Low-frequency fatigue in individuals with spinal cord injury

Impact of rehabilitation on volumetric muscle loss in subjects with traumatic spinal cord injury: A systematic review

BACKGROUND

Spinal cord injury (SCI) leads to spinal nerve fiber tract damage resulting in functional impairments. Volumetric muscle loss (VML), a skeletal muscle volume abnormal reduction, is represented by atrophy below the injury level. The strategies for VML management included personalized approaches, and no definite indications are available.

OBJECTIVE

To identify the rehabilitation effects of VML in subjects with SCI (humans and animals).

METHODS

PubMed, Scopus, and Web of Science databases were systematically searched to identify longitudinal observational studies with individuals affected by traumatic SCI as participants; rehabilitation treatment as intervention; no control, sham treatment, and electrical stimulation programs as control; total lean body and lower limb lean mass, cross-sectional area, functional gait recovery, muscle thickness, and ultrasound intensity, as outcome.

RESULTS

Twenty-four longitudinal observational studies were included, evaluating different rehabilitation approaches' effects on the VML reduction in subjects affected by SCI. The data showed that electrical stimulation and treadmill training are effective in reducing the VML in this population.

CONCLUSION

This systematic review underlines the need to treat subjects with traumatic SCI (humans and animals) with different rehabilitation approaches to prevent VML in the subacute and chronic phases. Further clinical observations are needed to overcome the bias and to define the intervention's timing and modalities.

Invasive and Non-Invasive Approaches of Electrical Stimulation to Improve Physical Functioning after Spinal Cord Injury

This review of literature provides the latest evidence involving invasive and non-invasive uses of electrical stimulation therapies that assist in restoring functional abilities and the enhancement of quality of life in those with spinal cord injuries. The review includes neuromuscular electrical stimulation and functional electrical stimulation activities that promote improved body composition changes and increased muscular strength, which have been shown to improve abilities in activities of daily living. Recommendations for optimizing electrical stimulation parameters are also reported. Electrical stimulation is also used to enhance the skills of reaching, grasping, standing, and walking, among other activities of daily living. Additionally, we report on the use of invasive and non-invasive neuromodulation techniques targeting improved mobility, including standing, postural control, and assisted walking. We attempt to summarize the effects of epidural stimulation on cardiovascular performance and provide a mechanistic explanation to the current research findings. Future trends such as the combination of epidural stimulation and exoskeletal-assisted walking are also discussed.

Neural Network-Based Muscle Torque Estimation Using Mechanomyography During Electrically-Evoked Knee Extension and Standing in Spinal Cord Injury

This study sought to design and deploy a torque monitoring system using an artificial neural network (ANN) with mechanomyography (MMG) for situations where muscle torque cannot be independently quantified. The MMG signals from the quadriceps were used to derive knee torque during prolonged functional electrical stimulation (FES)-assisted isometric knee extensions and during standing in spinal cord injured (SCI) individuals. Three individuals with motor-complete SCI performed FES-evoked isometric quadriceps contractions on a Biodex dynamometer at 30° knee angle and at a fixed stimulation current, until the torque had declined to a minimum required for ANN model development. Two ANN models were developed based on different inputs; Root mean square (RMS) MMG and RMS-Zero crossing (ZC) which were derived from MMG. The performance of the ANN was evaluated by comparing model predicted torque against the actual torque derived from the dynamometer. MMG data from 5 other individuals with SCI who performed FES-evoked standing to fatigue-failure were used to validate the RMS and RMS-ZC ANN models. RMS and RMS-ZC of the MMG obtained from the FES standing experiments were then provided as inputs to the developed ANN models to calculate the predicted torque during the FES-evoked standing. The average correlation between the knee extension-predicted torque and the actual torque outputs were 0.87 ± 0.11 for RMS and 0.84 ± 0.13 for RMS-ZC. The average accuracy was 79 ± 14% for RMS and 86 ± 11% for RMS-ZC. The two models revealed significant trends in torque decrease, both suggesting a critical point around 50% torque drop where there were significant changes observed in RMS and RMS-ZC patterns. Based on these findings, both RMS and RMS-ZC ANN models performed similarly well in predicting FES-evoked knee extension torques in this population. However, interference was observed in the RMS-ZC values at a time around knee buckling. The developed ANN models could be used to estimate muscle torque in real-time, thereby providing safer automated FES control of standing in persons with motor-complete SCI.

Endurance neuromuscular electrical stimulation training improves skeletal muscle oxidative capacity in individuals with motor-complete spinal cord injury

INTRODUCTION

Spinal cord injury (SCI) results in skeletal muscle atrophy, increases in intramuscular fat, and reductions in skeletal muscle oxidative capacity. Endurance training elicited with neuromuscular electrical stimulation (NMES) may reverse these changes and lead to improvement in muscle metabolic health.

