Fatigue of paralyzed and control thenar muscles induced by variable or constant frequency stimulation

Intrinsic Neuromuscular Fatigability in Humans: The Critical Role of Stimulus Frequency

Electrically evoked contractions provide insight into intrinsic neuromuscular fatigability and also represent a valuable technique to maintain muscle mass in a clinical setting. To appropriately investigate intrinsic fatigability and design optimal stimulation protocols, it would seem to be crucial to stimulate the muscle at a frequency equivalent to the mean motor unit discharge rate expected at the target force level.

Joint angle based motor point tracking stimulation for surface FES: A Study on biceps brachii

Functional electrical stimulation (FES) has been an effective treatment option in clinical rehabilitation such as motor function recovery after stroke. The main limitation of FES is the lack of stimulation efficiency in motor unit recruitment compared with voluntary contractions, which may cause the early onset of muscle fatigue. The stimulation efficiency of FES can be improved by optimizing electrode positions to target the motor point (MP). However, the location of MP relative to the skin may shift with the change of muscle geometry during dynamic exercise. Hence, the purpose of this study is to maintain the stimulation efficiency of FES in dynamic exercise by switching the stimulation position to follow the shift of MP. We first measured the shift of the MP of the biceps brachii with respect to the elbow joint angle, and then conducted an experiment to compare four stimulation methods: 2-channel simultaneous stimulation (SS), 2-channel time based shifting stimulation (TSS), 2-channel joint angle based shifting stimulation (JASS), and 3-channel JASS. TSS and JASS were designed as two different MP tracking strategies. The experimental results show that the 3-channel JASS caused the smallest decrease in the maximal elbow angle and the angular velocity. The results also suggest that MP tracking stimulation based on joint angle is effective for the sustainable induction of muscle contraction. Both tracking selectivity and tracking density were shown to be important to improve the stimulation efficiency of FES.

Quadriceps mechanomyography reflects muscle fatigue during electrical stimulus-sustained standing in adults with spinal cord injury - a proof of concept

This study investigates whether mechanomyography (MMG) produced from contracting muscles as a measure of their performance could be a proxy of muscle fatigue during a sustained functional electrical stimulation (FES)-supported standing-to-failure task. Bilateral FES-evoked contractions of quadriceps and glutei muscles, of four adults with motor-complete spinal cord injury (SCI), were used to maintain upright stance using two different FES frequencies: high frequency (HF - 35 Hz) and low frequency (LF - 20 Hz). The time at 30° knee angle reduction was taken as the point of critical "fatigue failure", while the generated MMG characteristics were used to track the pattern of force development during stance. Quadriceps fatigue, which was primarily responsible for the knee buckle, was characterized using MMG-root mean square (RMS) amplitude. A double exponential decay model fitted the MMG fatigue data with good accuracy [R2 = 0.85-0.99; root mean square error (RMSE) = 2.12-8.10] implying changes in the mechanical activity performance of the muscle's motor units. Although the standing duration was generally longer for the LF strategy (31-246 s), except in one participant, when compared to the HF strategy, such differences were not significant (p > 0.05) but suggested a faster muscle fatigue onset during HF stimulation. As MMG could discriminate between different stimulation frequencies, we speculate that this signal can quantify muscle fatigue characteristics during prolonged FES applications.

Mitigation of excessive fatigue associated with functional electrical stimulation

OBJECTIVE

Restoration of motor function in paralyzed limbs using functional electrical stimulation (FES) is undermined by rapid fatigue associated with artificial stimulation. Typically, single electrodes are used to activate muscles with FES. However, due to the highly distributed branching of muscle nerves, a single electrode may not be able to activate the entire array of motor axons supplying a muscle. Therefore, stimulating muscle with multiple electrodes might enable access to a larger volume of muscle and thereby reduce fatigue.

APPROACH

Accordingly, we compared the endurance times that ankle dorsiflexion could be sustained at 20% maximum voluntary force using feedback controlled stimulation (25 Hz) of human tibialis anterior (TA) using one or four percutaneous intramuscular electrodes. In addition, we measured endurance times in response to direct stimulation of the nerve supplying TA and during voluntary contraction. In all sessions involving electrical stimulation, an anesthetic nerve block proximal to the site of stimulation was used to isolate the effects of stimulation and alleviate discomfort.

MAIN RESULTS

Endurance time associated with stimuli delivered by a single intramuscular electrode (84  ±  19 s) was significantly smaller than that elicited by four intramuscular electrodes (232  ±  123 s). Moreover, endurance time in response to nerve stimulation (787  ±  201 s) was not significantly different that that produced during voluntary contraction (896  ±  272 s).

SIGNIFICANCE

Therefore, excessive fatigue associated with FES is probably due to the inability of conventional FES systems to enlist the full complement of motor axons innervating muscle and can be mitigated using multiple electrodes or nerve-based electrodes.

Stochastically modulated inter-pulse intervals to increase the efficiency of functional electrical stimulation cycling

Introduction

Functional electrical stimulation cycling has various health benefits, but the mechanical power output and efficiency are very low compared to volitional muscle activation. Stimulation with variable frequency showed significantly higher power output values in experiments with a knee dynamometer. The aim of the present work was to compare stochastic modulation of inter-pulse interval to constant inter-pulse interval stimulation during functional electrical stimulation cycling.

Methods

Seventeen able-bodied subjects participated (n = 17). Quadriceps and hamstring muscle groups were stimulated with two activation patterns: P1-constant frequency, P2-stochastic inter-pulse interval. Power output was measured on functional electrical stimulation ergometer.

Results

Overall, mean power output with the stochastically modulated pattern P2 was lower than with P1 (12.57 ± 3.74 W vs. 11.44 ± 3.81 W, P1 vs. P2, p = 0.022), but no significant differences during the first 30 s and the last 30 s were observed.

Conclusions

This study showed that stimulation strategies that use randomized modulation of inter-pulse intervals can negatively affect power output generation during functional electrical stimulation cycling. To minimise voluntary contractions, power measurement and assessment should be focused on the periods where only the quadriceps are stimulated.

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.

A functional electrical stimulation system for human walking inspired by reflexive control principles

This study presents an innovative multichannel functional electrical stimulation gait-assist system which employs a well-established purely reflexive control algorithm, previously tested in a series of bipedal walking robots. In these robots, ground contact information was used to activate motors in the legs, generating a gait cycle similar to that of humans. Rather than developing a sophisticated closed-loop functional electrical stimulation control strategy for stepping, we have instead utilised our simple reflexive model where muscle activation is induced through transfer functions which translate sensory signals, predominantly ground contact information, into motor actions. The functionality of the functional electrical stimulation system was tested by analysis of the gait function of seven healthy volunteers during functional electrical stimulation-assisted treadmill walking compared to unassisted walking. The results demonstrated that the system was successful in synchronising muscle activation throughout the gait cycle and was able to promote functional hip and ankle movements. Overall, the study demonstrates the potential of human-inspired robotic systems in the design of assistive devices for bipedal walking.

