Spatial distribution of blood flow in electrically stimulated human muscle: a positron emission tomography study

Differential changes in blood flow and oxygen utilization in active muscles between voluntary exercise and electrical muscle stimulation in young adults

The physiological effects on blood flow and oxygen utilization in active muscles during and after involuntary contraction triggered by electrical muscle stimulation (EMS) remain unclear, particularly compared with those elicited by voluntary (VOL) contractions. Therefore, we used diffuse correlation and near-infrared spectroscopy (DCS-NIRS) to compare changes in local muscle blood flow and oxygen consumption during and after these two types of muscle contractions in humans. Overall, 24 healthy young adults participated in the study, and data were successfully obtained from 17 of them. Intermittent (2-s contraction, 2-s relaxation) isometric ankle dorsiflexion with a target tension of 20% of maximal VOL contraction was performed by EMS or VOL for 2 min, followed by a 6-min recovery period. DCS-NIRS probes were placed on the tibialis anterior muscle, and relative changes in local tissue blood flow index (rBFI), oxygen extraction fraction (rOEF), and metabolic rate of oxygen (rMRO2) were continuously derived. EMS induced more significant increases in rOEF and rMRO2 than VOL exercise but a comparable increase in rBFI. After EMS, rBFI and rMRO2 decreased more slowly than after VOL and remained significantly higher until the end of the recovery period. We concluded that EMS augments oxygen consumption in contracting muscles by enhancing oxygen extraction while increasing oxygen delivery at a rate similar to the VOL exercise. Under the conditions examined in this study, EMS demonstrated a more pronounced and/or prolonged enhancement in local muscle perfusion and aerobic metabolism compared with VOL exercise in healthy participants.NEW & NOTEWORTHY This is the first study to visualize continuous changes in blood flow and oxygen utilization within contracted muscles during and after electrical muscle stimulation (EMS) using combined diffuse correlation and near-infrared spectroscopy. We found that initiating EMS increases blood flow at a rate comparable to that during voluntary (VOL) exercise but enhances oxygen extraction, resulting in higher oxygen consumption. Furthermore, EMS increased postexercise muscle perfusion and oxygen consumption compared with that after VOL exercise.

Cardiovasomobility: an integrative understanding of how disuse impacts cardiovascular and skeletal muscle health

Cardiovasomobility is a novel concept that encompasses the integration of cardiovascular and skeletal muscle function in health and disease with critical modification by physical activity, or lack thereof. Compelling evidence indicates that physical activity improves health while a sedentary, or inactive, lifestyle accelerates cardiovascular and skeletal muscle dysfunction and hastens disease progression. Identifying causative factors for vascular and skeletal muscle dysfunction, especially in humans, has proven difficult due to the limitations associated with cross-sectional investigations. Therefore, experimental models of physical inactivity and disuse, which mimic hospitalization, injury, and illness, provide important insight into the mechanisms and consequences of vascular and skeletal muscle dysfunction. This review provides an overview of the experimental models of disuse and inactivity and focuses on the integrated responses of the vasculature and skeletal muscle in response to disuse/inactivity. The time course and magnitude of dysfunction evoked by various models of disuse/inactivity are discussed in detail, and evidence in support of the critical roles of mitochondrial function and oxidative stress are presented. Lastly, strategies aimed at preserving vascular and skeletal muscle dysfunction during disuse/inactivity are reviewed. Within the context of cardiovasomobility, experimental manipulation of physical activity provides valuable insight into the mechanisms responsible for vascular and skeletal muscle dysfunction that limit mobility, degrade quality of life, and hasten the onset of disease.

Motor point stimulation induces more robust F-waves than peripheral nerve stimulation

The F-wave is a motor response induced by electrical stimulation of peripheral nerves via the antidromic firing of motor nerves, which reflects the motoneuron excitability. To induce F-waves, transcutaneous peripheral nerve stimulation (PNS) is used, which activates nerve branches via transcutaneous electrodes over the nerve branches. An alternative method to activate peripheral nerves, i.e., motor point stimulation (MPS) which delivers electrical stimulation over the muscle belly, has not been used to induce F-waves. In our previous studies, we observed that MPS induced F-wave like responses, i.e., motor responses at the latency of F-waves at a supramaximal stimulation. Here we further investigated the F-wave like responses induced by MPS in comparison to PNS in the soleus muscle. Thirteen individuals participated in this study. We applied MPS and PNS on the participant's left soleus muscle. Using a monopolar double-pulse stimulation, the amplitude of the second H-reflex induced by PNS decreased, while the amplitude of the motor response at the F-wave latency induced by MPS did not decrease. These results suggest that the motor response at the F-wave latency induced by MPS was not an H-reflex but an F-wave. We also found that the F-wave induced by MPS had a greater amplitude, higher persistence, and caused less pain when compared to the F-waves induced using PNS. We conclude that MPS evokes antidromic firing inducing F-waves more consistently compared to PNS.

Sitting for Too Long, Moving Too Little: Regular Muscle Contractions Can Reduce Muscle Stiffness During Prolonged Periods of Chair-Sitting

In modern Western societies, sedentary behavior has become a growing health concern. There is increasing evidence that prolonged sitting periods can be associated with musculoskeletal disorders. While it is generally recognized that back muscle activity is low during chair-sitting, little is known about the consequences of minor to no muscle activity on muscle stiffness. Muscle stiffness may play an important role in musculoskeletal health. This study investigated the effects of regular muscle contractions on muscle stiffness in a controlled experiment in which participants sat for 4.5 h. Neuromuscular electrical stimulation in the lumbar region of the back was applied to trigger regular muscle contractions. Using stiffness measurements and continuous motion capturing, we found that prolonged sitting periods without regular muscle contractions significantly increased back muscle stiffness. Moreover, we were able to show that regular muscle contractions can prevent those effects. Our results highlight the importance of consistent muscle activity throughout the day and may help explain why prolonged periods of chair-sitting increase the susceptibility to common pathological conditions such as low back pain.