METHODS

Fourteen participants with complete SCI performed 16 weeks of home-based endurance NMES training of knee extensor muscles. Skeletal muscle oxidative capacity, muscle composition, and blood metabolic and lipid profiles were assessed pre- and post-training.

RESULTS

There was an increase in number of contractions performed throughout the duration of training. The average improvement in skeletal muscle oxidative capacity was 119%, ranging from -14% to 387% (P = 0.019). There were no changes in muscle composition or blood metabolic and lipid profiles.

CONCLUSION

Endurance training improved skeletal muscle oxidative capacity, but endurance NMES of knee extensor muscles did not change blood metabolic and lipid profiles. Muscle Nerve 55: 669-675, 2017.

Fatigue reduction during aggregated and distributed sequential stimulation

INTRODUCTION

Transcutaneous neuromuscular electrical stimulation (NMES) can generate muscle contractions for rehabilitation and exercise. However, NMES-evoked contractions are limited by fatigue when they are delivered "conventionally" (CONV) using a single active electrode. Researchers have developed "sequential" (SEQ) stimulation, involving rotation of pulses between multiple "aggregated" (AGGR-SEQ) or "distributed" (DISTR-SEQ) active electrodes, to reduce fatigue (torque-decline) by reducing motor unit discharge rates. The primary objective was to compare fatigue-related outcomes, "potentiation," "variability," and "efficiency" between CONV, AGGR-SEQ, and DISTR-SEQ stimulation of knee extensors in healthy participants.

METHODS

Torque and current were recorded during testing with fatiguing trains using each NMES type under isometric and isokinetic (180°/s) conditions.

RESULTS

Compared with CONV stimulation, SEQ techniques reduced fatigue-related outcomes, increased potentiation, did not affect variability, and reduced efficiency.

CONCLUSIONS

SEQ techniques hold promise for reducing fatigue during NMES-based rehabilitation and exercise; however, optimization is required to improve efficiency. Muscle Nerve 56: 271-281, 2017.

Strategies for Rapid Muscle Fatigue Reduction during FES Exercise in Individuals with Spinal Cord Injury: A Systematic Review

Background

Rapid muscle fatigue during functional electrical stimulation (FES)-evoked muscle contractions in individuals with spinal cord injury (SCI) is a significant limitation to attaining health benefits of FES-exercise. Delaying the onset of muscle fatigue is often cited as an important goal linked to FES clinical efficacy. Although the basic concept of fatigue-resistance has a long history, recent advances in biomedical engineering, physiotherapy and clinical exercise science have achieved improved clinical benefits, especially for reducing muscle fatigue during FES-exercise. This review evaluated the methodological quality of strategies underlying muscle fatigue-resistance that have been used to optimize FES therapeutic approaches. The review also sought to synthesize the effectiveness of these strategies for persons with SCI in order to establish their functional impacts and clinical relevance.

Methods

Published scientific literature pertaining to the reduction of FES-induced muscle fatigue was identified through searches of the following databases: Science Direct, Medline, IEEE Xplore, SpringerLink, PubMed and Nature, from the earliest returned record until June 2015. Titles and abstracts were screened to obtain 35 studies that met the inclusion criteria for this systematic review.

Results

Following the evaluation of methodological quality (mean (SD), 50 (6) %) of the reviewed studies using the Downs and Black scale, the largest treatment effects reported to reduce muscle fatigue mainly investigated isometric contractions of limited functional and clinical relevance (n = 28). Some investigations (n = 13) lacked randomisation, while others were characterised by small sample sizes with low statistical power. Nevertheless, the clinical significance of emerging trends to improve fatigue-resistance during FES included (i) optimizing electrode positioning, (ii) fine-tuning of stimulation patterns and other FES parameters, (iii) adjustments to the mode and frequency of exercise training, and (iv) biofeedback-assisted FES-exercise to promote selective recruitment of fatigue-resistant motor units.

Conclusion

Although the need for further in-depth clinical trials (especially RCTs) was clearly warranted to establish external validity of outcomes, current evidence was sufficient to support the validity of certain techniques for rapid fatigue-reduction in order to promote FES therapy as an integral part of SCI rehabilitation. It is anticipated that this information will be valuable to clinicians and other allied health professionals administering FES as a treatment option in rehabilitation and aid the development of effective rehabilitation interventions.

