Skeletal muscle adaptability. III: Muscle properties following chronic electrical stimulation

Procedures for obtaining muscle physiology parameters during a gracilis free-functioning muscle transfer in adult patients with brachial plexus injury

A complete understanding of muscle mechanics allows for the creation of models that closely mimic human muscle function so they can be used to study human locomotion and evaluate surgical intervention. This includes knowledge of muscle-tendon parameters required for accurate prediction of muscle forces. However, few studies report experimental data obtained directly from whole human muscle due to the invasive nature of these experiments. This article presents an intraoperative, in vivo measurement protocol for whole muscle-tendon parameters that include muscle-tendon unit length, sarcomere length, passive tension, and active tension in response to external stimulation. The advantage of this protocol is the ability to obtain these rare experimental data in situ in addition to muscle volume and weight since the gracilis is also completely removed from the leg. The entire protocol including the surgical steps for gracilis harvest takes ~ 3 h. Actual testing of the gracilis where experimental data is measured takes place within a 30-min window during surgery.

The role of the microcirculation in muscle function and plasticity

It is widely acknowledged that maintenance of muscle, size, strength and endurance is necessary for quality of life and the role that skeletal muscle microcirculation plays in muscle health is becoming increasingly clear. Here we discuss the role that skeletal muscle microcirculation plays in muscle function and plasticity. Besides the density of the capillary network, also the distribution of capillaries is crucial for adequate muscle oxygenation. While capillaries are important for oxygen delivery, the capillary supply to a fibre is related to fibre size rather than oxidative capacity. This link between fibre size and capillary supply is also reflected by the similar time course of hypertrophy and angiogenesis, and the cross-talk between capillaries and satellite cells. A dense vascular network may in fact be more important for a swift repair of muscle damage than the abundance of satellite cells and a lower capillary density may also attenuate the hypertrophic response. Capillary rarefaction does not only occur during ageing, but also during conditions as chronic heart failure, where endothelial apoptosis has been reported to precede muscle atrophy. It has been suggested that capillary rarefaction precedes sarcopenia. If so, stimulation of angiogenesis by for instance endurance training before a hypertrophic stimulus may enhance the hypertrophic response. The microcirculation may thus well be a little-explored target to improve muscle function and the success of rehabilitation programmes during ageing and chronic diseases.

Intramuscular connective tissue differences in spastic and control muscle: a mechanical and histological study

Cerebral palsy (CP) of the spastic type is a neurological disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks. Secondary to the spasticity, muscle adaptation is presumed to contribute to limitations in the passive range of joint motion. However, the mechanisms underlying these limitations are unknown. Using biopsies, we compared mechanical as well as histological properties of flexor carpi ulnaris muscle (FCU) from CP patients (n = 29) and healthy controls (n = 10). The sarcomere slack length (mean 2.5 µm, SEM 0.05) and slope of the normalized sarcomere length-tension characteristics of spastic fascicle segments and single myofibre segments were not different from those of control muscle. Fibre type distribution also showed no significant differences. Fibre size was significantly smaller (1933 µm2, SEM 190) in spastic muscle than in controls (2572 µm2, SEM 322). However, our statistical analyses indicate that the latter difference is likely to be explained by age, rather than by the affliction. Quantities of endomysial and perimysial networks within biopsies of control and spastic muscle were unchanged with one exception: a significant thickening of the tertiary perimysium (3-fold), i.e. the connective tissue reinforcement of neurovascular tissues penetrating the muscle. Note that this thickening in tertiary perimysium was shown in the majority of CP patients, however a small number of patients (n = 4 out of 23) did not have this feature. These results are taken as indications that enhanced myofascial loads on FCU is one among several factors contributing in a major way to the aetiology of limitation of movement at the wrist in CP and the characteristic wrist position of such patients.

Relationship between intensity of quadriceps muscle neuromuscular electrical stimulation and strength recovery after total knee arthroplasty

BACKGROUND

Neuromuscular electrical stimulation (NMES) can facilitate the recovery of quadriceps muscle strength after total knee arthroplasty (TKA), yet the optimal intensity (dosage) of NMES and its effect on strength after TKA have yet to be determined.

