618174

research-article2015
Sports Health: A Multidisciplinary Approach OnlineFirst, published on November 18, 2015 as doi:10.1177/1941738115618174
SPHXXX10.1177/1941738115618174Glaviano and SalibaSports Health

vol. XX • no. X SPORTS HEALTH

[ Physical Therapy ]

Can the Use of Neuromuscular Electrical

Stimulation Be Improved to Optimize
Quadriceps Strengthening?
Neal R. Glaviano, MEd, ATC,*† and Susan Saliba, PhD, ATC, PT‡

Context: Neuromuscular electrical stimulation (NMES) is a common modality used to retrain muscles and improve
muscular strength after injury or surgery, particularly for the quadriceps muscle. There are parameter adjustments that can
be made to maximize the effectiveness of NMES. While NMES is often used in clinical practice, there are some limitations
that clinicians should be aware of, including patient discomfort, muscle fatigue, and muscle damage.
Evidence Acquisition: PubMed was searched through August 2014 and all articles cross-referenced.
Study Design: Clinical review.
Level of Evidence: Level 3.
Results: Clinicians can optimize torque production and decrease discomfort by altering parameter selection (pulse duration,
pulse frequency, duty cycle, and amplitude). Pulse duration of 400 to 600 µs and a pulse frequency of 30 to 50 Hz appear to
be the most effective parameters to optimize torque output while minimizing discomfort, muscle fatigue, or muscle damage.
Optimal electrode placement, conditioning programs, and stimulus pattern modulation during long-term NMES use may
improve results.
Conclusion: Torque production can be enhanced while decreasing patient discomfort and minimizing fatigue.
Keywords: myoelectric stimulation; therapeutic modalities; weakness

I
njury and surgical intervention often lead to muscle weakness successful than traditional exercise to recover muscle mass or to
and long-term muscle inhibition.34 Clinicians can use many improve healthy muscle.44
possible interventions to address quadriceps weakness during Potential limitations may be responsible for suboptimal NMES
the rehabilitation process. One common intervention used is outcomes,34 such as differences between physiological and
neuromuscular electrical stimulation (NMES).12,31,34 There is electrically induced contractions and decreased functional
conflicting evidence with respect to NMES parameter selection, applications.5 NMES may preferentially target fast motor units,
electrode placement, and training effects on its effectiveness or which is beneficial for fast-twitch muscle fibers that are often
best application to improve quadriceps strength and fatigued after injury and surgery.34 The trade off with electrical
function.34,36 Results vary regarding quadriceps muscle stimulation targeting fast motor units is early muscular fatigue,
reeducation, measureable strength improvements, patient- greater patient discomfort, and an increased possibility of
reported outcomes, and functional return using NMES.34 NMES muscle damage with the treatment.46 NMES may not follow the
is more effective than volitional exercise in the rehabilitation of size principle, and motor units are recruited in a nonselective
muscle mass preservation after immobilization34 but not more manner.34 While a random recruitment pattern of motor units

From the †Department of Kinesiology, Exercise and Sport Injury Laboratory, University of Virginia, Charlottesville, Virginia, and ‡Curry School of Education, Department of
Kinesiology, University of Virginia, Charlottesville, Virginia
*Address correspondence to Neal R. Glaviano, MEd, ATC, Exercise and Sport Injury Laboratory, University of Virginia, Memorial Gymnasium, PO Box 400407, Charlottesville,
VA 22904 (email: ng2w@virginia.edu).
The authors report no potential conflicts of interest in the development and publication of this article.
DOI: 10.1177/1941738115618174
© 2015 The Author(s)

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 Glaviano and Saliba Mon • Mon 2015

Table 1. Patient discomfort due to NMES treatment

Study Subjects, n Results

Lyons et al31 12 Using a 19.63-cm2 electrode decreased pain when compared with a
38.48-cm2 electrode
Rooney et al46 27 Altering frequency does not decrease pain tolerated
Gondin et al16 12 Intensity varied between 30 and 120 mA due to pain threshold of
subjects