Effect of Stochastic Modulation of Inter-Pulse Interval During Stimulated Isokinetic Leg Extension

Recumbent cycling exercise achieved by functional electrical stimulation (FES) of the paralyzed leg muscles is effective for cardiopulmonary and musculoskeletal conditioning after spinal cord injury, but its full potential has not yet been realized. Mechanical power output and efficiency is very low and endurance is limited due to early onset of muscle fatigue. The aim of this work was to compare stochastic modulation of the inter-pulse interval (IPI) to constant-frequency stimulation during an isokinetic leg extension task similar to FES-cycling. Seven able-bodied subjects participated: both quadriceps muscles were stimulated (n = 14) with two activation patterns (P1-constant frequency, P2-stochastic IPI). There was significantly higher power output with P2 during the first 30 s (p = 0.0092), the last 30 s (p = 0.018) and overall (p = 0.0057), but there was no overall effect on fatiguability when stimulation frequency was randomly modulated.

Torque and mechanomyogram relationships during electrically-evoked isometric quadriceps contractions in persons with spinal cord injury

The interaction between muscle contractions and joint loading produces torques necessary for movements during activities of daily living. However, during neuromuscular electrical stimulation (NMES)-evoked contractions in persons with spinal cord injury (SCI), a simple and reliable proxy of torque at the muscle level has been minimally investigated. Thus, the purpose of this study was to investigate the relationships between muscle mechanomyographic (MMG) characteristics and NMES-evoked isometric quadriceps torques in persons with motor complete SCI. Six SCI participants with lesion levels below C4 [(mean (SD) age, 39.2 (7.9) year; stature, 1.71 (0.05) m; and body mass, 69.3 (12.9) kg)] performed randomly ordered NMES-evoked isometric leg muscle contractions at 30°, 60° and 90° knee flexion angles on an isokinetic dynamometer. MMG signals were detected by an accelerometer-based vibromyographic sensor placed over the belly of rectus femoris muscle. The relationship between MMG root mean square (MMG-RMS) and NMES-evoked torque revealed a very high association (R(2)=0.91 at 30°; R(2)=0.98 at 60°; and R(2)=0.97 at 90° knee angles; P<0.001). MMG peak-to-peak (MMG-PTP) and stimulation intensity were less well related (R(2)=0.63 at 30°; R(2)=0.67 at 60°; and R(2)=0.45 at 90° knee angles), although were still significantly associated (P≤0.006). Test-retest interclass correlation coefficients (ICC) for the dependent variables ranged from 0.82 to 0.97 for NMES-evoked torque, between 0.65 and 0.79 for MMG-RMS, and from 0.67 to 0.73 for MMG-PTP. Their standard error of measurements (SEM) ranged between 10.1% and 31.6% (of mean values) for torque, MMG-RMS and MMG-PTP. The MMG peak frequency (MMG-PF) of 30Hz approximated the stimulation frequency, indicating NMES-evoked motor unit firing rate. The results demonstrated knee angle differences in the MMG-RMS versus NMES-isometric torque relationship, but a similar torque related pattern for MMG-PF. These findings suggested that MMG was well associated with torque production, reliably tracking the motor unit recruitment pattern during NMES-evoked muscle contractions. The strong positive relationship between MMG signal and NMES-evoked torque production suggested that the MMG might be deployed as a direct proxy for muscle torque or fatigue measurement during leg exercise and functional movements in the SCI population.

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.

Torque decrease during submaximal evoked contractions of the quadriceps muscle is linked not only to muscle fatigue

The aim of this study was to analyze the neuromuscular mechanisms involved in the torque decrease induced by submaximal electromyostimulation (EMS) of the quadriceps muscle. It was hypothesized that torque decrease after EMS would reflect the fatigability of the activated motor units (MUs), but also a reduction in the number of MUs recruited as a result of changes in axonal excitability threshold. Two experiments were performed on 20 men to analyze 1) the supramaximal twitch superimposed and evoked at rest during EMS (Experiment 1, n = 9) and 2) the twitch response and torque-frequency relation of the MUs activated by EMS (Experiment 2, n = 11). Torque loss was assessed by 15 EMS-evoked contractions (50 Hz; 6 s on/6 s off), elicited at a constant intensity that evoked 20% of the maximal voluntary contraction (MVC) torque. The same stimulation intensity delivered over the muscles was used to induce the torque-frequency relation and the single electrical pulse evoked after each EMS contraction (Experiment 2). In Experiment 1, supramaximal twitch was induced by femoral nerve stimulation. Torque decreased by ~60% during EMS-evoked contractions and by only ~18% during MVCs. This was accompanied by a rightward shift of the torque-frequency relation of MUs activated and an increase of the ratio between the superimposed and posttetanic maximal twitch evoked during EMS contraction. These findings suggest that the torque decrease observed during submaximal EMS-evoked contractions involved muscular mechanisms but also a reduction in the number of MUs recruited due to changes in axonal excitability.

Method to Reduce Muscle Fatigue During Transcutaneous Neuromuscular Electrical Stimulation in Major Knee and Ankle Muscle Groups

BACKGROUND

A critical limitation with transcutaneous neuromuscular electrical stimulation as a rehabilitative approach is the rapid onset of muscle fatigue during repeated contractions. We have developed a method called spatially distributed sequential stimulation (SDSS) to reduce muscle fatigue by distributing the center of electrical field over a wide area within a single stimulation site, using an array of surface electrodes.

OBJECTIVE

To extend the previous findings and to prove feasibility of the method by exploring the fatigue-reducing ability of SDSS for lower limb muscle groups in the able-bodied population, as well as in individuals with spinal cord injury (SCI).

METHODS

SDSS was delivered through 4 active electrodes applied to the knee extensors and flexors, plantarflexors, and dorsiflexors, sending a stimulation pulse to each electrode one after another with 90° phase shift between successive electrodes. Isometric ankle torque was measured during fatiguing stimulations using SDSS and conventional single active electrode stimulation lasting 2 minutes.

RESULTS

We demonstrated greater fatigue-reducing ability of SDSS compared with the conventional protocol, as revealed by larger values of fatigue index and/or torque peak mean in all muscles except knee flexors of able-bodied individuals, and in all muscles tested in individuals with SCI.

CONCLUSIONS

Our study has revealed improvements in fatigue tolerance during transcutaneous neuromuscular electrical stimulation using SDSS, a stimulation strategy that alternates activation of subcompartments of muscles. The SDSS protocol can provide greater stimulation times with less decrement in mechanical output compared with the conventional protocol.

