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.

Changes in Post-Stroke Gait Biomechanics Induced by One Session of Gait Training.

The objective of this study was to determine whether one session of targeted locomotor training can induce measurable improvements in the post-stroke gait impairments. Thirteen individuals with chronic post-stroke hemiparesis participated in one locomotor training session combining fast treadmill training and functional electrical stimulation (FES) of ankle dorsi- and plantar-flexor muscles. Three dimensional gait analysis was performed to assess within-session changes (after versus before training) in gait biomechanics at the subject's self-selected speed without FES. Our results showed that one session of locomotor training resulted in significant improvements in peak anterior ground reaction force (AGRF) and AGRF integral for the paretic leg. Additionally, individual subject data showed that a majority of study participants demonstrated improvements in the primary outcome variables following the training session. This study demonstrates, for the first time, that a single session of intense, targeted post-stroke locomotor retraining can induce significant improvements in post-stroke gait biomechanics. We posit that the within-session changes induced by a single exposure to gait training can be used to predict whether an individual is responsive to a particular gait intervention, and aid with the development of individualized gait retraining strategies. Future studies are needed to determine whether these single-session improvements in biomechanics are accompanied by short-term changes in corticospinal excitability, and whether single-session responses can serve as predictors for the longer-term effects of the intervention with other targeted gait interventions.

Catchlike property of human muscle during isovelocity movements.

This study examined the catchlike property of skeletal muscle during eccentric and concentric isovelocity contractions of fresh and fatigued quadriceps femoris muscles of 10 healthy subjects. During concentric contractions of fresh muscles, stimulation trains that elicited a catchlike response (CITs) produced greater force outputs and rates of rise force than comparable constant-frequency trains. These enhancements became more pronounced during fatigue. CITs were less effective in enhancing forces during eccentric contractions but did improve the rates of rise of force. Overall, the CIT that produced the greatest augmentation had a 5-ms initial interpulse interval. Proposed mechanisms for the catchlike property involve enhanced muscle stiffness for more efficient transmission of tension and increased calcium release. These results suggest that stimulation trains that take advantage of the catchlike property of skeletal muscle may be helpful during clinical applications where neuromuscular electrical stimulation is used to restore function in patients with damaged central nervous systems.

Effects of activation frequency on dynamic performance of human fresh and fatigued muscles.

The force-frequency relationship for an individual muscle depends on the fatigue state, the length at which it is activated, and the muscle's activation history. The relationship among stimulation frequency and dynamic (nonisometric) muscle performance measurements (e.g., excursion, work, peak power, and average power) has not been reported. The purpose of this study was to identify the relationship between stimulation frequency and dynamic performance measurements for fresh and fatigued muscles. Constant-frequency and catchlike-inducing trains (CFT and CIT, respectively) were tested. When fresh, interpulse intervals of 40-50 ms [20-25 pulses/s (pps)] produced maximum performance for CFTs. For CITs, maximum performance occurred at interpulse intervals of 50-60 ms ( approximately 16-20 pps). Generally, CFTs produced slightly greater performance than did CITs. When fatigued, however, CITs produced greater performance than did CFTs. Maximum performance for CFTs occurred at interpulse intervals of 20-40 ms (25-50 pps) and at 30-50 ms (20-33 pps) for CITs. Enhancement of performance by CITs when fatigued may be due to less susceptibility to impairments in excitation-contraction coupling and greater ability to maintain rates of rise of force than CFTs.

Effects of activation frequency and force on low-frequency fatigue in human skeletal muscle.

No comparison of the amount of low-frequency fatigue (LFF) produced by different activation frequencies exists, although frequencies ranging from 10 to 100 Hz have been used to induce LFF. The quadriceps femoris of 11 healthy subjects were tested in 5 separate sessions. In each session, the force-generating ability of the muscle was tested before and after fatigue and at 2, approximately 13, and approximately 38 min of recovery. Brief (6-pulse), constant-frequency trains of 9.1, 14.3, 33.3, and 100 Hz and a 6-pulse, variable-frequency train with a mean frequency of 14.3 Hz were delivered at 1 train/s to induce fatigue. Immediately postfatigue, there was a significant effect of fatiguing protocol frequency. Muscles exhibited greater LFF after stimulation with the 9.1-, 14.3-, and variable-frequency trains. These three trains also produced the greatest mean force-time integrals during the fatigue test. At 2, approximately 13, and approximately 38 min of recovery, however, the LFF produced was independent of the fatiguing protocol frequency. The findings are consistent with theories suggesting two independent mechanisms behind LFF and may help identify the optimal activation pattern when functional electrical stimulation is used.