Jubeau et al27 10 Intensity varied between 21 and 121 mA due to pain threshold of
subjects
Maffiuletti et al36 20 Intensity varied between 60 and 100 mA due to pain threshold of
subjects
Broderick et al10 20 17/20 patients had increased VAS scores during NMES treatment
Vanderthommen et al47 16 Increase VAS scores >4/10 after NMES
Forrester and Petrofsky13 6 Increase VAS scores >6/10 after NMES
48
Vanderthommen et al 10 Increase VAS scores >2/10 after NMES

NMES, neuromuscular electrical stimulation; VAS, visual analog scale.

may occur with electrical stimulation, early fatigue may still those motor points that need to be stimulated to elicit a muscular
occur due to the stimulus to identical muscle fibers.34 contraction are located near free nerve endings and nociceptive
Additionally, NMES has limited functional applications since it receptors, which results in discomfort, pain, and a burning
is commonly applied in an open kinetic chain position.34 The sensation.25 There is a linear relationship between amplitude of
majority of clinical research utilizes NMES applications on the current and quadriceps torque production.6 The challenge is
individuals during isometric quadriceps sets, straight leg raises, that by increasing amplitude of the current to recruit additional
or knee extension tasks.43 While these activities are beneficial motor units and subsequent torque production, there is an
during early rehabilitation, they do not translate to functional increase in patient discomfort.10 The charge density, product of the
tasks where pathological individuals present with long-term pulse duration, and amplitude also play a role in patient
muscle dysfunction.36 discomfort and muscle damage.24 Identical total charges with
While NMES is used in a variety of settings and pathologies, varying combinations of pulse duration and amplitude play a role
establishing ways to maximize its effectiveness should become a in pain, fatigue, and torque production.21
priority for clinicians using this modality. This review evaluates Sex and body type differences should also be taken into
common limitations and presents ways from NMES treatments to consideration with the onset and severity of patient discomfort
optimize this modality. with NMES treatments.37,38 Female patients present with
increased pain levels and earlier perception of the stimulus
Methods when compared with their male counterparts.37,38 Obese
individuals also have greater pain levels during electrical
PubMed, Ovid MEDLINE, SPORTDiscus, CINAHL, and the stimulation treatments, with obese female patients presenting
Cochrane Library were searched for articles published between with the lowest pain tolerance.38 To optimize NMES treatment, a
1975 and August 2014 pertaining to electrical stimulation theory balance between maximal quadriceps activation with minimized
and clinical use, parameters, and limitations of NMES. Articles patient discomfort is vital.
that were not written in English and did not use human
participants were excluded. Bibliographies were cross-
referenced to locate additional research articles of interest. Fatigue
Neuromuscular electrical stimulation often produced muscular
Patient Discomfort fatigue at a faster rate than repetitive voluntary contractions (Table
As the intensity of the stimulus is increased, excitation of sensory, 2).4,6,7,18,49 One suggestion for fatigue is that electrically induced
motor, and pain fibers occurs (Table 1).31 While the excitation of muscular contractions place different stresses on the muscle fibers
the motor neurons is the fundamental premise behind NMES, than if an individual performed a physiological muscle

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Table 2. Fatigue after NMES treatment

Study Subjects, n Results

Binder-Macleod et al6 50 20% MVIC produced the least fatigue compared with 50% MVIC
49
Zory et al 12 20% reduction in MVIC after NMES; EMG of the VL and RF decreased by 17.3%
and 14.5%, respectively
Jubeau et al26 9 NMES resulted in a 22% decrease in MVIC compared with a 9% decrease with
voluntary contraction
Botter et al9 18 EMG-assessed fatigue was found in the VMO and VL after NMES
4
Bickel et al 13 A low-frequency protocol resulted in a 25% decline in torque production; a
low–pulse duration protocol resulted in a 50% decline in torque production; a
low-voltage protocol resulted in a 48% decline in torque production
Gorgey et al18 7 A low-frequency protocol resulted in a 39% decrease in torque production;
a short phase duration protocol resulted in a 71% decrease in torque
production; a low-amplitude protocol resulted in a 70% decrease in torque
production
Kesar and Binder- 12 A low frequency–long pulse duration protocol resulted in a 22% decrease in
Macleod28 torque production; a medium frequency–medium pulse duration protocol
resulted in a 28% decrease in torque production; a high frequency–short
pulse duration protocol resulted in a 46% decrease in torque production