Neuromuscular Electrical Stimulation-Induced Resistance Training After SCI: A Review of the Dudley Protocol

BACKGROUND

Neuromuscular electrical stimulation (NMES), often referred to as functional electrical stimulation (FES), has been used to activate paralyzed skeletal muscle in people with spinal cord injury (SCI). The goal of NMES has been to reverse some of the dramatic losses in skeletal muscle mass, to stimulate functional improvements in people with incomplete paralysis, and to produce some of the health benefits associated with exercise.

OBJECTIVE

The purpose of this brief review is to describe a quantifiable resistance training form of NMES developed by Gary A. Dudley.

METHODS

People with motor complete SCI were first tested to confirm that an NMES-induced muscle contraction of the quadriceps muscle could be achieved. The contraction stimulus consisted of biphasic pulses at 35 Hz performed with increasing current up to what was needed to produce full knee extension. Four sets of 10 knee extensions were elicited, if possible. Training occurred biweekly for 3 to 6 months, with ankle weights being increased up to an added weight of 9.1 kg if the 40 repetitions could be performed successfully for 2 sessions.

RESULTS

Many participants have performed this protocol without adverse events, and all participants showed progression in the number of repetitions and/or the amount of weight lifted. Large increases in muscle mass occur, averaging 30% to 40%. Additional physiological adaptations to stimulated muscle have also been reported.

CONCLUSIONS

These results demonstrate that the affected skeletal muscle after SCI responds robustly to progressive resistance training many years after injury. Future work with NMES should determine whether gains in lean mass translate to improved health, function, and quality of life.

The effects of electrical stimulation on body composition and metabolic profile after spinal cord injury--Part II

Diet and exercise are cornerstones in the management of obesity and associated metabolic complications, including insulin resistance, type 2 diabetes, and disturbances in the lipid profile. However, the role of exercise in managing body composition adaptations and metabolic disorders after spinal cord injury (SCI) is not well established. The current review summarizes evidence about the efficacy of using neuromuscular electrical stimulation or functional electrical stimulation in exercising the paralytic lower extremities to improve body composition and metabolic profile after SCI. There are a number of trials that investigated the effects on muscle cross-sectional area, fat-free mass, and glucose/lipid metabolism. The duration of the intervention in these trials varied from 6 weeks to 24 months. Training frequency ranged from 2 to 5 days/week. Most studies documented significant increases in muscle size but no noticeable changes in adipose tissue. While increases in skeletal muscle size after twice weekly training were greater than those trials that used 3 or 5 days/week, other factors such as differences in the training mode, i.e. resistance versus cycling exercise and pattern of muscle activation may be responsible for this observation. Loading to evoke muscle hypertrophy is a key component in neuromuscular training after SCI. The overall effects on lean mass were modest and did not exceed 10% and the effects of training on trunk or pelvic muscles remain unestablished. Most studies reported improvement in glucose metabolism with the enhancement of insulin sensitivity being the major factor following training. The effect on lipid profile is unclear and warrants further investigation.

Skeletal muscle fatigue

Skeletal muscle fatigue is defined as the fall of force or power in response to contractile activity. Both the mechanisms of fatigue and the modes used to elicit it vary tremendously. Conceptual and technological advances allow the examination of fatigue from the level of the single molecule to the intact organism. Evaluation of muscle fatigue in a wide range of disease states builds on our understanding of basic function by revealing the sources of dysfunction in response to disease.

Near-infrared assessments of skeletal muscle oxidative capacity in persons with spinal cord injury

After spinal cord injury (SCI) skeletal muscle decreases in size, increases in intramuscular fat, and has potential declines in mitochondrial function. Reduced mitochondrial function has been linked to the development of metabolic disease. The aim of this study was to measure mitochondrial function in persons with SCI using near-infrared spectroscopy (NIRS). Oxygen consumption of the vastus lateralis muscle was measured with NIRS during repeated short-duration arterial occlusions in nine able-bodied (AB) and nine persons with motor complete SCI. Skeletal muscle oxidative capacity (V max) was evaluated with two approaches: (1) rate constant of the recovery of oxygen consumption after exercise and (2) extrapolated maximum oxygen consumption from a progressive work test. V max as indicated by the rate constant (k) from the recovery kinetics test was lower in SCI compared with AB participants (k: SCI 0.7 ± 0.3 vs. AB 1.9 ± 0.4 min(-1); p < 0.001). Time constants were SCI 91.9 ± 37.8 vs. AB 33.6 ± 8.3 s. V max from the progressive work test approached a significant difference between groups (SCI 5.1 ± 2.9 vs. AB 9.8 ± 5.5 % Hb-Mb/s; p = 0.06). NIRS measurements of V max suggest a deficit of 50-60 % in participants with SCI compared with AB controls, consistent with previous studies using (31)P-MRS and muscle biopsies. NIRS measurements can assess mitochondrial capacity in people with SCI and potentially other injured/diseased populations.