Prolonged electrical stimulation-induced gluteal and hamstring muscle activation and sitting pressure in spinal cord injury: effect of duty cycle

Pressure ulcers (PUs) are highly prevalent in people with spinal cord injury (SCI). Electrical stimulation (ES) activates muscles and might reduce risk factors. Our objectives were to study and compare the effects of two duty cycles during 3 h of ES-induced gluteal and hamstring activation on interface pressure distribution in sitting individuals with SCI and study the usability of a newly developed electrode garment (ES shorts). Ten individuals with SCI participated in this study, in which two ES protocols with different duty cycles (1:1 s vs 1:4 s on-off) were applied in counterbalanced order using a custom-made garment with built-in electrodes. Outcome variables included interface pressure of the ischial tuberosities (ITs) and pressure gradient. A questionnaire was used to determine usability of the ES shorts. In both protocols, ES caused a significant decrease in average IT pressure compared with rest (no ES); on average, 35% for protocol 1:4 and 13% for protocol 1:1. The ES on-off duty cycle of protocol 1:4 showed less muscle fatigue. In general, participants scored the usability of the ES shorts as satisfactory. In this study, the application of ES resulted in a significant decrease in IT pressure. The ES on-off duty cycle of 1:4 s is recommended because of the less fatiguing effect. ES of the hamstrings and gluteal muscles might be a promising method in preventing PUs, but further study is needed.

Electrical stimulation of transplanted motoneurons improves motor unit formation

Motoneurons die following spinal cord trauma and with neurological disease. Intact axons reinnervate nearby muscle fibers to compensate for the death of motoneurons, but when an entire motoneuron pool dies, there is complete denervation. To reduce denervation atrophy, we have reinnervated muscles in Fisher rats from local transplants of embryonic motoneurons in peripheral nerve. Since growth of axons from embryonic neurons is activity dependent, our aim was to test whether brief electrical stimulation of the neurons immediately after transplantation altered motor unit numbers and muscle properties 10 wk later. All surgical procedures and recordings were done in anesthetized animals. The muscle consequences of motoneuron death were mimicked by unilateral sciatic nerve section. One week later, 200,000 embryonic day 14 and 15 ventral spinal cord cells, purified for motoneurons, were injected into the tibial nerve 10-15 mm from the gastrocnemii muscles as the only neuron source for muscle reinnervation. The cells were stimulated immediately after transplantation for up to 1 h using protocols designed to examine differential effects due to pulse number, stimulation frequency, pattern, and duration. Electrical stimulation that included short rests and lasted for 1 h resulted in higher motor unit counts. Muscles with higher motor unit counts had more reinnervated fibers and were stronger. Denervated muscles had to be stimulated directly to evoke contractions. These results show that brief electrical stimulation of embryonic neurons, in vivo, has long-term effects on motor unit formation and muscle force. This muscle reinnervation provides the opportunity to use patterned electrical stimulation to produce functional movements.

A new method for muscle fatigue assessment: Online model identification techniques

INTRODUCTION

The purpose of this study was to propose a method that allows extraction of the current muscle state under electrically induced fatigue.

METHODS

The triceps surae muscle of 5 subjects paralyzed by spinal cord injury was fatigued by intermittent electrical stimulation (5 × 5 trains at 30 Hz). Classical fatigue indices representing muscle contractile properties [peak twitch (Pt) and half-relaxation time (HRT)] were assessed before and after each 5-train series and were used to identify 2 relevant parameters (Fm , Ur ) of a previously developed mathematical model using the Sigma-Point Kalman Filter.

RESULTS

Pt declined significantly during the protocol, whereas HRT remained unchanged. Identification of the model parameters with experimental data yielded a model-based fatigue assessment that gave a more stable evaluation of fatigue than classical parameters.

CONCLUSIONS

This work reinforces clinical research by providing a tool that clinicians can use to monitor fatigue development during stimulation.

Age at spinal cord injury determines muscle strength

As individuals with spinal cord injury (SCI) age they report noticeable deficits in muscle strength, endurance and functional capacity when performing everyday tasks. These changes begin at ~45 years. Here we present a cross-sectional analysis of paralyzed thenar muscle and motor unit contractile properties in two datasets obtained from different subjects who sustained a cervical SCI at different ages (≤46 years) in relation to data from uninjured age-matched individuals. First, completely paralyzed thenar muscles were weaker when C6 SCI occurred at an older age. Muscles were also significantly weaker if the injury was closer to the thenar motor pools (C6 vs. C4). More muscles were strong (>50% uninjured) in those injured at a younger (≤25 years) vs. young age (>25 years), irrespective of SCI level. There was a reduction in motor unit numbers in all muscles tested. In each C6 SCI, only ~30 units survived vs. 144 units in uninjured subjects. Since intact axons only sprout 4-6 fold, the limits for muscle reinnervation have largely been met in these young individuals. Thus, any further reduction in motor unit numbers with time after these injuries will likely result in chronic denervation, and may explain the late-onset muscle weakness routinely described by people with SCI. In a second dataset, paralyzed thenar motor units were more fatigable than uninjured units. This gap widened with age and will reduce functional reserve. Force declines were not due to electromyographic decrements in either group so the site of failure was beyond excitation of the muscle membrane. Together, these results suggest that age at SCI is an important determinant of long-term muscle strength, and fatigability, both of which influence functional capacity.

Reducing muscle fatigue during transcutaneous neuromuscular electrical stimulation by spatially and sequentially distributing electrical stimulation sources

Purpose

A critical limitation with transcutaneous neuromuscular electrical stimulation is the rapid onset of muscle fatigue. We have previously demonstrated that spatially distributed sequential stimulation (SDSS) shows a drastically greater fatigue-reducing ability compared to a single active electrode stimulation (SES). The purposes of this study were to investigate (1) the fatigue-reducing ability of SDSS in more detail focusing on the muscle contractile properties and (2) the mechanism of this effect using array-arranged electromyogram (EMG).

Methods

SDSS was delivered through four active electrodes applied to the plantarflexors, sending a stimulation pulse to each electrode one after another with 90° phase shift between successive electrodes. In the first experiment, the amount of exerted ankle torque and the muscle contractile properties were investigated during a 3 min fatiguing stimulation. In the second experiment, muscle twitch potentials with SDSS and SES stimulation electrode setups were compared using the array-arranged EMG.

Results

The results demonstrated negligible torque decay during SDSS in contrast to considerable torque decay during SES. Moreover, small changes in the muscle contractile properties during the fatiguing stimulation using SDSS were observed, while slowing of muscle contraction and relaxation was observed during SES. Further, the amplitude of the M-waves at each muscle portion was dependent on the location of the stimulation electrodes during SDSS.

Conclusion

We conclude that SDSS is more effective in reducing muscle fatigue compared to SES, and the reason is that different sets of muscle fibers are activated alternatively by different electrodes.