EMG, electromyography; MVIC, maximal voluntary isometric contraction; NMES, neuromuscular electrical stimulation; RF, rectus femoris; VL, vastus
lateralis; VMO, vastus medialis oblique.

contraction.34 During a physiological contraction, the number of Muscle damage has also been measured directly by identifying
recruited motor units is dispersed, varies in the number active at a histological changes after electrical stimulation treatments.33 While
given time, and often occurs in a rotational pattern (termed spatial the number of studies examining direct measures is limited, it has
recruitment), which is a neurophysiological adaptation to been reported that electrical stimulation causes histological
minimize fatigue.5,34 However, during an electrically stimulated changes of macrophage infiltration, extracellular matrix
muscle contraction, there is a nonselective order of recruitment alterations, muscle fiber disturbance, and Z-line disruption.32,33,41
where only the motor units located between the electrodes are Indirect measures of muscle damage include creatine kinase
activated.5,34 This is termed incomplete muscle recruitment since circulating within the blood 24 to 96 hours after both single and
the entire muscle is not stimulated, just those motor units between multiple electrical stimulation treatments.3,26,32 Delayed onset
the electrodes.34 Because of this incomplete and superficial muscle soreness with decreased flexibility and increased pain
activation, identical motor units will be activated repetitively, with palpation can occur after NMES treatments.3,26,47
resulting in a fixed spatial recruitment.34 The inability to alter the Rhabdomyolysis resulting from a home electrical stimulation
motor units being recruited results in the decrease of force unit has been reported.22 For NMES to be beneficial, muscle
production because of fatigue.5,8 damage must be reduced.

Muscle Damage
Optimizing NMES Outcomes
There has been growing evidence that electrical stimulation can
have temporary detrimental effects on the muscle being Stimulus Pattern
stimulated (Table 3).3,22,26,32,33,41 A positive relationship has been Repetitive isometric NMES contractions commonly use duty
found between amplitude and the force per area unit being cycles that do not mimic functional activities. Altered stimulus
stimulated.30 Greater muscular fatigue, increased creatine kinase patterns exist in both acute rehabilitation and functional
levels, histological damage to the muscle fibers, soreness, and activities.12,23 While altering stimulus patterns is a novel
changes in muscle volume measured by magnetic resonance intervention for NMES applications, there is great promise for
imaging (MRI) are seen with increased force per unit area, more functional uses of NMES.12,23
suggesting that lower amplitudes may be more advantageous During the phases of rehabilitation, multiple electrodes
during NMES treatment.30 produce beneficial results.12,39 Increasing the number of

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Table 3. Muscle changes after NMES

Study Subjects, n Results

Mackey et al32 7 Increased muscle tenderness to palpation, stretch, and tenderness 1-4 days post-
NMES (increase in VAS between 3 and 7/10)
Z-line disruption after NMES when assessed by muscle biopsy
Increase CK levels from baseline (200 IU/L) at day 2 (400 IU/L), day 4 (>1000
IU/L), and day 7 (800 IU/L)
Increased cell inflammation and desmin staining when assessed by
immunohistochemistry
Guarascio et al22a 1 Rhabdomyolysis (CK, 2917 mU/mL)
Aldayel et al3 9 Increased pain 1-4 days after NMES during palpation and squat; increase in
baseline CK levels 3 and 4 days after NMES
Vanderthommen et al48 10 Increase in baseline CK (136 ± 50 IU/L) day 1 and day 2 after NMES (927 ± 613
IU/L and 3021 ± 2693 IU/L)
Decrease in muscle flexibility by 13°
Jubeau et al26 9 Increase in baseline CK levels 2 days (>1000 IU/L) and 3 days (>3000 IU/L) after
NMES

CK, creatine kinase; NMES, neuromuscular electrical stimulation; VAS, visual analog scale.
a
Case study.