OBJECTIVE

The primary objective of this study was to determine whether the intensity of NMES application was related to the recovery of quadriceps muscle strength early after TKA. A secondary objective was to quantify quadriceps muscle fatigue and activation immediately after NMES to guide decisions about the timing of NMES during rehabilitation sessions.

DESIGN

This study was an observational experimental investigation.

METHODS

Data were collected from 30 people who were 50 to 85 years of age and who received NMES after TKA. These people participated in a randomized controlled trial in which they received either standard rehabilitation or standard rehabilitation plus NMES to the quadriceps muscle to mitigate strength loss. For the NMES intervention group, NMES was applied 2 times per day at the maximal tolerable intensity for 15 contractions beginning 48 hours after surgery over the first 6 weeks after TKA. Neuromuscular electrical stimulation training intensity and quadriceps muscle strength and activation were assessed before surgery and 3.5 and 6.5 weeks after TKA.

RESULTS

At 3.5 weeks, there was a significant association between NMES training intensity and a change in quadriceps muscle strength (R(2)=.68) and activation (R(2)=.22). At 6.5 weeks, NMES training intensity was related to a change in strength (R(2)=.25) but not to a change in activation (R(2)=.00). Furthermore, quadriceps muscle fatigue occurred during NMES sessions at 3.5 and 6.5 weeks, whereas quadriceps muscle activation did not change.

LIMITATIONS

Some participants reached the maximal stimulator output during at least 1 treatment session and might have tolerated more stimulation.

CONCLUSIONS

Higher NMES training intensities were associated with greater quadriceps muscle strength and activation after TKA.

Review of electrical stimulation in cerebral palsy and recommendations for future directions

Electrical stimulation (ES) for treatment of neuromuscular disorders is introduced. Various forms of ES are defined. Characteristics of cerebral palsy (CP) and treatment options are given. The clinical objectives of ES for CP treatment are stated. A review of the literature for treatment in CP is given. Several common themes within the literature and limitations in prior studies are explored. The majority of studies have used surface stimulation, which has several inherent limitations. To address these limitations, implanted devices may be used. Implanted device systems include percutaneous stimulation systems, and fully implantable leaded systems. While both of these technologies have advantages over surface stimulation, they also have their own limitations. To further address the limitations of percutaneous and fully implantable leaded systems, the Alfred Mann Foundation has developed a completely implantable, telemetered device known as the Radio Frequency Microstimulator (RFM). Results from a study using the RFM for arm rehabilitation in poststroke patients are given. A list of desirable design features for an ES system for CP is given. The next generation microstimulator device under development at the Alfred Mann Foundation is presented. This device may well serve the needs for ES in CP.

Effects of chronic electrical stimulation on paralyzed expiratory muscles

Following spinal cord injury, the expiratory muscles develop significant disuse atrophy characterized by reductions in their weight, fiber cross-sectional area, and force-generating capacity. We determined the extent to which these physiological alterations can be prevented with electrical stimulation. Because a critical function of the expiratory muscles is cough generation, an important goal was the maintenance of maximal force production. In a cat model of spinal cord injury, short periods of high-frequency lower thoracic electrical spinal cord stimulation (SCS) at the T(10) level (50 Hz, 15 min, twice/day, 5 days/wk) were initiated 2 wk following spinalization and continued for a 6-mo period. Airway pressure (P)-generating capacity was determined by SCS. Five acute, spinalized animals served as controls. Compared with controls, initial P fell from 43.9 +/- 1.0 to 41.8 +/- 0.7 cmH(2)O (not significant) in the chronic animals. There were small reductions in the weight of the external oblique, internal oblique, transverses abdominis, internal intercostal, and rectus abdominis muscles (not significant for each). There were no significant changes in the population of fast muscle fibers. Because prior studies (Kowalski KE, Romaniuk JR, DiMarco AF. J Appl Physiol 102: 1422-1428, 2007) have demonstrated significant atrophy following spinalization in this model, these results indicate that expiratory muscle atrophy can be prevented by the application of short periods of daily high-frequency stimulation. Because the frequency of stimulation is similar to the expected pattern of clinical use for cough generation, the daily application of electrical stimulation could potentially serve the dual purpose of maintenance of expiratory muscle function and airway clearance.

