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.

Relationship between stimulation train characteristics and dynamic human skeletal muscle performance.

AIM: The purpose of the present study was to investigate the effect of activation frequency on dynamic human muscle performance for a range of train durations and number of pulses during free limb movement. METHODS: The quadriceps femoris muscles of 10 subjects were activated with stimulation trains with different activation frequency, train durations and number of pulses. The peak excursion produced in response to each train was the dependent measure of muscle performance. RESULTS: The excursion-frequency (for a 300-ms train duration) and excursion-train duration (for trains with frequencies of 10, 30 or 59 Hz) relationships could each be fit with a two-parameter exponential equation (R(2) values > 0.97). Because the number of pulses in a stimulation train is a function of both train duration and frequency, the excursion produced as a function of the number of pulses was characterized by a three-parameter exponential equation that represented this combined relationship. The relationship between the measured and predicted excursions in response to a wide range of stimulation trains had a R(2) = 0.96. In addition, one-way repeated measures analyses of variance (anovas) showed that the frequency at which the maximum excursion was produced increased with an increase in the number of pulses in the trains tested. CONCLUSION: These results show the importance of train duration and the number of pulses contained within a train on the relationship between activation frequency and human skeletal muscle performance.

Challenging the role of pH in skeletal muscle fatigue.

Muscle fatigue is frequently defined as a temporary loss in force- or torque-generating ability because of recent, repetitive muscle contraction (1). The development of this temporary loss of force is a complex process and results from the failure of a number of processes, including motor unit recruitment and firing rate, chemical transmission across the neuromuscular junction, propagation of the action potential along the muscle membrane and T tubules, Ca2+ release from the sarcoplasmic reticulum (SR), Ca2+ binding to troponin C, and cross-bridge cycling (for detailed reviews, see Bigland-Ritchie and Woods(1), McLester(2), and Favero(3)). Muscle fatigue may limit the time a person can stand, the distance a person can ambulate, or the number of stairs a person can ascend or descend. In practical terms, however, we cannot know what actually leads to a decline in function for a given patient. For a phenomenon that may have profound clinical implications, muscle fatigue often receives inadequate attention in physiology textbooks, many of which contain a page or less of information on the entire topic (4-8). In addition, many textbooks report that muscle fatigue is mainly the result of a decrease in pH within the muscle cell due to a rise in hydrogen ion concentration ([H+]) resulting from anaerobic metabolism and the accumulation of lactic acid (6-8). Recent literature, however, contradicts this assertion (9-10). The purpose of this update, therefore, is to provide a brief review of the role of pH in the development of muscle fatigue.

Comparison of fatigue produced by various electrical stimulation trains.

Previous work has shown that variable-frequency trains (VFTs) that use an initial doublet to take advantage of the catch-like property of muscle produce more force in fatigued muscle than constant-frequency trains (CFTs); however, it is unclear whether repetitive activation with VFTs is more or less fatiguing than repetitive activation with CFTs. The purpose of this research was to investigate the forces and fatigue produced by various stimulation trains during repetitive isometric muscle contractions. Two force measurements, peak force and force-time integral, were used to measure the performance of the human quadriceps muscle. Three fatiguing protocols, each consisting exclusively of either CFTs, trains with an initial doublet (VFTs), or trains with doublets separated by longer intervals [doublet-frequency trains (DFTs)], were tested. In addition, force responses to each of the three train types were tested before and immediately following each fatiguing protocol. Regardless of the fatiguing protocol, the doublet-frequency testing trains produced the greatest peak forces and force-time integrals before and immediately following the fatiguing protocols. Repetitive activation with exclusively DFTs produced greater attenuation of the testing trains than repetitive activation with CFTs or VFTs. These results suggest that clinical applications of electrical stimulation to activate skeletal muscle may need to contain a combination of train types to optimize performance.

A novel stimulation pattern improves performance during repetitive dynamic contractions.