electrodes over the quadriceps modulates the stimulus pattern Neuromuscular Electrical
using multiple pathways to improve torque production and Stimulation Parameters
minimize the common limitations of muscle damage and Pulse Duration
fatigue.12 By alternating the quadriceps fibers being recruited by Pulse durations between 400 and 600 μs selectively target motor
the stimulus, more motor units are being activated to produce fibers as shorter durations target sensory fibers and have a
greater strength gains while ample recovery time is provided to positive influence on torque production without negative factors
minimize fatigue. Two novel devices can improve outcomes by of muscle fatigue or metabolic demands.16,19,28 Pulse durations
altering stimulation patterns (Kneehab and Patterned Electrical closer to 400 μs produce greater quadriceps cross-sectional
Neuromuscular Stimulation [PENS]).12,14,23 The Kneehab uses a activation compared with 150 μs.20 Pulse duration is often
neoprene sleeve with multiple electrodes where a current is preselected depending on the NMES unit, requiring clinicians to
altered between 4 differently sized electrodes (10 × 20 cm, 3 × evaluate and compare NMES devices.
18 cm, 10 × 7.5 cm, and 7 × 14 cm); electrical current is
alternated between the 4 electrodes to stimulate multiple motor
Pulse Frequency
units.12 Kneehab produced significant improvements in
quadriceps strength, single-leg hop test, and running speed Pulse frequency directly correlates with torque production;
performance and allowed for a quicker return to work time however, it comes at the cost of muscle fatigue.28 A linear
period and higher intensity quadriceps contractions with less relationship also exists between increases in pulse frequency
discomfort.12 PENS provides an electrical stimulation pattern to and metabolic demands, including pH levels, greater inorganic
both agonist and antagonist muscle groups to mimic healthy phosphocreatine ratio values, and energy costs.16 These
firing patterns based off electromyography studies.11 Spinal metabolic demands may cause early muscle fatigue and muscle
alterations are replicated by the rhythmical contraction of the damage after NMES treatments.16 The threshold between
agonist and antagonist muscles seen in the pattern of PENS.40 increasing torque production and fatigue due to increased
This rhythmical contraction replicates muscle stretch receptor metabolic demands appears to be between 30 and 50 Hz.7,16
and motor neuron stimulation that occurs during locomotion.40
A 6-week training study with PENS improved vertical jump Duty Cycle
height by 10%,23 and PENS was found to have an immediate Duty cycle commonly uses a 1:5 ratio, which consists of
improvement on pain and gluteus medius activation in 10 seconds on and 50 seconds of rest.42 This cycle is an
individuals with patellofemoral pain during functional tasks.14 acceptable ratio for minimizing muscular fatigue compared with