Evaluation of healthy and diseased muscle with magnetic resonance elastography

OBJECTIVE

To investigate whether a new tissue-imaging technique, magnetic resonance elastography (MRE), offers a viable, noninvasive way to study healthy and diseased muscle.

DESIGN

Convenience sample.

SETTING

A magnetic resonance imaging (MRI) laboratory.

PARTICIPANTS

Eight control subjects (4 men, 4 women), between the ages of 24 and 41 years, with normal neuromuscular examinations and histories, and 6 subjects (3 men, 3 women), ages 17 to 63 years, with lower-extremity neuromuscular dysfunction (1 with childhood poliomyelitis, 2 with flaccid, 3 with spastic paraplegia).

INTERVENTIONS

Subjects lay supine with their legs within the coils of a 1.5T MRI machine, with their feet strapped to a footplate positioned so that the axes of rotation of their ankles coincided with the apparatus. All subjects were tested in a no-load (0 torque) condition. Control subjects were also evaluated as they isometrically resisted ankle dorsi- (20.2Nm, 40.5Nm) and plantar- (8.2Nm, 16.4Nm) flexion moments. Subjects with neuromuscular dysfunction were evaluated in the same manner, except 1 individual with residual lower-extremity strength who could only be tested in the resting and passive ankle dorsiflexion modes. Shear waves were induced with a 150-Hz electromechanic transducer located over the belly tibialis anterior. MRE images were collected with a gradient-echo technique gated to the transducer's motion. Wave-phase propagation was visualized with 8 equally offset images across 1 vibration-cycle.

MAIN OUTCOME MEASURES

Changes in shear-wave wavelength (lambda) and muscle stiffness (as expressed by the shear modulus [G]) in the tibialis anterior and gastrocnemius muscles.

RESULTS

Wavelength and G differed between the groups in all the muscles studied, and increased as the load increased. Moreover, lambda and G in the neuromuscular disease group at rest (eg, 3.88+/-0.48cm; range, 2.87-4.91cm; 38.40+/-00.77kPa; range, 22.35-59.67kPa) and in the lateral gastrocnemius were, respectively, more than 1.5 and 2.4 times larger than they were in the same muscle in the control group (2.56+/-0.28cm, 16.16+/-00.19kPa; P=.0002) (1Pa=1N/m(2)).

CONCLUSIONS

Shear-wave wavelength and muscle stiffness increased with load in healthy muscle. In addition, at least for our sample, these quantities differed significantly between muscles with and without neuromuscular disease. In summary, MRE appears to provide in vivo physiologic information about the mechanical properties of muscle at rest and during contraction that is not otherwise available. The potential of this technique for monitoring the effects of treatment and exercise on both healthy and diseased muscle merits further research.

Mechanisms of muscle injury gleaned from animal models

Eccentric contractions of skeletal muscles produce injury and, ultimately, muscle strengthening. Current data suggest that the earliest events associated with injury are mechanical in nature and may be based primarily on the sarcomere strain experienced by the muscle. In this review, recent experimental data, primarily from rabbit dorsiflexor muscles, are used to provide general information regarding the factors that cause injury and means for preventing injury. Mechanical experiments reveal that excessive sarcomere strain is the primary cause of injury. We hypothesize that excessive strain permits extracellular or intracellular membrane disruption that may permit hydrolysis of structural proteins, leading to the myofibrillar disruption that is commonly observed. Inflammation that occurs after injury further degrades the tissue, but prevention of the inflammation leads to a long-term loss in muscle function. Simple preventative treatments such as increasing muscle oxidative capacity (getting into shape) or cyclic stress-relaxation of tissue (stretching out) have no measurable effect on the magnitude of muscle injury that occurs. Ultimately, an improved understanding of the damage mechanism may improve our ability to provide rehabilitative and strengthening prescriptions that have a rational scientific basis.