Neuromuscular fatigue is not different between constant and variable frequency stimulation

This study compared fatigue development of the triceps surae induced by two electrical stimulation protocols composed of constant and variable frequency trains (CFTs, VFTs, 450 trains, 30 Hz, 167 ms ON, 500 ms OFF and 146 ms ON, 500 ms OFF respectively). For the VFTs protocol a doublet (100 Hz) was used at the beginning of each train. The intensity used evoked 30% of a maximal voluntary contraction (MVC) and was defined using CFTs. Neuromuscular tests were performed before and after each protocol. Changes in excitation-contraction coupling were assessed by analysing the M-wave [at rest (M_max) and during MVC (M_sup)] and associated peak twitch (Pt). H-reflex [at rest (H_max) and during MVC (H_sup)] and the motor evoked potential (MEP) during MVC were studied to assess spinal and corticospinal excitability of the soleus muscle. MVC decrease was similar between the protocols (−8%, P<0.05). M_max, M_sup and Pt decreased after both protocols (P<0.01). H_max/M_max was decreased (P<0.05), whereas H_sup/M_sup and MEP/M_sup remained unchanged after both protocols. The results indicate that CFTs and VFTs gave rise to equivalent neuromuscular fatigue. This fatigue resulted from alterations taking place at the muscular level. The finding that cortical and spinal excitability remained unchanged during MVC indicates that spinal and/or supraspinal mechanisms were activated to compensate for the loss of spinal excitability at rest.

Human spinal cord injury: motor unit properties and behaviour

Spinal cord injury (SCI) results in widespread variation in muscle function. Review of motor unit data shows that changes in the amount and balance of excitatory and inhibitory inputs after SCI alter management of motoneurons. Not only are units recruited up to higher than usual relative forces when SCI leaves few units under voluntary control, the force contribution from recruitment increases due to elevation of twitch/tetanic force ratios. Force gradation and precision are also coarser with reduced unit numbers. Maximal unit firing rates are low in hand muscles, limiting voluntary strength, but are low, normal or high in limb muscles. Unit firing rates during spasms can exceed voluntary rates, emphasizing that deficits in descending drive limit force production. SCI also changes muscle properties. Motor unit weakness and fatigability seem universal across muscles and species, increasing the muscle weakness that arises from paralysis of units, motoneuron death and sensory impairment. Motor axon conduction velocity decreases after human SCI. Muscle contractile speed is also reduced, which lowers the stimulation frequencies needed to grade force when paralysed muscles are activated with patterned electrical stimulation. This slowing does not necessarily occur in hind limb muscles after cord transection in cats and rats. The nature, duration and level of SCI underlie some of these species differences, as do variations in muscle function, daily usage, tract control and fibre-type composition. Exploring this diversity is important to promote recovery of the hand, bowel, bladder and locomotor function most wanted by people with SCI.

High-versus low-frequency stimulation effects on fine motor control in chronic hemiplegia: a pilot study

BACKGROUND

The optimal parameters of neuromuscular electrical stimulation (NMES) for recovery of hand function after stroke are not known. This clinical pilot study examined whether higher or lower frequencies are more effective for improving fine motor control of the hand in a chronic poststroke population.

METHODS

A 1-month, 4 times per week, in-home regimen of either a high-frequency (40 Hz) or low-frequency (20 Hz) NMES program was applied to the hemiplegic thenar muscles of 16 persons with chronic stroke. Participants were identified a priori as having a low level of function (LF) or a high level of function (HF). Outcome measures of strength, dexterity, and endurance were measured before and after participation in the regimen.

RESULTS

LF subjects showed no significant changes with either the high- or the low-frequency NMES regimen. HF subjects showed significant changes in strength, dexterity, and endurance. Within this group, higher frequencies of stimulation yielded strength gains and increased motor activation; lower frequencies affected dexterity and endurance.

CONCLUSIONS

The results suggest that higher frequencies of stimulation could be more effective in improving strength and motor activation properties and that lower frequencies may affect coordination and endurance changes. Results also indicate that persons with a higher functional level of recovery may respond more favorably to NMES regimens, but further study with larger patient groups is warranted.

Can the efficacy of electrically stimulated pedaling using a commercially available ergometer BE improved by minimizing the muscle stress-time integral?

INTRODUCTION

The cardiorespiratory and muscular strength benefits of functional electrical stimulation (FES) pedaling for spinal cord injury (SCI) subjects are limited because the endurance of electrically stimulated muscle is low.

METHODS

We tested new electrical stimulation timing patterns (Stim3, designed using a forward dynamic simulation to minimize the muscle stress-time integral) to determine whether SCI subjects could increase work and metabolic responses when pedaling a commercial FES ergometer. Work, rate of oxygen uptake (VO(2)), and blood lactate data were taken from 11 subjects (injury level T4-T12) on repeated trials.

RESULTS

Subjects performed 11% more work pedaling with Stim3 than with existing stimulation patterns (StimErg) (P = 0.043). Average (VO(2)) and blood lactate concentrations were not significantly different between Stim3 (442 ml/min, 5.9 mmol/L) and StimErg (417 ml/min, 5.9 mmol/L).

CONCLUSION

The increased mechanical work performed with Stim3 supports the use of patterns that minimize the muscle stress-time integral to prolong FES pedaling.

A novel modulation strategy to increase stimulation duration in neuromuscular electrical stimulation

INTRODUCTION

Neuromuscular electrical stimulation (NMES) has been shown to be an effective treatment for muscular dysfunction. Yet, a fundamental barrier to NMES treatments is the rapid onset of muscle fatigue. The purpose of this study is to examine the effect of feedback-based frequency modulation on the closed-loop performance of the quadriceps during repeated dynamic contractions.

METHODS

In the first experiment, subjects completed four different frequency modulation NMES protocols utilizing the same amplitude modulation control to compare the successful run times (SRTs). A second experiment was performed to determine the change in muscle response to high- and low-frequency stimulation.

RESULTS

Compared with constant-frequency stimulation, results indicate that using an error-driven strategy to vary the stimulation frequency during amplitude modulation increases the number of successful contractions during non-isometric conditions.

CONCLUSION

Simultaneous frequency and amplitude modulation increases the SRT during closed-loop NMES control.

Muscle spasticity associated with reduced whole-leg perfusion in persons with spinal cord injury

OBJECTIVE

To determine the association between peripheral blood flow and spasticity in individuals with spinal cord injury (SCI).

DESIGN

A cross-sectional study with measurements of muscle spasticity and whole-limb blood flow in individuals with SCI.

SETTING

University of Texas at Austin and Brain & Spine Recovery Center, Austin, TX, USA.

PARTICIPANTS

Eighteen individuals (14 males and 4 females) with SCI were classified into high (N = 7), low (N = 6), and no (N = 5) spasticity groups according to the spasticity levels determined by the modified Ashworth scale scores.

INTERVENTIONS

Whole-limb blood flow was measured in the femoral and brachial arteries using Doppler ultrasound and was normalized to lean limb mass obtained with dual-energy X-ray absorptiometry.

OUTCOME MEASURES

Limb blood flow and muscle spasticity.

RESULTS

Age, time post-SCI, and the American Spinal Injury Association impairment scale motor and sensory scores were not different among groups with different muscle spasticity. Femoral artery blood flow normalized to lean leg mass was different (P = 0.001) across the three spasticity groups (high 78.9 ± 16.7, low 98.3 ± 39.8, no 142.5 ± 24.3 ml/minute/kg). Total leg muscle spasticity scores were significantly and negatively correlated with femoral artery blood flow (r = -0.59, P < 0.01). There was no significant difference in brachial artery blood flow among the groups.