A Generic Sequential Stimulation Adapter for Reducing Muscle Fatigue during Functional Electrical Stimulation

Background: Clinical applications of conventional functional electrical stimulation (FES) administered via a single electrode are limited by rapid onset neuromuscular fatigue. “Sequential” (SEQ) stimulation, involving the rotation of pulses between multiple active electrodes, has been shown to reduce fatigue compared to conventional FES. However, there has been limited adoption of SEQ in research and clinical settings. Methods: The SEQ adapter is a small, battery-powered device that transforms the output of any commercially available electrical stimulator into SEQ stimulation. We examined the output of the adaptor across a range of clinically relevant stimulation pulse parameters to verify the signal integrity preservation ability of the SEQ adapter. Pulse frequency, amplitude, and duration were varied across discrete states between 4 and 200 Hz, 10 and100 mA, and 50 and 2000 μs, respectively. Results: A total of 420 trials were conducted, with 80 stimulation pulses per trial. The SEQ adapter demonstrated excellent preservation of signal integrity, matching the pulse characteristics of the originating stimulator within 1% error. The SEQ adapter operates as expected at pulse frequencies up to 160 Hz, failing at a frequency of 200 Hz. Conclusion: The SEQ adapter represents an effective and low-cost solution to increase the utilization of SEQ in existing rehabilitation paradigms.

Activation of Superficial and Deep Finger Flexors Through Transcutaneous Nerve Stimulation

OBJECTIVE

Functional electrical stimulation (FES) is a common technique to elicit muscle contraction and help improve muscle strength. Traditional FES over the muscle belly typically only activates superficial muscle regions. In the case of hand FES, this prevents the activation of the deeper flexor muscles which control the distal finger joints. Here, we evaluated whether an alternative transcutaneous nerve-bundle stimulation approach can activate both superficial and deep extrinsic finger flexors using a high-density stimulation grid.

METHODS

Transverse ultrasound of the forearm muscles was used to obtain cross-sectional images of the underlying finger flexors during stimulated finger flexions and kinematically-matched voluntary motions. Finger kinematics were recorded, and an image registration method was used to capture the large deformation of the muscle regions during each flexion. This deformation was used as a surrogate measure of the contraction of muscle tissue, and the regions of expanding tissue can identify activated muscles.

RESULTS

The nerve-bundle stimulation elicited contractions in the superficial and deep finger flexors. Both separate and concurrent activation of these two muscles were observed. Joint kinematics of the fingers also matched the expected regions of muscle contractions.

CONCLUSIONS

Our results showed that the nerve-bundle stimulation technique can activate the deep extrinsic finger flexors, which are typically not accessible via traditional surface FES.

SIGNIFICANCE

Our nerve-bundle stimulation method enables us to produce the full range of motion of different joints necessary for various functional grasps, which could benefit future neuroprosthetic applications.

Effect of electromyostimulation on intramyocellular lipids of the vastus lateralis in older adults: a randomized controlled trial

BACKGROUND

Excessive intramyocellular lipid (IMCL) accumulation is a primary cause of skeletal muscle insulin resistance, especially in older adults, and interventions that reduce IMCL contents are important to improve insulin sensitivity. Electromyostimulation (EMS)-induced changes in IMCL content in older adults remain unknown. The purpose of this study was to clarify the effects of a single bout of EMS on the IMCL content of the vastus lateralis muscle in older adults.

METHODS

Twenty-two physically active, non-obese older men and women were randomly assigned to an EMS intervention group (69.0 ± 5.2 years, n = 12) or a control group (68.4 ± 3.5 years, n = 10). EMS was applied to the vastus lateralis (7 s on and 7 s off) for 30 min; control participants sat quietly for 30 min. IMCL content within the vastus lateralis was quantified with ¹H-magnetic resonance spectroscopy (n = 7 per group). Fasting plasma glucose and insulin values were determined from blood samples collected before and after the EMS intervention.

RESULTS

EMS induced a significant reduction in plasma glucose (93.1 ± 9.6 to 89.5 ± 9.1 mg/dL, p < 0.01), but not IMCL content (15.7 ± 15.7 to 15.8 ± 13.1 mmol/kg wet weight, p = 0.49) or insulin (5.4 ± 2.4 to 4.7 ± 2.7 μIU/mL, p = 0.18). In the control group, no changes in IMCL content in the vastus lateralis was observed after prolonged quiet sitting.

CONCLUSION

EMS intervention for 30 min induces changes in plasma glucose, but no changes in IMCL content in older adults.

TRIAL REGISTRATION

University hospital Medical Information Network (UMIN) Center ID: UMIN000020126 . Retrospectively registered on December 222,015. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000023242.

Skeletal Muscle Damage Produced by Electrically Evoked Muscle Contractions

Understanding the physiological/mechanical mechanisms leading to skeletal muscle damage remains one of the challenges in muscle physiology. This review presents the functional, structural, and cellular consequences of electrically evoked submaximal isometric contractions that can elicit severe and localized skeletal muscle damage. Hypotheses related to underlying physiological and mechanical processes involved in severe and localized muscle damage also are discussed.

Architectural Changes in Superficial and Deep Compartments of the Tibialis Anterior During Electrical Stimulation Over Different Sites

Electrical stimulation is widely used in rehabilitation to prevent muscle weakness and to assist the functional recovery of neural deficits. Its application is however limited by the rapid development of muscle fatigue due to the non-physiological motor unit (MU) recruitment. This issue can be mitigated by interleaving muscle belly (mStim) and nerve stimulation (nStim) to distribute the temporal recruitment among different MU groups. To be effective, this approach requires the two stimulation modalities to activate minimally-overlapped groups of MUs. In this manuscript, we investigated spatial differences between mStim and nStim MU recruitment through the study of architectural changes of superficial and deep compartments of tibialis anterior (TA). We used ultrasound imaging to measure variations in muscle thickness, pennation angle, and fiber length during mStim, nStim, and voluntary (Vol) contractions at 15% and 25% of the maximal force. For both contraction levels, architectural changes induced by nStim in the deep and superficial compartments were similar to those observed during Vol. Instead, during mStim superficial fascicles underwent a greater change compared to those observed during nStim and Vol, both in absolute magnitude and in their relative differences between compartments. These observations suggest that nStim results in a distributed MU recruitment over the entire muscle volume, similarly to Vol, whereas mStim preferentially activates the superficial muscle layer. The diversity between spatial recruitment of nStim and mStim suggests the involvement of different MU populations, which justifies strategies based on interleaved nerve/muscle stimulation to reduce muscle fatigue during electrically-induced contractions of TA.