Mechanisms of muscle injury after eccentric contraction

Eccentric contractions of skeletal muscles produce injury and, ultimately, muscle strengthening. Current data suggests that the earliest events associated with injury are mechanical in nature and may be based primarily on the sarcomere strain experienced by the muscle. In this review, recent experimental data, primarily from rabbit dorsiflexor muscles, are used to provide general information regarding the factors that cause injury and means for preventing injury. Mechanical experiments reveal that excessive sarcomere strain is the primary cause of injury. We hypothesize that excessive strain permits extracellular or intracellular membrane disruption that may permit hydrolysis of structural proteins leading to the myofibrillar disruption that is commonly observed. Inflammation that occurs after injury actually further degrades the tissue, but prevention of the inflammation leads to a long-term loss in muscle function. Simple treatments such as increasing muscle oxidative capacity ("getting into shape") or cyclic stress-relaxation of tissue ("stretching out") have no measurable effect on the magnitude of muscle injury that occurs. Ultimately, an improved understanding of the damage mechanism may improve our ability to provide rehabilitative and strengthening prescriptions that have a rational scientific basis.

Electrical stimulation of denervated muscle: is it worthwhile?

Research conducted over the past 25 years has demonstrated that muscle activity, not neurotrophic substances, is the most important factor in the regulation of specific physiological and biochemical properties of muscle fibers. Application of this knowledge has led to considerable experimentation with chronic electrical stimulation as a possible clinical tool for the treatment of denervated muscles. Evidence accumulated from animal studies has indicated that direct electrical stimulation of denervated muscles can to a large extent substitute for innervation and preserve or restore the normal properties of the muscles. Appropriate stimulation parameters were critical for a successful intervention, and the best results were obtained when the stimulation pattern resembled the firing pattern of the normal motoneuron. Thus, fast muscles required intermittent, brief, high frequency stimulation and slow muscles needed continuous, low frequency stimulation. For human denervated muscles, critical questions still remain to be resolved before electrical stimulation will yield the optimum benefit. Research must be performed in human subjects to define the appropriate stimulation parameters the stimulation current, and the type and placement of electrodes.

Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery

Neuromuscular electrical stimulation and voluntary muscle contraction are two exercise modes widely used in rehabilitation to strengthen skeletal muscle. Since there is no debate as to which mode is most effective, we compared electrical stimulation with voluntary contraction performed at matched intensities following reconstructive surgery of the anterior cruciate ligament. Forty men and women, aged 15-44, were randomly assigned to either an electrical stimulation or a voluntary contraction group. None of the subjects had a previous history of neuromuscular injury. The subjects received treatment for 30 minutes a day, 5 days a week, for 4 weeks. Knee extension torque was monitored during treatment to try to match the absolute muscular tensions (quantified as "activity") achieved during therapy. To match the activity of the subjects in the electrical stimulation group, who were treated at the highest stimulation intensity they could tolerate, the subjects in the voluntary contraction group were paced at progressively increasing intensities corresponding to 15, 25, 35, and 45% of the injured limb's maximum voluntary torque during weeks 1, 2, 3, and 4, respectively. We found no significant difference between the groups in terms of maximum voluntary knee extension torque throughout the study period. In addition, 1 year after surgery, there was still no significant difference between groups with regard to knee extension torque (p > 0.4). These data suggest that neuromuscular electrical stimulation and voluntary muscle contraction treatments, when performed at the same intensity, are equally effective in strengthening skeletal muscle that has been weakened by surgical repair of the anterior cruciate ligament.