CONCLUSIONS

Whole-leg blood flow was lower in individuals with greater spasticity scores. These results suggest that a reduction in lower-limb perfusion may play a role, at least in part, in the pathogenesis leading to muscle spasticity after SCI.

Non-invasive muscle contraction assay to study rodent models of sarcopenia

Background

Age-related sarcopenia is a disease state of loss of muscle mass and strength that affects physical function and mobility leading to falls, fractures, and disability. The need for therapies to treat age-related sarcopenia has attracted intensive preclinical research. To facilitate the discovery of these therapies, we have developed a non-invasive rat muscle functional assay system to efficiently measure muscle force and evaluate the efficacy of drug candidates.

Methods

The lower leg muscles of anesthetized rats are artificially stimulated with surface electrodes on the knee holders and the heel support, causing the lower leg muscles to push isometric pedals that are attached to force transducers. We developed a stimulation protocol to perform a fatigability test that reveals functional muscle parameters like maximal force, the rate of fatigue, fatigue-resistant force, as well as a fatigable muscle force index. The system is evaluated in a rat aging model and a rat glucocorticoid-induced muscle loss model

Results

The aged rats were generally weaker than adult rats and showed a greater reduction in their fatigable force when compared to their fatigue-resistant force. Glucocorticoid treated rats mostly lost fatigable force and fatigued at a higher rate, indicating reduced force from glycolytic fibers with reduced energy reserves.

Conclusions

The involuntary contraction assay is a reliable system to assess muscle function in rodents and can be applied in preclinical research, including age-related sarcopenia and other myopathy.

Spatially distributed sequential stimulation reduces fatigue in paralyzed triceps surae muscles: a case study

Functional electrical stimulation (FES) is limited by the rapid onset of muscle fatigue caused by localized nerve excitation repeatedly activating only a subset of motor units. The purpose of this study was to investigate reducing fatigue by sequentially changing, pulse by pulse, the area of stimulation using multiple surface electrodes that cover the same area as one electrode during conventional stimulation. Paralyzed triceps surae muscles of an individual with complete spinal cord injury were stimulated, via the tibial nerve, through four active electrodes using spatially distributed sequential stimulation (SDSS) that was delivered by sending a stimulation pulse to each electrode one after another with 90° phase shift between successive electrodes. For comparison, single electrode stimulation was delivered through one active electrode. For both modes of stimulation, the resultant frequency to the muscle as a whole was 40 Hz. Isometric ankle torque was measured during fatiguing stimulations lasting 2 min. Each mode of stimulation was delivered a total of six times over 12 separate days. Three fatigue measures were used for comparison: fatigue index (final torque normalized to maximum torque), fatigue time (time for torque to drop by 3 dB), and torque-time integral (over the entire trial). The measures were all higher during SDSS (P < 0.001), by 234, 280, and 171%, respectively. The results are an encouraging first step toward addressing muscle fatigue, which is one of the greatest problems for FES.

Enhancing muscle force and femur compressive loads via feedback-controlled stimulation of paralyzed quadriceps in humans

OBJECTIVE

To compare paralyzed quadriceps force properties and femur compressive loads in an upright functional task during conventional constant-frequency stimulation and force feedback-modulated stimulation.

DESIGN

Crossover trial.

SETTING

Research laboratory.

PARTICIPANTS

Subjects (N=13; 12 men, 1 woman) with motor-complete spinal cord injury.

INTERVENTIONS

Subjects performed 2 bouts of 60 isometric quadriceps contractions while supported in a standing frame. On separate days, subjects received constant-frequency stimulation at 20Hz (CONST) or frequency-modulated stimulation triggered by a change in force (FDBCK). During FDBCK, a computer algorithm responded to each 10% reduction in force with a 20% increase in stimulation frequency.

MAIN OUTCOME MEASURES

A biomechanical model was used to derive compressive loads on the femur, with a target starting dose of load equal to 1.5 times body weight.

RESULTS

Peak quadriceps force and fatigue index were higher for FDBCK than CONST (P<.05). Within-train force decline was greater during FDBCK bouts, but mean force remained above CONST values (P<.05). As fatigue developed during repetitive stimulation, FDBCK was superior to CONST for maintenance of femur compressive loads (P<.05).

CONCLUSIONS

Feedback-modulated stimulation in electrically activated stance is a viable method to maximize the physiologic performance of paralyzed quadriceps muscle. Compared with CONST, FDBCK yielded compressive loads that were closer to a targeted dose of stress with known osteogenic potential. Optimization of muscle force with FDBCK may be a useful tactic for future training-based antiosteoporosis protocols.

Distributed low-frequency functional electrical stimulation delays muscle fatigue compared to conventional stimulation

We present a low-frequency stimulation method via multi-pad electrodes for delaying muscle fatigue. We compared two protocols for muscle activation of the quadriceps in paraplegics. One protocol involved a large cathode at 30 HZ (HPR, high pulse-rate), and the other involved four smaller cathodes at 16 HZ (LPR, low pulse-rate). The treatment included 30-min daily sessions for 20 days. One leg was treated with the HPR protocol and the other with the LPR protocol. Knee-joint torque was measured before and after therapy to assess the time interval before the knee-joint torque decreased to 70% of the initial value. The HPR therapy provided greater increases in muscle endurance and force in prolonged training. Yet the LPR stimulation produced less muscle fatigue compared to the HPR stimulation. The results suggest that HPR is the favored protocol for training, and LPR is better suited for prolonged stimulation.

Effects of baclofen on motor units paralysed by chronic cervical spinal cord injury

Baclofen, a gamma-aminobutyric acid receptor(B) agonist, is used to reduce symptoms of spasticity (hyperreflexia, increases in muscle tone, involuntary muscle activity), but the long-term effects of sustained baclofen use on skeletal muscle properties are unclear. The aim of our study was to evaluate whether baclofen use and paralysis due to cervical spinal cord injury change the contractile properties of human thenar motor units more than paralysis alone. Evoked electromyographic activity and force were recorded in response to intraneural stimulation of single motor axons to thenar motor units. Data from three groups of motor units were compared: 23 paralysed units from spinal cord injured subjects who take baclofen and have done so for a median of 7 years, 25 paralysed units from spinal cord injured subjects who do not take baclofen (median: 10 years) and 45 units from uninjured control subjects. Paralysed motor unit properties were independent of injury duration and level. With paralysis and baclofen, the median motor unit tetanic forces were significantly weaker, twitch half-relaxation times longer and half maximal forces reached at lower frequencies than for units from uninjured subjects. The median values for these same parameters after paralysis alone were comparable to control data. Axon conduction velocities differed across groups and were slowest for paralysed units from subjects who were not taking baclofen and fastest for units from the uninjured. Greater motor unit weakness with long-term baclofen use and paralysis will make the whole muscle weaker and more fatigable. Significantly more paralysed motor units need to be excited during patterned electrical stimulation to produce any given force over time. The short-term benefits of baclofen on spasticity (e.g. management of muscle spasms that may otherwise hinder movement or social interactions) therefore have to be considered in relation to its possible long-term effects on muscle rehabilitation. Restoring the strength and speed of paralysed muscles to pre-injury levels may require more extensive therapy when baclofen is used chronically.