A predictive model of fatigue in human skeletal muscles.

Fatigue is a major limitation to the clinical application of functional electrical stimulation. The activation pattern used during electrical stimulation affects force and fatigue. Identifying the activation pattern that produces the greatest force and least fatigue for each patient is, therefore, of great importance. Mathematical models that predict muscle forces and fatigue produced by a wide range of stimulation patterns would facilitate the search for optimal patterns. Previously, we developed a mathematical isometric force model that successfully identified the stimulation patterns that produced the greatest forces from healthy subjects under nonfatigue and fatigue conditions. The present study introduces a four-parameter fatigue model, coupled with the force model that predicts the fatigue induced by different stimulation patterns on different days during isometric contractions. This fatigue model accounted for 90% of the variability in forces produced by different fatigue tests. The predicted forces at the end of fatigue testing differed from those observed by only 9%. This model demonstrates the potential for predicting muscle fatigue in response to a wide range of stimulation patterns.

Activation of human quadriceps femoris muscle during dynamic contractions: effects of load on fatigue.

Muscle fatigue is both multifactorial and task dependent. Electrical stimulation may assist individuals with paralysis to perform functional activities [functional electrical stimulation (FES), e.g., standing or walking], but muscle fatigue is a limiting factor. One method of optimizing force is to use stimulation patterns that exploit the catchlike property of skeletal muscle [catchlike-inducing trains (CITs)]. Although nonisometric (dynamic) contractions are important parts of both normal physiological activation of skeletal muscles and FES, no previous studies have attempted to identify the effect that the load being lifted by a muscle has on the fatigue produced. This study examined the effects of load on fatigue during dynamic contractions and the augmentation produced by CITs as a function of load. Knee extension in healthy subjects was electrically elicited against three different loads. The highest load produced the least excursion, work, and average power, but it produced the greatest fatigue. CIT augmentation was greatest at the highest load and increased with fatigue. Because CITs were effective during shortening contractions for a variety of loads, they may be of benefit during FES applications.

Development of a mathematical model that predicts optimal muscle activation patterns by using brief trains.

Because muscles must be repetitively activated during functional electrical stimulation, it is desirable to identify the stimulation pattern that produces the most force. Previous experimental work has shown that the optimal pattern contains an initial high-frequency burst of pulses (i.e., an initial doublet or triplet) followed by a low, constant-frequency portion. Pattern optimization is particularly challenging, because a muscle's contractile characteristics and, therefore, the optimal pattern change under different physiological conditions and are different for each person. This work describes the continued development and testing of a mathematical model that predicts isometric forces from fresh and fatigued muscles in response to brief trains of electrical pulses. By use of this model and an optimization algorithm, stimulation patterns that produced maximum forces from each subject were identified.

Catchlike-inducing train activation of human muscle during isotonic contractions: burst modulation.

Stimulation trains that exploit the catchlike property [catchlike-inducing trains (CITs)] produce greater forces and rates of rise of force than do constant-frequency trains (CFTs) during isometric contractions and isovelocity movements. This study examined the effect of CITs during isotonic contractions in healthy subjects. Knee extension was electrically elicited against a load of 10% of maximum voluntary isometric contraction. The stimulation intensity was set to produce 20% of maximum voluntary isometric contraction. The muscle was tested before and after fatigue with a 6-pulse CFT and 6-pulse CITs that contained an initial doublet, triplet, or quadruplet. For prefatigue responses, the greatest isotonic performance was produced by CITs with initial doublets. When the muscles were fatigued, triplet CITs were best. CITs produce greater excursion, work, peak power, and average power than do CFTs, because CITs produced more rapid rates of rise of force. Faster rates of rise of force enabled the preload on the muscle to be exceeded earlier during the stimulation train.

