD = 0.55, 95% CrI: 0.06–1.05) showed significant improvements. ART+GT+NMES (SUCRA = 84.23%) ranked highest for lower limb functional mobility. The results of the two-dimensional cluster ranking indicated that GT+NMES (SUCRA = 65.22%/49.29%/62.22%) demonstrated relatively stable ranking performance across multiple domains of lower limb dysfunction in patients with stroke. Subgroup analyses further indicated that CST+NMES appeared to be more effective for patients in the acute phase, GT+NMES for those in the subacute phase, and ART+GT+NMES for patients in the chronic phase. These subgroup-level rankings were based on limited evidence and should be considered exploratory. Conclusions NMES-based combination strategies have demonstrated beneficial effects on the recovery of lower limb function among individuals after stroke. Based on the results of this NMA, GT+NMES demonstrated relatively stable ranking performance across multiple outcomes, including balance, walking ability, and lower limb functional mobility, suggesting that it warrants further investigation as a combined intervention for clinical application. In addition, patients at different stages of stroke showed variable responses to NMES-based combined interventions, highlighting the importance of stage-specific and individualized rehabilitation strategies. Trial registration: PROSPERO CRD420251229835.
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