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1:1 and 1:3.42 The 1:5 ratio produces less fatigue and is often to be examined in pathological groups.15 Motor point reference
used42; inconsistency with this parameter is seen with varying charts provide a general location; however, emerging evidence
ratios: 10:80,44 8:12,7 4:25,35 and 3:17.36 The optimal duty cycle suggests a great deal of interindividual variability, and the exact
selection is unclear, and additional clarity is needed comparing location depends on joint angles of the surrounding muscles.9,15
multiple duty cycle ratios with regard to fatigue and discomfort. By applying the electrodes and providing stimulation directly
Burst duty cycles within the delivered current can minimize over the motor point’s motor axon, excitation occurs with less
patient discomfort and change torque output.29 Burst duty amplitude and less chance for excitation of surrounding sensory
cycles of 10% to 20% improve torque production, contractions, nerves.9,13,15 Motor point stimulation has been found to
and patient discomfort, while burst duty cycles of 50% to 90% significantly increase torque production and decrease patient
produce negative results.29 If the duty cycle is too short, the discomfort.15
muscle is not provided adequate recovery time and fatigue is By increasing the number of electrodes delivering a stimulus,
more likely to occur sooner.42 The time specified allows for spatial recruitment is altered and more motor units are
almost complete regeneration of the substrates necessary for stimulated.34 The utilization of multiple-channel electrodes over
repeated contractions.42 a single muscle can decrease fatigue and increase in a more
complete contraction.12
Amplitude Electrode size also plays a role in discomfort, since it will
Amplitude may be one of the most challenging but important recruit axonal branches in close proximity.31 Electrode sizes vary
parameters to optimize the effectiveness of an NMES treatment. from 5 × 5 cm38 to 7 × 10 cm,19 as well as other diameters.27
Amplitude is the intensity of the current administered and is Increasing electrode size decreases current density, which is
positively related to increased motor unit activation, force related to discomfort.31 Electrodes too large might be
generation, and cross-sectional area of the quadriceps detrimental as well by stimulating the wrong motor units and
activation.2,20,48 Since strength development is related directly to reducing the force produced. Electrodes that are approximately
dose response, force production must be greater than 50% of 20 cm2 produce the most comfortable stimulus for the
the maximal voluntary contraction.45 The challenge with quadriceps.31
producing maximal amplitude intensity is that pain and fatigue
Training Effect
increase with greater amplitude.6
Body composition between sexes and obese and nonobese Beneficial results have been found over multiple NMES training
individuals also plays a role in the amplitude needed to sessions due to muscular adaptations to the stimulus.17,27,47
produce desirable muscular contractions; subcutaneous adipose Repeated exposure to NMES will produce a training effect that
tissue and intramuscular fat affect the results.37,38 The increase in decreases patient discomfort, muscular fatigue, and
adipose tissue and intramuscular fat functions as insulation to development of creatine kinase and other indirect measures of
the NMES current, resulting in a greater amplitude level needed muscle damage.27,47 There is a protective effect with a
to produce full motor contractions.37,38 Altering electrode preconditioning program with decreases in pain, muscle
placement and using training effect adaptations over multiple soreness, and creatine kinase levels and an increase in torque
treatments can overcome these limitations.5,15,47 production.47 Increasing the amplitude during a single treatment
between each individual stimulus may stimulate deeper muscle
Influence of Electrodes fibers in the quadriceps muscle.34 Tracking alternating amplitude
Traditional electrode placement for the quadriceps is over the during the rehabilitation program may ensure depolarization of
distal vastus medialis oblique and proximal vastus lateralis different motor units over multiple treatments and improve
muscles.1,44 Placing the electrodes at opposite ends of the muscular adaptation during NMES.34
muscle should produce a more complete contraction with
deeper stimulation during tetanus contraction.49 This electrode
Conclusion
position can produce measureable contractile activity across all
4 quadriceps muscles when assessed by MRI.1 Longitudinal Subtle changes in NMES can create large positive effects in the
electrode position can increase torque production of the treatment for the patient. Quadriceps strength may be improved
quadriceps compared with a transverse orientation.34 by utilizing optimal parameters (pulse duration between 200
Neuromusclar electrical stimulation electrodes placed directly and 400 μs and a pulse frequency of 30-50 Hz) over multiple
over the motor points can deliver optimal treatment but are yet NMES sessions and novel stimulus patterns.

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Clinical Recommendations
SORT: Strength of Recommendation Taxonomy
A: consistent, good-quality patient-oriented evidence
B: inconsistent or limited-quality patient-oriented evidence
C: consensus, disease-oriented evidence, usual practice, expert opinion, or case series
SORT Evidence
Clinical Recommendation Rating
Utilization of NMES can produce limitations such as fatigue,4,6,7,18,34,49 patient discomfort,10,13,37,38,47,48 and muscle damage.3,22,26,30,32,33,41,47 A
Minor adjustments in NMES parameters (pulse duration of 400-600 µs and pulse frequency of 30-50 Hz) can improve torque production,
B
minimize fatigue, and improve patient comfort levels.7,16,19,20,28
Increasing the number of stimulating electrodes and electrode placement over motor points have minimized fatigue and patient discomfort
B
while also improving torque production.9,12,13,15,34
Preconditioning NMES training sessions produce muscular adaptations that improve patient comfort levels, decrease muscular fatigue, and
B
minimize muscle damage.17,27,34,47

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