Two-step, predictive, isometric force model tested on data from human and rat muscles.

Functional electrical stimulation can assist paralyzed individuals to perform functional movements, but muscle fatigue is a major limitation to its practical use. An accurate and predictive mathematical model can facilitate the design of stimulation patterns that optimize aspects of the force transient while minimizing fatigue. Solution nonuniqueness, a major shortcoming in previous work, was overcome with a simpler model. The model was tested on data collected during isometric contractions of rat gastrocnemius muscles and human quadriceps femoris muscles under various physiological conditions. For each condition tested, parameter values were identified using the force response to one or two stimulation trains. The parameterized model was then used to predict forces in response to other stimulation patterns. The predicted forces closely matched the measured forces. The model was not sensitive to initial parameter estimates, demonstrating solution uniqueness. By predicting the force that develops in response to an arbitrary pattern of stimulation, we envision the present model helping identify optimal stimulation patterns for activation of skeletal muscle during functional electrical stimulation.

Variable-frequency train stimulation of canine latissimus dorsi muscle during shortening contractions.

In cardiomyoplasty, the latissimus dorsi muscle (LDM) is wrapped around the heart ventricles and electrically activated with a constant-frequency train (CFT). This study tested the hypotheses that increased mechanical performance from the LDM could be achieved by activating the muscle with variable-frequency trains (VFTs) of shorter duration or containing fewer stimulus pulses than the CFT now used. The mechanical performance of the canine LDM (n = 7) during shortening contractions was measured while the muscle was stimulated with 5- and 6-pulse CFTs (of duration 132 and 165 ms, respectively) and 5- and 6-pulse VFTs (of duration 104 and 143 ms, respectively) that were designed to take advantage of the catchlike property of skeletal muscle. Measurements were made from fresh and fatigued muscles. For the fresh muscles, the VFTs elicited significantly greater peak power than did the 6-pulse CFT. When the muscles were fatigued, VFT stimulation significantly improved both the peak and mean power produced compared with stimulation by CFTs. These results show that stimulation of the LDM with shorter duration VFTs is potentially useful for application in cardiomyoplasty.

Fatigability of human quadriceps femoris muscle following anterior cruciate ligament reconstruction.

The responses of quadriceps femoris muscles to an electrically elicited fatigue test were recorded from both lower extremities of 18 patients who had recently undergone unilateral, anterior cruciate ligament reconstruction. The fatigue test consisted of 40 pps, 13-pulse electrical trains that were repeated once per second for 3 min. The intensity of stimulation was set for each extremity to produce 20% of the maximum voluntary isometric contraction of the uninvolved muscle. The uninvolved quadriceps femoris muscle showed a significantly greater rate of decline in force over the first minute than the involved muscle (0.803%.s-1 for uninvolved muscle vs 0.620%.s-1 for involved muscle). Similarly, the average forces produced over the last minute were significantly lower for the uninvolved than the involved quadriceps femoris muscle (uninvolved = 42.6%, involved = 50.4% of their original forces). These surprising results showed that the involved quadriceps femoris muscles were more endurant than the uninvolved muscles. It is suggested that the increases in endurance of the involved muscle may have been due, in part, to greater recruitment of Type I fibers with electrical stimulation or selective Type II fiber atrophy in the involved muscle.

Effects of stimulation intensity on the physiological responses of human motor units.