The purpose of this study was to determine the effect of three different stimulation patterns on repetitive knee movements. Each subject's quadriceps femoris was stimulated with: (1) a constant-frequency train (CFT) with an interpulse interval (IPI) of 50 ms; (2) a variable-frequency train (VFT)-similar to the CFT, except with an initial doublet with an IPI of 5 ms; and (3) a doublet-frequency train (DFT) with multiple doublets (doublet IPI 5 ms) separated by 50 ms, while the muscle was resisted by a load equal to 10% of the muscle's maximum voluntary isometric contraction. The muscle was stimulated while the knee moved through a 50 degrees arc of motion (90 degrees to 40 degrees of flexion). Testing was stopped when the subject failed to reach the target three consecutive times. Results showed that DFTs reached the target (mean +/- SD) 36.4 +/- 14.4 times, followed by VFTs (25.4 +/- 17.9) and CFTs (17.4 +/- 11.9). The DFT was the best pattern for producing shortening contractions. The results suggest that DFTs may have significant benefits during clinical functional electrical stimulation.

Maximum voluntary activation in nonfatigued and fatigued muscle of young and elderly individuals.

BACKGROUND AND PURPOSE: Researchers studying central activation of muscles in elderly subjects (> or = 65 years of age) have investigated activation in only the nonfatigued state. This study examined the ability of young and elderly people to activate their quadriceps femoris muscles voluntarily under both fatigued and nonfatigued conditions to determine the effect of central activation failure on age-related loss of force. SUBJECTS AND METHODS: Twenty young subjects (11 men, 9 women; mean age = 22.67 years, SD = 4.14, range = 18-32 years) and 17 elderly subjects (8 men, 9 women; mean age = 71.5 years, SD = 5.85, range = 65-84 years) participated in this study. Subjects were seated on a dynamometer and stabilized. Central activation was quantified, based on the change in force produced by a 100-Hz, 12-pulse electrical train that was delivered during a 3- to 5-second isometric maximum voluntary contraction (MVC) of the quadriceps femoris muscle. Next, subjects performed 25 MVCs (a 5-second contraction with 2 seconds of rest) to fatigue the muscle. During the last MVC, central activation was measured again. RESULTS: In the nonfatigued state, elderly subjects had lower central activation than younger subjects. In the fatigued state, this difference became larger. DISCUSSION AND CONCLUSION: Central activation of the quadriceps femoris muscle in elderly subjects was reduced in both the fatigued and nonfatigued states when compared with young subjects. Some part of age-related weakness, therefore, may be attributed to failure of central activation in both the fatigued and nonfatigued states.

Measurement of central activation failure of the quadriceps femoris in healthy adults.

The purpose of this investigation was to describe the relationship between the central activation ratio (CAR) and the percent maximum voluntary effort (% MVE) during isometric quadriceps femoris contractions. Twenty-one healthy, young adults participated in three test sessions. During each session, one of three train types was tested: a 100-HZ 120-ms train, a 100-HZ 250-ms train, or a 50-HZ 500-ms train. Subjects were seated on a force dynamometer and stabilized to perform a 3-5-s isometric knee extension at MVE. Force targets were set at 25, 50, 75, and 100% of the MVE. With 5 min rest between efforts, subjects produced forces at the specified target levels. When each target was reached, the test train was delivered to quantify the amount of central activation. There were no significant differences in CARs across train types during maximal efforts, but during submaximal efforts at 25 and 50%, the 100-HZ 250-ms and 50-HZ 500-ms trains produced significantly lower CARs than the 100-HZ 120-ms train. The relationship between the CAR and the %MVE was curvilinear and best described by a second-order polynomial for all three train types. If tests of central activation are going to be used clinically, it is important to know the relationship between the CAR and voluntary effort; however, further study will be required to extend these results to specific patient populations.

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.

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.

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.

Effects of length on the catchlike property of human quadriceps femoris muscle.