Modulation of spinal excitability following neuromuscular electrical stimulation superimposed to voluntary contraction

Purpose

Neuromuscular electrical stimulation (NMES) superimposed on voluntary muscle contraction has been recently shown as an innovative training modality within sport and rehabilitation, but its effects on the neuromuscular system are still unclear. The aim of this study was to investigate acute responses in spinal excitability, as measured by the Hoffmann (H) reflex, and in maximal voluntary contraction (MVIC) following NMES superimposed to voluntary isometric contractions (NMES + ISO) compared to passive NMES only and to voluntary isometric contractions only (ISO).

Method

Fifteen young adults were required to maintain an ankle plantar-flexor torque of 20% MVC for 20 repetitions during each experimental condition (NMES + ISO, NMES and ISO). Surface electromyography was used to record peak-to-peak H-reflex and motor waves following percutaneous stimulation of the posterior tibial nerve in the dominant limb. An isokinetic dynamometer was used to assess maximal voluntary contraction output of the ankle plantar flexor muscles.

Results

H-reflex amplitude was increased by 4.5% after the NMES + ISO condition (p < 0.05), while passive NMES and ISO conditions showed a decrease by 7.8% (p < 0.05) and no change in reflex responses, respectively. There was no change in amplitude of maximal motor wave and in MVIC torque during each experimental condition.

Conclusion

The reported facilitation of spinal excitability following NMES + ISO could be due to a combination of greater motor neuronal and corticospinal excitability, thus suggesting that NMES superimposed onto isometric voluntary contractions may provide a more effective neuromuscular stimulus and, hence, training modality compared to NMES alone.

Optimizing Neuromuscular Electrical Stimulation Pulse Width and Amplitude to Promote Central Activation in Individuals With Severe Spinal Cord Injury

Neuromuscular electrical stimulation (NMES) is one of the most effective treatments for counteracting the deleterious skeletal muscle adaptations that occur after spinal cord injury (SCI). Additionally, previous findings suggest that NMES can activate motor units via both peripheral and central mechanisms; however, this NMES-promoted central activation is not well understood. In this study, we aimed at investigating the effects of NMES on central activation in 10 individuals with motor complete SCI, focusing on understanding how to optimize NMES pulse width and amplitude for promoting central activation in this population. To this end, we used NMES to generate isometric contractions of the knee extensors and ankle plantarflexors while electromyographic (EMG) activity was recorded from the vastus lateralis and gastrocnemius medialis, respectively. We used EMG activity that persisted after the termination of NMES delivery (post-NMES) as a neurophysiological marker to assess central activation and explored differences in post-NMES EMG activity promoted by 500 and 1,000 μs pulse width NMES. Additionally, we explored the relationships between post-NMES EMG amplitude, torque output, and stimulation amplitude. Our results show that the higher pulse width (1,000 μs) demonstrated a greater effect on central activation as quantified by more frequent occurrences of post-NMES EMG activity (p = 0.002) and a 3.551 μV higher EMG amplitude (p = 0.003) when controlling for the torque output generated by 500 and 1,000 μs pulse width NMES. Importantly, we also found that the interplay among central activation, stimulation amplitude, and muscle torque output differs across SCI individuals, conceivably because of the individual-specific characteristics of the cord lesion and following plasticity of the spinal circuitry. These results suggest that NMES can be optimized to promote central activation, which may lead to novel opportunities for motor function recovery after SCI.

Submaximal Marker for Investigating Peak Muscle Torque Using Neuromuscular Electrical Stimulation after Paralysis

Spinal cord injury (SCI) results in deleterious skeletal muscle adaptations, such as relevant atrophy and loss of force. In particular, the relevant loss of lower-limb force-generating capacity may limit functional mobility even if neuronal control was sufficient. Currently, methods of assessing maximal force-generating capacity using neuromuscular electrical stimulation (NMES) are limited in individuals who cannot tolerate higher stimulation amplitudes, such as those with residual sensation and those at risk of fracture. In this study, we examined the relationship between NMES amplitude and muscle torque exerted (recruitment curve) in order to determine whether maximal torque output can be characterized by a submaximal marker. Recruitment curves for knee extensors, knee flexors, and ankle plantarflexors were recorded from 30 individuals with motor complete SCI. NMES was delivered starting with an amplitude of 5 mA, and increasing by 5 mA for every subsequent stimulation until either the participant requested to stop the stimulation or the maximum stimulation amplitude (140 mA) was reached. Significant correlations between peak slope of the recruitment curve and peak torque for all muscle groups were found (knee extensors, r = 0.75; p < 0.0001; knee flexors, r = 0.68; p < 0.0001; ankle plantarflexors, r = 0.91; p < 0.0001), indicating that muscles that show greater peak slope of the recruitment curve tend to generate a greater peak torque. This suggests that peak slope, which was achieved at an average stimulation intensity (55.0 mA) that was 43% smaller than that corresponding to peak torque (97.4 mA), may be used as a submaximal marker for characterizing maximal torque output in individuals with SCI.

Systematic Review of Three Electrical Stimulation Techniques for Rehabilitation After Total Knee Arthroplasty

BACKGROUND

The comparative effectiveness of neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and electroacupuncture (EA) for improving patient rehabilitation following total knee arthroplasty (TKA) is controversial. Therefore we conducted this systematic review to assess the available evidence.

METHODS

The PubMed, OVID, and ScienceDirect databases were comprehensively searched and studies were selected and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Data were extracted and qualitatively synthesized for several outcomes.

RESULTS

Data were analyzed from 17 randomized controlled trials involving 1285 procedures: 8 NMES studies (608 procedures), 7 TENS studies (560 procedures), and 2 EA studies (117 procedures). Qualitative analysis suggested that NMES was associated with higher quadriceps strength and functional recovery after TKA. Recovery benefits were maximal when the stimulation was performed once or twice a day for 4-6 weeks at an intensity of 100-120 mA and frequency of 30-100 Hz. The electrode should be sufficiently large (100-200 cm²) to reduce discomfort. TENS at an intensity of 15-40 mA and frequency of 70-150 Hz provided effective analgesia after TKA. EA at an intensity of 2 mA and frequency of 2 Hz may also provide postoperative analgesia of TKA.

CONCLUSION

As adjunct modalities, NMES and TENS can effectively improve rehabilitation after TKA without triggering significant intolerance, and maximal benefits depend on optimized parameters and intervention protocols. EA may be an effective adjunct modality for analgesia after TKA.