Quadriceps femoris muscles were studied in 50 healthy subjects to determine the physiological responses of the motor units recruited at different force levels during transcutaneous electrical stimulation. During one set of experiments force-frequency relationships were compared at stimulation intensities that produced tetanic contraction of 20%, 50%, or 80% of the maximum voluntary isometric contraction (MVC). No differences in the normalized force-frequency relationship were observed between the 20% and 50% of MVC conditions and only a slight shift to the left was observed at 80% of MVC. The other set of experiments measured the responses to electrically elicited fatigue tests using frequencies of 20, 40, or 60 pps and, at each frequency, intensities that produced 20% or 50% of MVC. Fatigue was greater for the 50% than 20% MVC force conditions. Within each force level fatigue increased with increasing frequency. However, though the differences in the level of recruitment needed to produce the two forces varied for each frequency, the differences in the amount of fatigue produced at each force did not vary between the three stimulation frequencies. This suggests that the fatigue characteristics of the recruited motor units were similar at all intensities tested. We posit, therefore, that the physiological recruitment order during transcutaneous electrical stimulation is less orderly than previously suggested.

A mathematical model that predicts skeletal muscle force.

This study demonstrates the validity of a mathematical model that predicts the force generated by rat skeletal muscles during brief subtetanic and tetanic isometric contractions. The model consists of three coupled differential equations (ODE's). The first two equations represent the calcium dynamics and the third equation represents force dynamics. The model parameters were identified from brief trains of regularly spaces pulses [constant-frequency trains (CFT's)] that produce subtetanic muscle responses. Using these parameters, the model was able to predict isometric forces from other stimulation patterns. For the gastrocnemius muscles predictions were made for responses to CFT's with interpulse intervals (IPI's) ranging from 10 to 50 ms and variable-frequency trains (VFT's), where the initial IPI = 10 ms and the remaining IPI's were identical to those used for the CFT's. For the soleus muscles predictions were made for 10-100-ms CFT's. The shape of the predicted responses closely match the experimental data. Comparisons between experimental and modeled force-time integrals, peak forces, and time-to-peak also suggest excellent agreement between the model and the experiment data. Many physiological parameters predicted by the model agree with values obtained independently by others. In conclusion, the model accurately predicts isometric forces generated by rat gastrocnemius and soleus muscles produced by brief stimulation trains.

Preservation of force output through progressive reduction of stimulation frequency in human quadriceps femoris muscle.

The purpose of this study was to determine the effects of a reduction in the pulse frequency on the fatigue rate of human quadriceps femoris muscle during intermittent (8-second) contractions. Twelve healthy subjects each participated in two experimental sessions. Thirty cycles (cycle time: 8 seconds "on"/12 seconds "off") were applied during each session. During one session, a frequency of 60 pulses per second (pps) was used for all trains. During the other session, the subjects were stimulated with 60 pps for the first train. The stimulating frequency of each train was then progressively reduced, in 5-pps steps, for contractions 2, 3, 5, 8, 12, and 20. By the fifth contraction, the differences in average force produced by the 60-pps trains and the reduced-frequency trains were significant. The difference between the two conditions increased, with the variable-frequency protocol producing 46% more force than the constant-frequency protocol during the last contraction. These results showed that, compared with a constant pulse frequency, reducing the pulse frequency during a fatiguing contraction can markedly decrease the rate of force fatigue of skeletal muscle. This finding suggests that a variable-frequency protocol, similar to the one used in this may prove to be a more effective pattern of stimulation for activation of skeletal muscle than the traditionally used constant-frequency protocol.

Muscle fatigue: clinical implications for fatigue assessment and neuromuscular electrical stimulation.

Muscle fatigue can be defined as a decrease in the force-generating ability of a muscle that resulted from recent activity. Recent studies of muscle fatigue are reviewed that are relevant to two areas of interest to physical therapists: clinical assessment of muscle fatigue and neuromuscular electrical stimulation. Volitional and electrical tests have been used to quantify muscle fatigue. Several variations on each type of test are discussed, as are the possible sites in which fatigue might occur. The rate of fatigue during the therapeutic application of electrical stimulation of skeletal muscle is much greater than that seen during volitional contractions. Factors contributing to this phenomenon are examined. The unique requirements affecting how stimulus variables can be manipulated to minimize muscle fatigue in three specific therapeutic uses of neuromuscular electrical stimulation are addressed.

Changes in the force-frequency relationship of the human quadriceps femoris muscle following electrically and voluntarily induced fatigue.