Influence of electrical stimulation of the tibialis anterior muscle in paraplegic subjects. 1. Contractile properties

In adult paraplegic subjects one tibialis anterior muscle received daily electrical stimulation for 4 weeks at twice motor threshold to determine changes of its contractile properties (this paper) and its morphological and histochemical profiles (following paper). Force, speed of contraction and fatigue resistance were assessed by percutaneous electrical stimulation of the muscle with torque measured about the ankle. Comparative contractile tests were performed on 51 normal adult subjects and new parameters for force measurement proposed, particularly where maximum voluntary contraction cannot be obtained. In paraplegic subjects before stimulation the tibialis anterior muscle showed evidence of disuse with decreased force, faster contraction and relaxation, and reduced fatigue resistance. The effects of two stimulus patterns were compared: 10 Hz, and 10 Hz with 100 Hz bursts. After stimulation contraction was slower, fatigue resistance increased and there was a tendency for force to increase. No differences occurred using the different stimulus patterns. Four weeks later fatigue resistance was partially maintained, while speed of contraction reverted to pre-stimulus levels.

Torque history of electrically stimulated human quadriceps: implications for stimulation therapy

The time course of knee extension torque was measured in human quadriceps muscles during 30 min of transcutaneous neuromuscular electrical stimulation (NMES). Ninety subjects were divided into six experimental groups (n = 15 per group), which received stimulation at one of the following frequency/duty cycle combinations: 10 Hz/50%, 30 Hz/50%, 50 Hz/50%, 10 Hz/70%, 30 Hz/70%, and 50 Hz/70%. Two-way analysis of variance revealed that the magnitude of the relative torque decrease (the percentage of decrease in torque relative to the initial value) was significantly different between frequencies (p < 0.005) and duty cycles (p < 0.02), with no significant interaction (p > 0.6). Increasing either frequency or duty cycle caused a greater decrease in torque. In spite of this result, there was no significant difference between groups in the total activity (torque-time integral) achieved during the 30 min treatment session. The magnitude of this activity corresponded to only about 7-14 maximum voluntary contractions. Finally, the average torque during the treatment session was significantly different among groups (p < 0.001), being greatest for the 50 Hz/50% group and least for the 10 Hz/70% group. Taken together, these data suggest that a smaller number of longer duration contractions produces the greatest muscle tension. They also suggest that the absolute torque levels achieved with NMES are relatively low compared with voluntary muscular activity.

The rehabilitation of children with spinal cord injury

Spinal cord injured children have special needs because of their potential for physical, intellectual, psychological and social growth. The overriding goal for comprehensive medical rehabilitation is to provide services required by the child for maximal recovery and to compensate for lost or impaired function while permitting the fullest development of potential in all areas. Because spinal cord injuries in childhood are not common, it is imperative that rehabilitation should be comprehensively coordinated and directed by a single specialist taking overall responsibility for the chronic phase of management. Rehabilitation involves the child and his family, a hospital-based and rehabilitation centre-based team and a school. Every effort must be made to prevent medical and/or physical complications that could interfere with rehabilitation or lead to greater disability.

Fiber type morphometry and capillary geometry in free, vascularized muscle transfers

In order to establish the relationship among intraoperative ischemia time, the recovery of contractile function, muscle fiber morphometry, and capillary geometry following free muscle transfer, 15 male dogs underwent unilateral, orthotopic free transfer of the left gracilis muscle with microneurovascular anastomosis. Intraoperative ischemia time varied from 0 to 4 hours. After a recovery period averaging 14 months, isometric contractile function was measured in the transfers and the contralateral, control muscles. Muscle fiber type composition, fiber size, and capillary geometry were quantified from histochemical sections. Transferred and control muscles had similar type I fiber percentages, type I fiber sizes, and capillary densities. Type II fiber sizes were reduced in transfers relative to controls. There was no significant effect of intraoperative ischemia on any morphometric variable. Although contractile function was generally reduced after free, vascularized transfer, there was only a weak correlation between the recovery of tetanic tension and type I fiber percentage (r = 0.53, P less than 0.05). It is concluded that free, vascularized muscle transfer results in minimal disturbance of muscle fiber type composition, fiber size, or capillary supply and that the diminished contractile function observed in this setting is still largely unexplained.