Utilizing Physiological Principles of Motor Unit Recruitment to Reduce Fatigability of Electrically-Evoked Contractions: A Narrative Review

Neuromuscular electrical stimulation (NMES) is used to produce contractions to restore movement and reduce secondary complications for individuals experiencing motor impairment. NMES is conventionally delivered through a single pair of electrodes over a muscle belly or nerve trunk using short pulse durations and frequencies between 20 and 40Hz (conventional NMES). Unfortunately, the benefits and widespread use of conventional NMES are limited by contraction fatigability, which is in large part because of the nonphysiological way that contractions are generated. This review provides a summary of approaches designed to reduce fatigability during NMES, by using physiological principles that help minimize fatigability of voluntary contractions. First, relevant principles of the recruitment and discharge of motor units (MUs) inherent to voluntary contractions and conventional NMES are introduced, and the main mechanisms of fatigability for each contraction type are briefly discussed. A variety of NMES approaches are then described that were designed to reduce fatigability by generating contractions that more closely mimic voluntary contractions. These approaches include altering stimulation parameters, to recruit MUs in their physiological order, and stimulating through multiple electrodes, to reduce MU discharge rates. Although each approach has unique advantages and disadvantages, approaches that minimize MU discharge rates hold the most promise for imminent translation into rehabilitation practice. The way that NMES is currently delivered limits its utility as a rehabilitative tool. Reducing fatigability by delivering NMES in ways that better mimic voluntary contractions holds promise for optimizing the benefits and widespread use of NMES-based programs.

Interleaved neuromuscular electrical stimulation after spinal cord injury

INTRODUCTION

Neuromuscular electrical stimulation (NMES) over a muscle belly (mNMES) recruits superficial motor units (MUs) preferentially, whereas NMES over a nerve trunk (nNMES) recruits MUs evenly throughout the muscle. We performed tests to determine whether "interleaving" pulses between the mNMES and nNMES sites (iNMES) reduces the fatigability of contractions for people experiencing paralysis because of chronic spinal cord injury.

METHODS

Plantar flexion torque and soleus electromyography (M-waves) were recorded from 8 participants. A fatigue protocol (75 contractions; 2 s on/2 s off for 5 min) was delivered by iNMES. The results were compared with previously published data collected with mNMES and nNMES in the same 8 participants.

RESULTS

Torque declined ∼40% more during mNMES than during nNMES or iNMES. M-waves declined during mNMES but not during nNMES or iNMES.

DISCUSSION

To reduce fatigability of electrically evoked contractions of paralyzed plantar flexors, iNMES is equivalent to nNMES, and both are superior to mNMES. Muscle Nerve 56: 989-993, 2017.

The pH heterogeneity in human calf muscle during neuromuscular electrical stimulation

PURPOSE

The aim of the study was to examine pH heterogeneity during fatigue induced by neuromuscular electrical stimulation (NMES) using phosphorus magnetic resonance spectroscopy (³¹ P-MRS). It is hypothesized that three pH components would occur in the ³¹ P-MRS during fatigue, representing three fiber types.

METHODS

The medial gastrocnemius of eight subjects was stimulated within a 3-Tesla whole body MRI scanner. The maximal force during stimulation (F_stim ) was examined by a pressure sensor. Phosphocreatine (PCr), adenosintriphosphate, inorganic phosphate (Pi), and the corresponding pH were estimated by a nonvolume-selective ³¹ P-MRS using a small loop coil at rest and during fatigue.

RESULTS

During fatigue, F_stim and PCr decreased to 27% and 33% of their initial levels, respectively. In all cases, the Pi peak increased when NMES was started and split into three different peaks. Based on the single Pi peaks during fatigue, an alkaline (6.76 ± 0.08), a medium (6.40 ± 0.06), and an acidic (6.09 ± 0.05) pH component were observed compared to the pH (7.02 ± 0.02) at rest.

CONCLUSION

It is suggested that NMES is able to induce pH heterogeneity in the medial gastrocnemius, and that the single Pi peaks represent the different muscle fiber types of the skeletal muscle. Magn Reson Med 77:2097-2106, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Skeletal muscle work efficiency with age: the role of non-contractile processes

Although skeletal muscle work efficiency probably plays a key role in limiting mobility of the elderly, the physiological mechanisms responsible for this diminished function remain incompletely understood. Thus, in the quadriceps of young (n=9) and old (n=10) subjects, we measured the cost of muscle contraction (ATP cost) with 31P-magnetic resonance spectroscopy (31P-MRS) during (i) maximal intermittent contractions to elicit a metabolic demand from both cross-bridge cycling and ion pumping and (ii) a continuous maximal contraction to predominantly tax cross-bridge cycling. The ATP cost of the intermittent contractions was significantly greater in the old (0.30±0.22 mM·min-1·N·m-1) compared with the young (0.13±0.03 mM·min-1·N·m-1, P<0.05). In contrast, at the end of the continuous contraction protocol, the ATP cost in the old (0.10±0.07 mM·min-1·N·m-1) was not different from the young (0.06±0.02 mM·min-1·N·m-1, P=0.2). In addition, the ATP cost of the intermittent contractions correlated significantly with the single leg peak power of the knee-extensors assessed during incremental dynamic exercise (r=-0.55; P<0.05). Overall, this study reveals an age-related increase in the ATP cost of contraction, probably mediated by an excessive energy demand from ion pumping, which probably contributes to both the decline in muscle efficiency and functional capacity associated with aging.

Feasibility of neuromuscular electrical stimulation in critically ill patients

OBJECTIVE

Critically ill patients often develop intensive care unit-acquired weakness. Reduction in muscle mass and muscle strength occurs early after admission to the intensive care unit (ICU). Although early active muscle training could attenuate this intensive care unit-acquired weakness, in the early phase of critical illness, a large proportion of patients are unable to participate in any active mobilization. Neuromuscular electrical stimulation (NMES) could be an alternative strategy for muscle training. The aim of this study was to investigate the safety and feasibility of NMES in critically ill patients.

DESIGN

This is an observational study.

SETTING

The setting is in the medical and surgical ICUs of a tertiary referral university hospital.

PATIENTS

Fifty patients with a prognosticated prolonged stay of at least 6 days were included on day 3 to 5 of their ICU stay. Patients with preexisting neuromuscular disorders and patients with musculoskeletal conditions limiting quadriceps contraction were excluded.

INTERVENTION

Twenty-five minutes of simultaneous bilateral NMES of the quadriceps femoris muscle. This intervention was performed 5 days per week (Monday-Friday). Effective muscle stimulation was defined as a palpable and visible contraction (partial or full muscle bulk).