Variable stimulation patterns for poststroke hemiplegia

Neuromuscular electrical stimulation can improve motor function in those affected by paralysis, but its use is limited by a high rate of muscular fatigue. Variable stimulation patterns have been examined in young adults with and without spinal cord injury, but much less investigation has been devoted to studying the effects of variable stimulation patterns administered to older adults or those paralyzed by stroke. Significant changes occur in the neuromuscular system with age that may affect the response to variable stimulation patterns. We administered three, 3-min intermittent stimulation patterns to the median nerves of 10 individuals with hemiplegia from stroke and 10 age-matched able-bodied adults: (1) constant 20 HZ, (2) a pattern that began at 20 HZ and progressively increased to 40 HZ in the latter half of the task, and (3) a 20-HZ pattern that switched to a 20-HZ doublet pattern after 90 s. In the able-bodied group the doublet pattern produced significantly higher force time integrals (FTI) (1409.72 +/- 3.15 N s) than the 20-40-HZ pattern (1067.46 +/- 1.15 N s) or the 20-HZ pattern (831 +/- 1.87 N s). In the poststroke individuals the doublet pattern also produced the highest FTI (724.04 +/- 2.02 N s), and there was no significant difference between the 20-40-HZ (636.42 +/- 1.65 N s) and 20-HZ (583.64 +/- 3.02 N s) patterns. These results indicate that protocols that incorporate doublets in the later stages of fatigue are effective in older adults and in older adults with paralysis from stroke.

Muscle fatigue of quadriceps in paraplegics: comparison between single vs. multi-pad electrode surface stimulation

We hypothesize that the asynchronous low frequency stimulation of pads within multi-pad electrode will be less fatiguing compared to the conventional stimulation (two single pad electrodes) when generating comparable large forces of paralyzed human muscles. The experiments to verify the hypothesis were conducted on quadriceps of six individuals with chronic spinal cord injury (ASIA score A) who had not participated in any electrical stimulation program. The following stimulation protocols were compared: stimulation with a self adhesive 7 cm x 10 cm Pals Platinum cathode positioned over the top of the quadriceps (f = 40 Hz), and four oval 4 cm x 6 cm cathodes positioned over the proximal upper leg (f = 16 Hz). The anode in both cases was the 7 cm x 10 cm Pals Platinum electrode positioned over the distal part of the quadriceps. We measured the knee joint torque vs. time with a custom made apparatus, and estimated the interval before the knee joint torque decreased to 70% of the maximum. Mean fatigue interval increase for the four-pad stimulation protocol vs. single-pad stimulation protocol was 153.18%. This suggests that the use of multi-pad electrodes is favorable in cases where a prolonged stimulation of muscles is required.

Force output during fatigue with progressively increasing stimulation frequency

There is currently a controversy over whether stimulation frequencies should increase or decrease to optimize force output over time. This study compared changes in thenar muscle force and M-wave amplitude during progressively increasing (20-40 Hz), decreasing (40-20 Hz) and constant (20 Hz) frequency stimulation of the median nerve continuously for 3 min. Twenty-three individuals participated in three sets of experiments. There was no significant difference in the force-time integrals between the three fatigue tasks. The rate of fatigue was not correlated to the number of stimulation pulses delivered (20 Hz: 3,600, 20-40 and 40-20 Hz: 5,400). All fatigue tasks caused a significant reduction in M-wave amplitude and the reduction was largest for the 20-40 Hz protocol. However, multiple linear regression analysis revealed that the M-wave amplitude could not predict the changes in force over time for the 20 Hz or 20-40 Hz protocols. Thus during sustained evoked contractions with stimulation frequencies within the physiological range, frequencies can vary significantly without changing the overall force-time integral.

Effect of random interpulse interval modulation on neuromuscular fatigue

Neuromuscular endurance during electrical stimulation may be enhanced if naturally occurring motor unit firing patterns are used. Variability in the interpulse interval (IPI) distribution may enable brief periods of rest and optimization of force output. Nine individuals participated in three 3-minute fatigue protocols of the thenar muscles elicited by supramaximal stimulation of the median nerve. All protocols consisted of a mean IPI of 33.3 ms and differed only in the type of IPI modulation, which was constant (0%), random (+/-20%), or ramped from 0% to +/-20%. M-wave amplitude declined following all protocols and the reduction was smallest following the ramp protocol. There was no significant difference among the starting or final forces or between the overall force-time integrals for the three protocols. Thus, IPI variability did not improve endurance time during electrical stimulation and the M-wave amplitude was not a reliable indicator of muscle force output.

La fatigue du blessé médullaire

OBJECTIVES

To identify variables increasing fatigue following spinal cord injury (SCI) and their functional consequences.

METHODS

A search of the Medline and Reedoc databases with the keywords SCI, fatigue, intrinsic muscular fatigue, chronic fatigue, aging, training, electrostimulation, quality of life and the same words in French.

RESULTS

Two kinds of fatigue are identified following SCI. Intrinsic fatigue in muscles totally or partially paralysed at the level of or below the spinal cord lesion; this peripheral fatigue is due to denervation, total or partial loss of motoneurons, or histological and metabolical changes in muscle; it is well-defined by electrophysiological technology; spasticity and spasms have little influence on its development; it is reversible in part with long term electrostimulation, but at this time, electroneuroprosthetic techniques do not reduce the excessive energetic cost to stand up and walk. Chronic fatigue appears in the long term following SCI; it is linked with aging, physiological, and psychological deconditioning; some data point to chronic fatigue after SCI similar to post-polio syndrome and chronic fatigue syndrome, which may explain the central nature of the fatigue; training programs could be useful in delaying this chronic fatigue and as a consequence, increasing the latent quality of life.

CONCLUSION

Muscular intrinsic fatigue after SCI is always of a peripherical nature in muscles partially or totally paralysed. Chronic fatigue during aging greatly decreases quality of life. Both intrinsic and chronic fatigue could be anticipated by electrostimulation technique on the one hand and long term training on the other.