The purpose of this study was to identify the changes in the force-frequency relationship (FFR) of the human quadriceps femoris muscle following electrically and voluntarily induced fatigue. Twenty nondisabled subjects each participated in one experimental session to test the effects of electrically induced fatigue on the FFR; 10 of these subjects participated in a second session in which voluntarily induced fatigue was produced. Fatigue was induced by having subjects perform repeated, 8-second, isometric contractions followed by 12-second rests until 50% of the initial force was produced. Markedly decreased forces were seen at all frequencies tested following fatigue. Low frequency fatigue was observed following both fatiguing protocols. The frequencies needed to produce near-maximum forces did not shift with fatigue. These results suggest that the most appropriate stimulation frequency to use when activating skeletal muscle depends on both the percentage of tetanic force desired and the fatigue state of the muscle. This study also provides the clinician with data on the FFR of healthy human quadriceps femoris muscle prior to fatigue. [Binder-Macleod SA, McDermond LR. Changes in the force-frequency relationship of the human quadriceps femoris muscle following electrically and voluntarily induced fatigue.

Electromyographic biofeedback applications to the hemiplegic patient. Changes in upper extremity neuromuscular and functional status.

The effect of a specific EMG biofeedback treatment protocol on quantified changes in neuromuscular measures and functional activities was examined among the upper extremities of 22 chronic stroke patients who each received 60 feedback training sessions. These data were compared with changes measured from a Control Group of 9 (no treatment) patients. Those patients receiving feedback training showed significant improvements in numerous neuromuscular measures but not in functional measures. When the Experimental Group was subdivided into two groups (hand, n = 5; no hand, n = 17) on the basis of acquiring a specific hand function, significant pretreatment differences in neuromuscular status emerged. Based upon these pretreatment differences and outcome measures, characteristics possibly predictive of beneficial outcomes from EMG biofeedback training were exposed. Chronic stroke patients who gained maximal functional benefits from the biofeedback intervention initially had greater active range of motion at all major upper extremity joints and comparatively less hyperactivity within typically "spastic" muscles. Electromyographic biofeedback can lead to substantial improvements among select chronic stroke patients and can be of considerable functional benefit to others.

Electromyographic biofeedback applications to the hemiplegic patient. Changes in lower extremity neuromuscular and functional status.

The efficacy of EMG biofeedback in improving neuromuscular and functional measures of involved lower extremities in an Experimental Group of chronic stroke patients (n = 7) was examined. Differences in pretreatment-posttreatment measures of the Experimental Group were compared with those of groups of chronic stroke patients receiving no treatment (n = 6), biofeedback treatment of the involved upper extremity only (n = 16), and general relaxation training (n = 8). All examinations were performed in a blind fashion. The Experimental Group showed significant improvement in active range of motion at the knee and ankle that appeared to result from increases in EMG output to muscles governing these movements. Experimental patients did not improve substantially in walking speed over different terrains but did require significantly fewer or less complex assistive devices to walk. Limitations in the design and implementation of this study are provided, and suggestions for future investigation are offered.

Use of the Krusen Limb Load Monitor to quantify temporal and loading measurements of gait.

The purposes of this investigation were to determine whether the temporal and force measurements from the Krusen Limb Load Monitor produced clinically reliable data and to begin identifying the factors that determine the monitor's reliability. Temporal and loading measurements were made from the output of the Krusen Limb Load Monitor and compared to values obtained from a calibrated force platform. Such comparisons were made for 30 steps taken by two subjects on three separate occasions and from the same two subjects plus a third subject for 100 consecutive steps. For most measures, mean values from the limb-load monitor were significantly different from those recorded from the force platform. From a clinical perceptive, however, the range of measures was narrow for the 95 percent confidence level of the observed differences for the temporal components of stance between the limb-load monitor and force platform, with the narrowest range of measures related to the appropriateness of "fit" of the limb-load monitor force plate within the shoe. The loading components of stance showed a relatively wide 95 percent confidence interval that appeared unrelated to fit. Thus, given a "good fitting" force plate insert, the therapist can make clinically meaningful measurements of the temporal components of the stance phase of gait using the limb-load monitor.