MEASUREMENTS

The following parameters, potentially affecting contraction upon NMES, were assessed: functional status before admission to the ICU (Barthel index), type and severity of illness (Acute Physiology And Chronic Health Evaluation II score and sepsis), treatments possibly influencing the muscle contraction (corticosteroids, vasopressors, inotropes, aminoglycosides, and neuromuscular blocking agents), level of consciousness (Glasgow Coma Scale, score on 5 standardized questions evaluating awakening, and sedation agitation scale), characteristics of stimulation (intensity of the NMES, number of sessions per patient, and edema), and neuromuscular electrophysiologic characteristics. Changes in heart rate, blood pressure, oxygen saturation, respiratory rate, and skin reactions were registered to assess the safety of the technique.

RESULTS

In 50% of the patients, an adequate quadriceps contraction was obtained in at least 75% of the NMES sessions. Univariate analysis showed that lower limb edema (P<.001), sepsis (P=.008), admission to the medical ICU (P=.041), and treatment with vasopressors (P=.011) were associated with impaired quadriceps contraction. A backward multivariate analysis identified presence of sepsis, lower limb edema, and use of vasopressors as independent predictors of impaired quadriceps contraction (R2=59.5%). Patients responded better to NMES in the beginning of their ICU stay in comparison with after 1 week of ICU stay. There was no change in any of the safety end points with NMES.

CONCLUSIONS

Critically ill patients having sepsis, edema, or receiving vasopressors were less likely to respond to NMES with an adequate quadriceps contraction. Neuromuscular electrical stimulation is a safe intervention to be administered in the ICU.

H-reflexes reduce fatigue of evoked contractions after spinal cord injury

INTRODUCTION

Neuromuscular electrical stimulation (NMES) over a muscle belly (mNMES) generates contractions predominantly through M-waves, while NMES over a nerve trunk (nNMES) can generate contractions through H-reflexes in people who are neurologically intact. We tested whether the differences between mNMES and nNMES are present in people with chronic motor-complete spinal cord injury and, if so, whether they influence contraction fatigue.

METHODS

Plantar-flexion torque and soleus electromyography were recorded from 8 participants. Fatigue protocols were delivered using mNMES and nNMES on separate days.

RESULTS

nNMES generated contractions that fatigued less than mNMES. Torque decreased the least when nNMES generated contractions, at least partly through H-reflexes (n = 4 participants; 39% decrease), and torque decreased the most when contractions were generated through M-waves, regardless of NMES site (nNMES 71% decrease, n = 4; mNMES, 73% decrease, n = 8).

CONCLUSIONS

nNMES generates contractions that fatigue less than mNMES, but only when H-reflexes contribute to the evoked contractions.

Effect of neuromuscular electrical stimulation intensity over the tibial nerve trunk on triceps surae muscle fatigue

PURPOSE

This study was designed to investigate whether the intensity modulation of a neuromuscular electrical stimulation (NMES) protocol delivered over the nerve trunk of the plantar flexors would lead to differential peripheral and central contributions of muscle fatigue.

METHODS

Three fatiguing isometric protocols of the plantar flexors matched for the same amount of isometric torque-time integral (TTI) were randomly performed including a volitional protocol at 20 % of the maximal voluntary contraction (MVC) and two NMES protocols (one at constant intensity, CST; the other at intensity level progressively adjusted to maintain 20 % of MVC, PROG).

RESULTS

No time x protocol interaction was found for any of the variables. The MVC decreased similarly (≈12 %, p < 0.001) after all protocols, so did the potentiated twitch responses (p = 0.001). Although voluntary activation of the plantar flexors did not change, maximal H-reflex to M-wave ratio of the soleus (SOL) and the gastrocnemius medialis (GM) muscles showed an overall increase (SOL: p = 0.037, GM: p = 0.041), while it remained stable for the gastrocnemius lateralis muscle (p = 0.221). A main time effect was observed only for the SOL maximal V-wave to the superimposed M-wave ratio (p = 0.024) and to the superimposed H-reflex (p = 0.008). While similar central and peripheral adaptations were observed after the three fatiguing protocols, the individual contribution of the three different triceps surae muscles was different.

CONCLUSION

Whether the current intensity was increased or not, the adaptations after a NMES protocol yield to similar muscle fatigue adaptations as voluntary contractions likely through similar pathways matching a similar TTI.

Twitch and M-wave potentiation induced by intermittent maximal voluntary quadriceps contractions: differences between direct quadriceps and femoral nerve stimulation

INTRODUCTION

The aim of this study was to investigate differences in twitch and M-wave potentiation in the quadriceps femoris when electrical stimulation is applied over the quadriceps muscle belly versus the femoral nerve trunk.

METHODS

M-waves and mechanical twitches were evoked using direct quadriceps muscle and femoral nerve stimulation between 48 successive isometric maximal voluntary contractions (MVC) from 10 young, healthy subjects. Potentiation was investigated by analyzing the changes in M-wave amplitude recorded from the vastus medialis (VM) and vastus lateralis (VL) muscles and in quadriceps peak twitch force.

RESULTS

Potentiation of twitch, VM M-wave, and VL M-wave were greater for femoral nerve than for direct quadriceps stimulation (P < 0.05). Despite a 50% decrease in MVC force, the amplitude of the M-waves increased significantly during exercise.

CONCLUSIONS

In addition to enhanced electrogenic Na(+) -K(+) pumping, other factors (such as synchronization in activation of muscle fibers and muscle architectural properties) may significantly influence the magnitude of M-wave enlargement.

Alteration of synergistic muscle activity following neuromuscular electrical stimulation of one muscle

The aim of the study was to determine muscle activation of the m. triceps surae during maximal voluntary contractions (MVCs) following neuromuscular electrical stimulation (NMES) of the m. gastrocnemius lateralis (GL). The participants (n = 10) performed three MVC during pretest, posttest, and recovery, respectively. Subsequent to the pretest, the GL was stimulated by NMES. During MVC, force and surface electromyography (EMG) of the GL, m. gastrocnemius medialis (GM), and m. soleus (SOL) were measured. NMES of GL induced no significant decline (3%) in force. EMG activity of the GL decreased significantly to 81% (P < 0.05), whereas EMG activity of the synergistic SOL increased to 112% (P < 0.01). The GM (103%, P = 1.00) remained unaltered. Decreased EMG activity in the GL was most likely caused by failure of the electrical propagation at its muscle fiber membrane. The decline of EMG activity in GL was compensated by increased EMG activity of SOL during MVC. It is suggested that these compensatory effects are caused by central contributions induced by NMES.