Feedback-controlled stimulation enhances human paralyzed muscle performance

Chronically paralyzed muscle requires extensive training before it can deliver a therapeutic dose of repetitive stress to the musculoskeletal system. Neuromuscular electrical stimulation, under feedback control, may subvert the effects of fatigue, yielding more rapid and extensive adaptations to training. The purposes of this investigation were to 1) compare the effectiveness of torque feedback-controlled (FDBCK) electrical stimulation with classic open-loop constant-frequency (CONST) stimulation, and 2) ascertain which of three stimulation strategies best maintains soleus torque during repetitive stimulation. When torque declined by 10%, the FDBCK protocol modulated the base stimulation frequency in three ways: by a fixed increase, by a paired pulse (doublet) at the beginning of the stimulation train, and by a fixed decrease. The stimulation strategy that most effectively restored torque continued for successive contractions. This process repeated each time torque declined by 10%. In fresh muscle, FDBCK stimulation offered minimal advantage in maintaining peak torque or mean torque over CONST stimulation. As long-duration fatigue developed in subsequent bouts, FDBCK stimulation became most effective ( approximately 40% higher final normalized torque than CONST). The high-frequency strategy was selected approximately 90% of the time, supporting that excitation-contraction coupling compromise and not neuromuscular transmission failure contributed to fatigue of paralyzed muscle. Ideal stimulation strategies may vary according to the site of fatigue; this stimulation approach offered the advantage of online modulation of stimulation strategies in response to fatigue conditions. Based on stress-adaptation principles, FDBCK-controlled stimulation may enhance training effects in chronically paralyzed muscle.

The effect of random modulation of functional electrical stimulation parameters on muscle fatigue

Muscle contractions induced by functional electrical stimulation (FES) tend to result in rapid muscle fatigue, which greatly limits activities such as FES-assisted standing and walking. It was hypothesized that muscle fatigue caused by FES could be reduced by randomly modulating parameters of the electrical stimulus. Seven paraplegic subjects participated in this study. While subjects were seated, FES was applied to quadriceps and tibialis anterior muscles bilaterally using surface electrodes. The isometric force was measured, and the time for the force to drop by 3 dB (fatigue time) and the normalized force-time integral (FTI) were determined. Four different modes of FES were applied in random order: constant stimulation, randomized frequency (mean 40 Hz), randomized current amplitude, and randomized pulsewidth (mean 250 micros). In randomized trials, stimulation parameters were stochastically modulated every 100 ms in a range of +/-15% using a uniform probability distribution. There was no significant difference between the fatigue time measurements for the four modes of stimulation. There was also no significant difference in the FTI measurements. Therefore, our particular method of stochastic modulation of the stimulation parameters, which involved moderate (15%) variations updated every 100 ms and centered around 40 Hz, appeared to have no effect on muscle fatigue. There was a strong correlation between maximum force measurements and stimulation order, which was not apparent in the fatigue time or FTI measurements. It was concluded that a 10-min rest period between stimulation trials was insufficient to allow full recovery of muscle strength.

Fatigue of muscles weakened by death of motoneurons

Weakness is a characteristic of muscles influenced by the postpolio syndrome (PPS), amyotrophic lateral sclerosis (ALS), and spinal cord injury (SCI). The strength deficits relate to changes in muscle use and to the chronic denervation that can follow the spinal motoneuron death common to these disorders. PPS, ALS, and SCI also involve variable amounts of supraspinal neuron death, the effects of which on muscle weakness remains unclear. Nevertheless, weakness of muscle itself defines the functional consequences of these disorders. A weaker muscle requires an individual to work that muscle at higher than usual intensities relative to its maximal capacity, inducing progressive fatigue and an increased sense of effort. Little evidence is available to suggest that the fatigue commonly experienced by individuals with these disorders relates to an increase in the intrinsic fatigability of the muscle fibers. The only exception is when SCI induces chronic muscle paralysis. To reduce long-term functional deficits in these disorders, studies must identify the signaling pathways that influence neuron survival and determine the factors that encourage and limit sprouting of motor axons. This may ensure that a greater proportion of the fibers in each muscle remain innervated and available for use.

Fatigue properties of human thenar motor units paralysed by chronic spinal cord injury

Human muscles paralysed chronically by spinal cord injury (SCI) fatigue excessively. Whether these reductions in force reflect a decrease in the fatigue resistance of the motor units is unknown. Our aim was to determine the fatigability of thenar motor units paralysed chronically (10 +/- 2 years) by cervical SCI. Surface electromyographic activity (EMG) and force were recorded from 17 paralysed motor units (n = 7 subjects) in response to intraneural motor axon stimulation (13 pulses at 40 Hz, 1 s(-1) for 2 min). Unit force decreased progressively, reaching 8-60% of initial after 2 min, whereas both the amplitude and area of the first EMG potentials in the trains increased significantly (both P < 0.05). Thus, transmission of neural signals to the sarcolemma was effective and the reduction in force must reflect impaired processes in the muscle fibres. The median fatigue index for paralysed units (0.31), the ratio of the force at 2 min compared to the initial force, was significantly lower than that for units from control subjects (0.85, P < 0.05), but the distribution of fatigue indices for each population had a similar shape (ranges: 0.08-0.60 and 0.41-0.95, respectively). Hence, chronic paralysis did not limit the range of fatigability typically found for thenar units, only its magnitude. These findings suggest that all paralysed units underwent similar reductions in fatigue resistance. After fatigue, paralysed unit forces were reduced at all frequencies (1-100 Hz, P < 0.05). Twitch contraction and half-relaxation times were increased, as was the frequency needed to produce half maximal force (P < 0.05). Thus, stimulation protocols used to produce functional movements in paralysed muscles need to accommodate the significant and rapid fatigue of the motor units.

Musculoskeletal plasticity after acute spinal cord injury: effects of long-term neuromuscular electrical stimulation training

Maintaining the physiologic integrity of paralyzed limbs may be critical for those with spinal cord injury (SCI) to be viable candidates for a future cure. No long-term intervention has been tested to attempt to prevent the severe musculoskeletal deterioration that occurs after SCI. The purposes of this study were to determine whether a long-term neuromuscular electrical stimulation training program can preserve the physiological properties of the plantar flexor muscles (peak torque, fatigue index, torque-time integral, and contractile speed) as well as influence distal tibia trabecular bone mineral density (BMD). Subjects began unilateral plantar flexion electrical stimulation training within 6 wk after SCI while the untrained leg served as a control. Mean compliance for the 2-yr training program was 83%. Mean estimated compressive loads delivered to the tibia were approximately 1-1.5 times body weight. The training protocol yielded significant trained versus untrained limb differences for torque (+24%), torque-time integral (+27%), fatigue index (+50%), torque rise time (+45%), and between-twitch fusion (+15%). These between-limb differences were even greater when measured at the end of a repetitive stimulation protocol (125 contractions). Peripheral quantitative computed tomography revealed 31% higher distal tibia trabecular BMD in trained limbs than in untrained limbs. The intervention used in this study was sufficient to limit many of the deleterious muscular and skeletal adaptations that normally occur after SCI. Importantly, this method of load delivery was feasible and may serve as the basis for an intervention to preserve the musculoskeletal properties of individuals with SCI.

Strategies That Improve Paralyzed Human Quadriceps Femoris Muscle Performance During Repetitive, Nonisometric Contractions

OBJECTIVE

To determine the effect of combining different stimulation frequencies on the ability of paralyzed human quadriceps muscle to produce a 50 degrees knee excursion repetitively when starting at 90 degrees of flexion.

DESIGN

Repeated-measures design.

SETTING

Clinical research laboratory.