BACKGROUND AND PURPOSE: Recent reports have suggested that electrical stimulation trains that take advantage of the catchlike property of skeletal muscle can produce higher forces from skeletal muscle than traditionally used constant-frequency trains. This study investigated the effects of catchlike-inducing trains on human quadriceps femoris muscles while the kneejoint was held at 15 degrees of flexion. SUBJECTS AND METHODS: Subjects (N=12) were tested with constant-frequency trains that had interpulse intervals ranging from 10 to 160 milliseconds and comparable catchlike-inducing trains. Data were collected during the control condition (1 train every 10 seconds) and during repetitive contractions (1 train per second). RESULTS: During control and repetitive activation conditions, catchlike-inducing trains produced approximately 5% to 110% greater peak forces than comparable constant-frequency trains, depending on the frequencies being compared. Total forces produced (ie, force-time integrals) were increased up to 59% and 49% during the control and repetitive activation conditions, respectively. CONCLUSION AND DISCUSSION: These results support earlier findings that catchlike-inducing trains may be advantageous in functional electrical stimulation applications.

Variable-frequency trains offset low-frequency fatigue in human skeletal muscle.

Variable-frequency trains that exploit the catchlike property of skeletal muscle can augment force production in fatigued skeletal muscle. The present study is the first to examine the effect of such trains during recovery. The quadriceps femoris muscles of 12 healthy individuals were fatigued using six-pulse, 14.3-Hz trains delivered at a rate of 1/s for 3 min. The force-generating ability of the muscle was tested with several constant-frequency trains (8.3-100 Hz) and a variable-frequency train before and after fatigue and at 2, approximately 13, and approximately 38 min of recovery. The variable-frequency train produced significant augmentation of force versus the best constant-frequency train (12.5 Hz) in acute fatigue and during recovery. The fatiguing protocol also induced low-frequency fatigue (LFF); the time courses of the degree of LFF and the amount of variable-frequency train force augmentation were inversely related (r = 0.629; F = 38.024; P

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.

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.

Effects of activation pattern on human skeletal muscle fatigue.

Variable-frequency stimulation trains (VFTs) that take advantage of the catchlike property of skeletal muscle have been shown to augment the force production of fatigued muscles compared with constant-frequency trains (CFTs). The present study is the first to report the force augmentation produced by VFTs after fatiguing the muscle with VFTs versus fatiguing the muscle with CFTs. Data were obtained from the human quadriceps femoris muscles of 12 healthy subjects. Each subject participated in three experimental sessions. Each session fatigued the muscle with one of three protocols: CFTs with 70-ms interpulse intervals (CFT70); CFTs with 55.5-ms interpulse intervals (CFT55.5); or VFTs. Following each fatiguing protocol the muscles were tested with all three stimulation patterns (i.e., CFT55.5, CFT70, and VFT). At the end of the fatiguing protocol the VFT produced force-time integrals and peak forces approximately 18% and 32% greater than the CFT70, respectively. The testing trains showed that the VFT produced approximately 25-35% greater force-time integrals than either CFT and approximately 35-47% greater peak forces than the CFT70. For each testing train, approximately 10-15% greater force-time integrals were seen when the muscles were fatigued with the CFTs than when fatigued with the VFTs. These results support suggestions that VFTs may be useful during clinical applications of electrical stimulation.

New look at force-frequency relationship of human skeletal muscle: effects of fatigue.

A muscle does not have a unique force-frequency relationship; rather, it is dynamic and depends on the activation history of muscle. The purpose of this study was to investigate the force-frequency relationship of nonfatigued and fatigued skeletal muscle with the use of both catchlike-inducing trains (CITs) that exploited the catchlike property of skeletal muscle and constant-frequency trains (CFTs). Quadriceps femoris muscles were studied during isometric contractions in twelve healthy subjects (5 females, 7 males). Both the peak force and force-time integrals produced in response to each stimulation train were analyzed. Compared with nonfatigued muscles, higher frequencies of activation were needed to produce comparable normalized peak forces when the muscles were fatigued (i.e., a "rightward" shift in the force-frequency relationship) for both the CFTs and the CITs. When using the normalized force-time integral to measure muscle performance, the CFTs required slightly higher frequencies to produce comparable normalized forces from fatigued muscles, but the CITs did not. Furthermore, when the muscles were fatigued, the CITs produced greater peak forces and force-time integrals than all comparable CFTs with frequencies