Motor unit recruitment when neuromuscular electrical stimulation is applied over a nerve trunk compared with a muscle belly: quadriceps femoris

Neuromuscular electrical stimulation (NMES) can be delivered over a nerve trunk or muscle belly and both can generate contractions through peripheral and central pathways. Generating contractions through peripheral pathways is associated with a nonphysiological motor unit recruitment order, which may limit the efficacy of NMES rehabilitation. Presently, we compared recruitment through peripheral and central pathways for contractions of the knee extensors evoked by NMES applied over the femoral nerve vs. the quadriceps muscle. NMES was delivered to evoke 10 and 20% of maximum voluntary isometric contraction torque 2–3 s into the NMES (time1) in two patterns: 1) constant frequency (15 Hz for 8 s); and 2) step frequency (15–100-15 Hz and 25–100-25 Hz for 3–2-3 s, respectively). Torque and electromyographic activity recorded from vastus lateralis and medialis were quantified at the beginning (time1) and end (time2; 6–7 s into the NMES) of each pattern. M-waves (peripheral pathway), H-reflexes, and asynchronous activity (central pathways) during NMES were quantified. Torque did not differ regardless of NMES location, pattern, or time. For both muscles, M-waves were ∼7–10 times smaller and H-reflexes ∼8–9 times larger during NMES over the nerve compared with over the muscle. However, unlike muscles studied previously, neither torque nor activity through central pathways were augmented following 100 Hz NMES, nor was any asynchronous activity evoked during NMES at either location. The coefficient of variation was also quantified at time2to determine the consistency of each dependent measure between three consecutive contractions. Torque, M-waves, and H-reflexes were most variable during NMES over the nerve. In summary, NMES over the nerve produced contractions with the greatest recruitment through central pathways; however, considering some of the limitations of NMES over the femoral nerve, it may be considered a good complement to, as opposed to a replacement for, NMES over the quadriceps muscle for maintaining muscle quality and reducing contraction fatigue during NMES rehabilitation.

Measuring perfusion and bioenergetics simultaneously in mouse skeletal muscle: a multiparametric functional-NMR approach

A totally noninvasive set-up was developed for comprehensive NMR evaluation of mouse skeletal muscle function in vivo. Dynamic pulsed arterial spin labeling-NMRI perfusion and blood oxygenation level-dependent (BOLD) signal measurements were interleaved with (31)P NMRS to measure both vascular response and oxidative capacities during stimulated exercise and subsequent recovery. Force output was recorded with a dedicated ergometer. Twelve exercise bouts were performed. The perfusion, BOLD signal, pH and force-time integral were obtained from mouse legs for each exercise. All reached a steady state after the second exercise, justifying the pointwise summation of the last 10 exercises to compensate for the limited (31)P signal. In this way, a high temporal resolution of 2.5  s was achieved to provide a time constant for phosphocreatine (PCr) recovery (τ(PCr)). The higher signal-to-noise ratio improved the precision of τ(PCr) measurement [coefficient of variation (CV) = 16.5% vs CV = 49.2% for a single exercise at a resolution of 30  s]. Inter-animal summation confirmed that τ(PCr) was stable at steady state, but shorter (89.3 ± 8.6  s) than after the first exercise (148  s, p < 0.05). This novel experimental approach provides an assessment of muscle vascular response simultaneously to energetic function in vivo. Its pertinence was illustrated by observing the establishment of a metabolic steady state. This comprehensive tool offers new perspectives for the study of muscle pathology in mice models.

Comparison of quadriceps inactivation between nerve and muscle stimulation

We evaluated the use of direct muscle stimulation for quantifying quadriceps inactivation at different contraction levels as opposed to conventional twitch interpolation using nerve stimulation. Fourteen healthy volunteers were tested. Paired stimuli were delivered to the femoral nerve or to the quadriceps muscle belly during voluntary contractions ranging from 20% to 100% of maximum, and the amplitude of the superimposed doublet was quantified to investigate inactivation. Superimposed doublet for muscle and nerve stimulation, respectively between the range of 60% to 100% of maximum (e.g., at 100%, muscle stimulation was 14 ± 5 Nm and nerve stimulation was 15 ± 6 Nm). Despite higher current doses, muscle stimulation was associated with less discomfort than nerve stimulation (P < 0.05). Collectively, our data suggest that direct muscle stimulation could be used to assess quadriceps inactivation at maximal and quasi-maximal contraction levels as a valid alternative to motor nerve stimulation.

Impact of preinduced quadriceps fatigue on exercise response in chronic obstructive pulmonary disease and healthy subjects

Exercise intolerance in chronic obstructive pulmonary disease (COPD) results from a complex interaction between central (ventilatory) and peripheral (limb muscles) components of exercise limitation. The purpose of this study was to evaluate the influence of quadriceps muscle fatigue on exercise tolerance and ventilatory response during constant-workrate cycling exercise testing (CWT) in patients with COPD and healthy subjects. Fifteen patients with COPD and nine age-matched healthy subjects performed, 7 days apart, two CWTs up to exhaustion at 80% of their predetermined maximal work capacity. In a randomized order, one test was performed with preinduced quadriceps fatigue and the other in a fresh state. Quadriceps fatigue was produced by electrostimulation-induced contractions and quantified by maximal voluntary contraction and potentiated twitch force (TwQpot). Endurance time and ventilatory response during CWT were compared between fatigued and fresh state. Endurance time significantly decreased in the fatigued state compared with the fresh condition in COPD (356 ± 69 s vs. 294 ± 45 s, P < 0.05) and controls (450 ± 74 s vs. 340 ± 45 s, P < 0.05). Controls showed significantly higher ventilation and end-exercise dyspnea scores in the fatigued condition, whereas, in COPD, fatigue did not influence ventilation or dyspnea during exercise. The degree of ventilatory limitation, as expressed by the V̇e/maximum voluntary ventilation ratio, was similar in both conditions in patients with COPD. We conclude that it is possible to induce quadriceps fatigue by local electrostimulation-induced contractions. Our findings demonstrate that peripheral muscle fatigue is an additional important factor, besides intense dyspnea, that limits exercise tolerance in COPD.