PARTICIPANTS

Complete data were collected from 9 subjects aged 11 to 25 years (mean +/- standard deviation, 17.1+/-4.5y) with spinal cord injury (SCI).

INTERVENTION

Three protocols were each tested during separate sessions: 20-Hz trains of pulses followed by 66-Hz trains (C20+66), 33-Hz trains followed by 66-Hz trains (C33+66), and 66-Hz trains alone (C66). For each frequency, stimulation was repeated until the knee failed to produce a 50 degrees excursion. This approach allowed us to evaluate the response to stimulation with 20-, 33-, and 66-Hz and combinations of 20- and 66-Hz and 33- and 66-Hz trains.

MAIN OUTCOME MEASURE

Number of successful contractions.

RESULTS

The C20 and C33 did not differ (mean, 41.0+/-12.6 excursions and 42.0+/-12.3 excursions, respectively), and each produced more excursions than the C66 protocol. The C20+66 and C33+66 protocols produced 51.4+/-15.0 and 44.9+/-13.6 excursions, respectively, and the C20+66 was the best protocol overall (all P<or=.05).

CONCLUSIONS

This study showed that stimulation strategies that start with low frequencies and switch to higher frequencies as the muscle fatigues could improve the ability of functional electric stimulation applications to perform repetitive, nonisometric contractions in subjects with SCI.

Reducing muscle fatigue due to functional electrical stimulation using random modulation of stimulation parameters

A major limitation of many functional electrical stimulation (FES) applications is that muscles tend to fatigue very rapidly. It was hypothesized that FES-induced muscle fatigue could be reduced by randomly modulating the pulse frequency, amplitude, and pulse width in a range of +/-15%. Seven subjects with spinal-cord injuries participated in this study. FES was applied to quadriceps and tibialis anterior muscles using surface electrodes. Isometric force was measured, and the time for the force to drop by 3 dB (fatigue time) was compared between trials. Four different modes of FES were applied in random order: constant stimulation, randomized frequency, randomized amplitude, and randomized pulse width. There was no significant difference between the fatigue-time measurements for the four modes of stimulation (P=0.329). Therefore, random modulation appeared to have no effect. Based on an observed correlation between maximum force measurements and trial order, we concluded that having 10-min rest periods between trials was insufficient.

Catchlike property of skeletal muscle: Recent findings and clinical implications

The catchlike property of skeletal muscle is the force augmentation produced by the inclusion of an initial, brief, high-frequency burst of two to four pulses at the start of a subtetanic low-frequency stimulation train. Catchlike-inducing trains take advantage of the catchlike property of skeletal muscle and augment muscle performance compared with constant-frequency trains, especially in the fatigued state. Literature spanning more than 30 years has provided comprehensive information about the catchlike property of skeletal muscle. The pattern of the catchlike-inducing train that maximizes muscle performance is fairly similar across different muscles of different species and under various stimulation conditions. This review summarizes the mechanisms of the catchlike property, factors affecting force augmentation, techniques used to identify patterns of catchlike-inducing trains that maximize muscle performance, and potential clinical applications to provide a historical and current perspective of our understanding of the catchlike property.

Associations between force and fatigue in fast-twitch motor units of a cat hindlimb muscle

Associations were quantified between the control force and fatigue-induced force decline in 22 single fast-twitch-fatigable motor units of 5 deeply anesthetized adult cats. The units were subjected to intermittent stimulation at 1 train/s for 360 s. Two stimulation patterns were delivered in a pseudo-random manner. The first was a 500-ms train with constant interpulse intervals. The second pattern had the same number of stimuli, mean stimulus rate, and stimulus duration, but the stimulus pulses were rearranged to increase the force produced by the units in the control (prefatigue) state. The associations among the control peak tetanic force of these units, 3 indices of fatigue, and total cumulative force during fatiguing contractions were dependent, in part, on the stimulation pattern used to produce fatigue. The associations were also dependent, albeit to a lesser extent, on the force measure (peak vs. integrated) and the fatigue index used to quantify fatigue. It is proposed that during high-force fatiguing contractions, neural mechanisms are potentially available to delay and reduce the fatigue of fast-twitch-fatigable units for brief, but functionally relevant, periods. In contrast, the fatigue of slow-twitch fatigue-resistant units seems more likely to be controlled largely, if not exclusively, by metabolic processes within their muscle cells.Key words: cat, catch-like property, fatigue, force, motor units, size principle.

Quadriceps fatigue caused by catchlike-inducing trains is not altered in old age

The relative loss of peak force from electrical stimulation protocols has provided inconsistent results when used to compare muscle fatigability between young and old adults. In addition to the effect of task on these comparisons, age-related alterations in the development and relaxation of force are possible factors that have not been considered. The purposes of this study were to compare the fatigability of the quadriceps of young (26.7 +/- 1.0 years) and old men (78.3 +/- 1.3 years), as assessed by changes in peak force, force time integral (FTI), and half-relaxation time (HRT), during intermittent electrical stimulation protocols, and to determine whether manipulation of the activation frequency affected the comparisons. Fatigue was caused by constant-frequency (CF), and catchlike-inducing (CI) train protocols, both of which consisted of intermittent trains (6 pulses on: 650 ms off) of stimulation. After each protocol, the force-generating capacity of the fatigued muscle was assessed with three trains of stimuli: a CF train, a CI train and a 1-s 50-HZ train. There was no effect of age on the loss of peak force or the development of low-frequency fatigue induced by either protocol. Conversely, irrespective of the protocol, the FTI was better maintained by approximately 9% in the old than young men. Because peak force did not differ between groups during fatigue, it is likely that the FTI was preserved by the exacerbated slowing of HRT in the quadriceps of the old men. The results confirm an apparent paradox between muscle fatigue and stimulation with CI trains: a single CI train produces greater force than a CF train in a fatigued muscle, but there is greater fatigue induced by repetitive CI than CF train stimulation. Old age did not affect this fatigue paradox.

Increased blood pressure can reduce fatigue of thenar muscles paralyzed after spinal cord injury

The aim of this study was to evaluate whether increases in blood pressure, and presumably muscle perfusion pressure, improve the endurance of thenar muscles paralyzed chronically by cervical spinal cord injury (SCI). Resting mean arterial pressure (MAP) was low in all eight subjects (64 +/- 2 mmHg). Muscle fatigue (force decline) was produced on 2 days by intermittent supramaximal electrical stimulation of the median nerve at 20 Hz for 2 min. During one of the fatigue tests, a concurrent sustained voluntary contraction of the contralateral elbow flexors was used to increase resting MAP (by 22%, on average). Although this change in blood pressure resulted in no significant change in mean fatigue for the group, changes in MAP with exercise (median nerve stimulation with and without voluntary contraction) correlated with changes in thenar muscle fatigue in seven subjects. For every 10% increase in MAP, fatigue was reduced by approximately 3%. The data suggest that low blood pressure after chronic cervical SCI and poor blood pressure control during exercise exacerbate the fatigability of paralyzed muscles.