Open-loop control of the freely-swinging paralyzed leg

An experimental model has been used to study issues that are relevant to the use of electrical stimulation to help paralyzed individuals walk. Modulated stimulation sequences for the quadriceps muscles were manually selected using an iterative trial-and-error procedure to cause the knee angle to follow a specific movement pattern (desired trajectory). Four paraplegic subjects were tested before and after an eight-week program in which the quadriceps were exercised daily with electrical stimulation. It was found that 12.6 +/- 2.9 iterations were required to approximate the desired trajectory. The average error of the final match between the actual and desired trajectories was 2.1 degrees +/- 0.7. Repeated responses were extremely consistent; the average difference between successive trials was less than 1 degree in 81 percent of the trials. When the stimulation sequence was repeated every 3 s for 50 cycles, however, there was a progressive degradation in the response, even in exercised legs, that demonstrated the limitations of open-loop control. Stimulus modulation envelopes for all four subjects were similar in shape (although varied in amplitude) indicating that the iterative process can be shortened by starting with an "average" modulation envelope. Stimulation sequences achieved accurate matches of the desired trajectory on subsequent days when adjusted by a simple gain factor. The relevance of these results to multichannel control of walking is discussed.

Sarcomere length and joint kinematics during torque production in frog hindlimb

The relationship between semitendinosus muscle force and knee joint kinematics during isometric torque production was examined in the frog (Rana pipiens) hindlimb. Passive muscle sarcomere length was monitored by laser diffraction during knee rotation, and joint center of rotation was determined later using principles of rigid body kinematics. Contractile force at the distal tibia, resulting from semitendinosus contraction, was also measured, and, using the kinematic data, a torque vs. joint angle curve constructed. Muscle sarcomere length varied from 3.6 micron at full knee extension to 2.0 micron at full knee flexion. Effective lever arm varied almost as a sine function, with optimal lever arm at 90 degrees of flexion. Joint torque increased linearly from 0 to 140 degrees of flexion and then sharply decreased to 160 degrees of flexion. Thus the optimal joint angle occurred at an angle (140 degrees) that was neither the angle at which muscle force was maximum (160 degrees) nor the angle at which the effective lever arm was maximum (90 degrees). These data indicate that knee torque production in the frog results from the interaction between muscular and joint properties and not either property alone.

Differential effects of 10-Hz and 50 Hz-stimulation of the tibialis anterior on the ipsilateral, unstimulated soleus muscle

Twelve rabbits were cast-immobilized for 4 weeks during which either 10- or 50-Hz stimulation was applied transcutaneously to the anterior compartment muscles. After the treatment period, tibialis anterior and soleus muscle contractile and histochemical properties were measured. Tibialis anterior stimulation at either 10 or 50 Hz had significantly different effects on the ipsilateral, unstimulated soleus muscles. Whereas soleus muscles of both groups demonstrated significant atrophy relative to nonstimulated, nonimmobilized soleus muscles, the soleus muscles from the 50-Hz group demonstrated significantly less atrophy than did the soleus muscles from the 10-Hz group as indicated by significantly greater muscle mass, maximum tetanic tension, and fast fiber area. The results indicate that muscle stimulation may have beneficial effects on ipsilateral muscles that are passively stretched secondary to stimulation. In addition, passive tension, not just muscle activation, appears to have an important role in regulating muscle size.

Clenbuterol prevents or inhibits loss of specific mRNAs in atrophying rat skeletal muscle

It is known that denervation or hindlimb suspension both decrease the content of rRNA, alpha-actin mRNA, and cytochrome c mRNA in adult rat skeletal muscle. In the present study, the provision of clenbuterol (an anabolic agent) to adult female rats during a 7-day period of denervation of the soleus and gastrocnemius muscles prevented entirely the loss of rRNA, alpha-actin mRNA, and cytochrome c mRNA that normally occurs in denervated muscle. Although clenbuterol inhibited most of the loss of alpha-actin mRNA that occurred in the soleus and gastrocnemius muscles after 7 days of hindlimb suspension, clenbuterol administration had less effect on preventing the loss of rRNA and cytochrome c mRNA in hindlimb suspended skeletal muscle. Clenbuterol had no effect on protein content in atrophied muscle resulting from denervation or suspension. These data suggest that clenbuterol can maintain the expression of certain RNAs in atrophying adult rat skeletal muscle.