Age-related fatigue resistance in the knee extensor muscles is specific to contraction mode

The question of whether skeletal muscle fatigue is preserved or enhanced in older adults is a point of controversy. Disparate findings may be attributed to differences in subject population and study protocols, including contraction mode. The purpose of this study was to test the hypotheses that healthy older (65-80 years of age, 8 males and 8 females) adults who were matched to young adults (21-35 years of age; 8 males and 8 females) with similar physical activity levels would: (1) fatigue less during isometric knee extensor (KE) contractions, but (2) would show similar fatigue during dynamic KE contractions performed at 120 degrees s(-1). Fatigue was induced with 4 minutes of intermittent, isometric, or dynamic maximal voluntary contractions, performed on separate days. Electrically stimulated contractions were used to evaluate central activation during both fatigue protocols. Older subjects maintained a higher percentage of baseline maximum voluntary contraction (MVC) torque than young subjects during isometric contractions (mean +/- SE: 71 +/- 3% and 57 +/- 3%, respectively, P < 0.01). In contrast, there was no difference between age groups in torque maintenance during dynamic contractions (43 +/- 3% and 44 +/- 3%, respectively, P = 0.86). For both groups, changes in electrically stimulated and voluntary contractions followed similar trends, suggesting that central activation did not play a role in the age-related differences in fatigue. Fatigue during the isometric protocol was associated with fatigue during the dynamic protocol in the young group only (r = 0.62, P = 0.01), suggesting that distinct mechanisms influence fatigue during isometric and dynamic contractions in older adults. Muscle Nerve 39: 692-702, 2009.

Relative torque contribution of vastus medialis muscle at different knee angles

AIM

We investigated the relative contribution of the vastus medialis (VM) muscle to total isometric knee extension torque at 10 degrees , 30 degrees , 60 degrees and 90 degrees knee flexion. In the past a more prominent role of the VM muscle at more extended knee angles has been put forward. However, different components of the quadriceps muscle converge via a common distal tendon. We therefore hypothesized that the relative contribution of the VM to total knee extension torque would be similar across angles.

METHODS

At each knee angle the EMG isometric torque relations [20%, 25%, 30%, 35% maximal voluntary contraction (MVC)] of the rectus femoris (RF), vastus lateralis (VL) and VM muscle were established in 10 healthy male subjects; rectified surface EMG was normalized to M-wave area. Subsequently, the VM was functionally eliminated by selective electrical surface stimulation with occluded blood flow.

RESULTS

There was no evidence for preferential activation of VM at any of the knee angles. Following VM elimination, total knee extension torque during maximal femoral nerve stimulation (three pulses at 300 Hz) at 10 degrees , 30 degrees , 60 degrees and 90 degrees , respectively, decreased (P < 0.05) to (mean +/- SD): 75.7 +/- 12.2, 75.1 +/- 9.3, 78.2 +/- 7.2 and 76.0 +/- 5.8% (P > 0.05 among knee angles). In addition, during voluntary contractions at 20% MVC the increases in torque output of RF and VL compensating for the loss of VM function were calculated from the increases in EMG and found to be similar (P > 0.05) at 10 degrees , 30 degrees , 60 degrees and 90 degrees values (%MVC), respectively, were: 9.1 +/- 6.8, 7.5 +/- 2.9, 5.9 +/- 3.7 and 6.9 +/- 3.4.

CONCLUSION

The present findings support our hypothesis that the VM contributes similarly to total knee extension torque at different knee angles.

Electrical stimulation as a modality to improve performance of the neuromuscular system

Transcutaneous neuromuscular electrical stimulation (NMES) can modify the order of motor unit recruitment and has a profound influence on the metabolic demand associated with producing a given muscle force. Because of these differences, interventions that combine NMES with voluntary contractions can provide beneficial outcomes for some individuals. The adaptations evoked by NMES are not confined to the activated muscle but also involve neural adaptations through reflex inputs to the spinal cord and supraspinal centers.

Electrostimulation improves muscle perfusion but does not affect either muscle deoxygenation or pulmonary oxygen consumption kinetics during a heavy constant-load exercise

Electromyostimulation (EMS) is commonly used as part of training programs. However, the exact effects at the muscle level are largely unknown and it has been recently hypothesized that the beneficial effect of EMS could be mediated by an improved muscle perfusion. In the present study, we investigated rates of changes in pulmonary oxygen consumption (VO(2p)) and muscle deoxygenation during a standardized exercise performed after an EMS warm-up session. We aimed at determining whether EMS could modify pulmonary O(2) uptake and muscle deoxygenation as a result of improved oxygen delivery. Nine subjects performed a 6-min heavy constant load cycling exercise bout preceded either by an EMS session (EMS) or under control conditions (CONT). VO(2p) and heart rate (HR) were measured while deoxy-(HHb), oxy-(HbO(2)) and total haemoglobin/myoglobin (Hb(tot)) relative contents were measured using near infrared spectroscopy. EMS significantly increased (P < 0.05) the Hb(tot) resting level illustrating a residual hyperaemia. The EMS priming exercise did not affect either the HHb time constant (17.7 +/- 14.2 s vs. 13.1 +/- 2.3 s under control conditions) or the VO(2p) kinetics (time-constant = 18.2 +/- 5.2 s vs. 15.4 +/- 4.6 s under control conditions). Likewise, the other VO(2p) parameters were unchanged. Our results further indicated that EMS warm-up improved muscle perfusion through a residual hyperaemia. However, neither VO(2p) nor [HHb] kinetics were modified accordingly. These results suggest that improved O(2) delivery by residual hyperaemia induced by EMS does not accelerate the rate of aerobic metabolism during heavy exercise at least in trained subjects.

Neuromuscular electrical stimulation in neurorehabilitation

This review provides a comprehensive overview of the clinical uses of neuromuscular electrical stimulation (NMES) for functional and therapeutic applications in subjects with spinal cord injury or stroke. Functional applications refer to the use of NMES to activate paralyzed muscles in precise sequence and magnitude to directly accomplish functional tasks. In therapeutic applications, NMES may lead to a specific effect that enhances function, but does not directly provide function. The specific neuroprosthetic or "functional" applications reviewed in this article include upper- and lower-limb motor movement for self-care tasks and mobility, respectively, bladder function, and respiratory control. Specific therapeutic applications include motor relearning, reduction of hemiplegic shoulder pain, muscle strengthening, prevention of muscle atrophy, prophylaxis of deep venous thrombosis, improvement of tissue oxygenation and peripheral hemodynamic functioning, and cardiopulmonary conditioning. Perspectives on future developments and clinical applications of NMES are presented.

Differential changes in muscle oxygenation between voluntary and stimulated isometric fatigue of human dorsiflexors

The purpose of this study was to compare fatigue and recovery of maximal voluntary torque [maximal voluntary contraction (MVC)] and muscle oxygenation after voluntary (Vol) and electrically stimulated (ES) protocols of equal torque production. On 1 day, 10 male subjects [25 yr (SD 4)] completed a Vol fatigue protocol and, on a separate day, an ES fatigue protocol of the right dorsiflexors. Each task involved 2 min of intermittent (2-s on, 1-s off) isometric contractions at 50% of MVC. For the ES protocol, stimulation was delivered percutaneously to the common peroneal nerve at a frequency of 25 Hz. Compared with the Vol protocol, the ES protocol caused a greater impairment in MVC (75 vs. 83% prefatigue value; Pre) and greater increase in 50-Hz half relaxation time (165 vs. 117% Pre) postexercise. After acute (1 min) recovery, MVC impairment was similar for both protocols, whereas 50- Hz half relaxation time was still greater in the ES than Vol protocol. Total hemoglobin decreased to a similar extent in both protocols during exercise, but it was elevated above the resting value to a significantly greater extent for the ES protocol in recovery (18 vs. 11 microM). Oxygen saturation was significantly lower in the ES than Vol protocol during exercise (46 vs. 57% Pre), but it was significantly greater during recovery (120 vs. 105% Pre). These findings suggest that despite, equal torque production, ES contractions impose a greater metabolic demand on the muscle that leads to a transient greater impairment in MVC. The enforced synchronization and fixed frequency of excitation inherent to ES are the most likely causes for the exacerbated changes in the ES compared with the Vol protocol.

A comparison of voluntary and electrically induced contractions by interleaved 1H- and 31P-NMRS in humans

Skeletal muscle voluntary contractions (VC) and electrical stimulations (ES) were compared in eight healthy men. High-energy phosphates and myoglobin oxygenation were simultaneously monitored in the quadriceps by interleaved (1)H- and (31)P-NMR spectroscopy. For the VC protocol, subjects performed five or six bouts of 5 min with a workload increment of 10% of maximal voluntary torque (MVT) at each step. The ES protocol consisted of a 13-min exercise with a load corresponding to 10% MVT. For both protocols, exercise consisted of 6-s isometric contractions and 6-s rest cycles. For an identical mechanical level (10% MVT), ES induced larger changes than VC in the P(i)-to-phosphocreatine ratio [1.38 +/- 1.14 (ES) vs. 0.13 +/- 0.04 (VC)], pH [6.69 +/- 0.11 (ES) vs. 7.04 +/- 0.07 (VC)] and myoglobin desaturation [43 +/- 15.9 (ES) vs. 6.1 +/- 4.6% (VC)]. ES activated the muscle facing the NMR coil to a greater extent than did VCs when evaluated under identical technical conditions. This metabolic pattern can be interpreted in terms of specific temporal and spatial muscle cell recruitment. Furthermore, at identical levels of energy charge, the muscle was more acidotic and cytoplasm appeared more oxygenated during ES than during VC. These results are in accordance with a preferential recruitment of type II fibers and a relative muscle hyperperfusion during ES.

Agonist-antagonist common drive during fatiguing knee extension efforts using surface electromyography

AIM

This study examined the electromyographic (EMG) activity of knee extensor agonists and a knee extensor antagonist muscle during fatiguing isometric extensions across a range of force levels.

METHODS

Five female subjects performed isometric knee extensions at 25%, 50%, 75% and 100% of their maximal voluntary contraction (MVC) with the knee flexed to 75 degrees. Surface EMG (SEMG) was recorded with bipolar electrodes from the vastus lateralis (VL), vastus medialis (VM), rectus femoris (RF) and biceps femoris (BF) and the root-mean-squared (RMS) amplitude and the percentage frequency compression of these recordings were calculated. Commonality and cross talk between recordings were also examined.

RESULTS

Cross talk between recordings was deemed negligible despite significant levels of commonality between the agonist and antagonist SEMG, which was attributed to common drive. SEMG RMS amplitude increased significantly for all muscles during the 25%, 50%, 75% MVC knee extensions until task failure, and decreased significantly for 100% MVC. The frequency spectrum of the SEMG compressed significantly for all muscles and % MVC levels. The VM, VL and BF SEMG recordings responded similarly to fatigue. The RF's frequency spectrum compressed to a significantly higher degree.

CONCLUSIONS

The VM, VL, RF, and BF fatigue in parallel, with high similarity between VM, VL and BF, giving support to the concept of a shared agonist-antagonist motoneuron pool.

Vastus lateralis fatigue alters recruitment of musculus quadriceps femoris in humans

This study tested the hypothesis that fatigue of a single member of musculus quadriceps femoris (QF) would alter use of the other three muscles during knee extension exercise (KEE). Six men performed KEE with the left QF at a load equal to 50% of the 4 x 10 repetitions maximum. Subsequently, electromyostimulation (EMS), intended to stimulate and fatigue the left m. vastus lateralis (VL), was applied for 30 min. Immediately after EMS, subjects repeated the KEE. Transverse relaxation time (T2)-weighted magnetic resonance images were taken before and after each bout of KEE and at 3 and 30 min of EMS to assess use and stimulation, respectively, of the QF. T2 of each of the QF muscles was increased 8-13% after the first KEE. During EMS, T2 increased (P < 0.05) even more in VL (10%), whereas it decreased (P < 0.05) to pre-KEE levels in m. vastus medials (VM) and m. rectus femoris (RF). The VL and, to some extent, the m. vastus intermedius were stimulated, whereas the VM and RF were not, thereby recovering from the first bout of KEE. Isometric torque, initially 30% of maximal voluntary, was reduced to 13% at 3 min and 7% at 30 min. T2 was greater (P < 0.05) after the second than the first bout of KEE, especially the increase for the VM and RF. These results suggest that subjects were able to perform the second bout with little contribution of the VL by greater use of the other QF muscles. The simplest explanation is increased central command to the QF such that the intended act could be accomplished despite acute fatigue of one of its synergists.