Research Report

Relationship Between Intensity of

Quadriceps Muscle Neuromuscular
Electrical Stimulation and Strength
Recovery After Total Knee
Arthroplasty
Jennifer E. Stevens-Lapsley, Jaclyn E. Baiter, Pamela Wolfe, Donald G. Eckhoff,
Robert S. Schwartz, Margaret Schenkman, Wendy M. Kohrt

Background. Neuromuscular electrical stimulation (NMES) can facilitate the

recovery of quadriceps muscle strength after total knee arthroplasty (TKA), yet the
optimal intensity (dosage) of NMES and its effect on strength after TKA have yet to
he determined.
Objective. The primary objective of this study was to determine whether the
intensity of NMES application was related to the recovery of quadriceps muscle
strength early after TKA. A secondary objective was to quantify quadriceps muscle
fatigue and activation immediately after NMES to guide decisions about the timing of
NMES during rehabilitation sessions.
Design. This study was an observational experimental investigation.
Methods. Data were collected from 30 people who were 50 to 85 years of age and
who received NMES after TKA. These people participated in a randomized controlled
trial in which they received either standard rehabilitation or standard rehabilitation
plus NMES to the quadriceps muscle to mitigate strength loss. For the NMES intervention group, NMES was applied 2 times per day at the maximal tolerable intensity
for 15 contractions beginning 48 hours after surgery over thefirst6 weeks after TKA.
Neuromuscular electrical stimulation training intensity and quadriceps muscle
strength and activation were assessed before surgery and 35 and 6.5 weeks after
TKA.
Results. At 3.5 weeks, there was a significant association between NMES training
intensity and a change in quadriceps muscle strength (/?" = .68) and activation
iR^=.22). At 6.5 weeks, NMES training intensity was related to a change in strength
(i?^ = .25) but not to a change in activation (/?'=.00). Furthermore, quadriceps muscle
fatigue occurred during NMES sessions at 35 and 6.5 weeks, whereas quadriceps
muscle activation did not change.

J.E. Stevens-Lapsley, PT, PhD,

Physical
Therapy
Program,
Department of Physical Medicine
and Rehabilitation, University of
Colorado, Mail Stop C244, 1 3121
East 17th Ave, Room 3116,
Aurora, CO 80045 (USA). Address
all correspondence to Dr StevensLapsley at: jennifer.stevens-lapsley
@ucdenver.edu.
j.E. Baiter, MS, Physical Therapy
Program, Department of Physical
Medicine and Rehabilitation, University of Colorado.
P. Wolfe, MS, Department of Preventive Medicine and Biometrics,
University of Colorado.
D.C. Eckhoff, MD, Department of
Orthopedics,
University
of
Colorado.
R.S. Schwartz, MD, Division of
Ceriatric Medicine, University of
Colorado.
M. Schenkman, PT, PhD, FAPTA,
Physical
Therapy
Program,
Department of Physical Medicine
and Rehabilitation, University of
Colorado.
W.M. Kohrt, PhD, Division of Geriatric Medicine, University of
Colorado.
[Stevens-Lapsley JE, Balter JE,
Wolfe P, tal.
Relationship
between intensity of quadriceps
muscle neuromuscular electrical
stimulation and strength recovery
after total knee arthroplasty. Phys
Ther. 2012;92:1187-1196.]

Limitations, some participants reached the maximal stimulator output during at

least 1 treatment session and might have tolerated more stimulation.

2012 American Physical Therapy

Association

Conclusions. Higher NMES training intensities -were associated with greater

quadriceps muscle strength and activation after TKA.

Published Ahead of Print:

May 31, 2012
Accepted: May 23, 2012
Submitted: December 20, 2011

Post a Rapid Response to

this article at:
ptjournai.apta.org

September 2012

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Intensity of Quadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After TKA

otal knee arthroplasty (TKA)

successfully relieves pain and
improves function in patients
w^ith knee osteoarthritis, although
the recovery of quadriceps muscle
force and function is suboptimal
compared with that in people who
are healthy and predisposes patients
to disability with increasing age.'-"*
Previous studies demonstrated quadriceps muscle strength deficits of
50% to 60% relative to preoperative
levels, despite the initiation of physical therapy within 48 hours of stirgery.^-^ Early quadriceps muscle
strength deficits after TKA have been
attributed largely to central activation deficits (also referred to as
"reflex inhibition")."^" Therefore,
neuromuscular electrical stimulation
(NMES) has been used as an adjunct
to traditional rehabilitation for
patients after TKA i-" because it may
provide a more effective means of
mitigating quadriceps muscle central
activation deficits and increasing
quadriceps muscle strength than voluntary exercise
Neuromuscular electrical stimulation has been widely used in both
research and clinical settings to preserve or restore muscle mass and
ftinction during prolonged periods
of disuse or immobilization.'**--"
Neuromuscular electrical stimulation causes a muscle contraction
through transcutaneous application
of electrical current to terminal
branches of motoneurons.'"-' One
of the unique features of NMES is
that it elicits a less orderly recruitment of motoneurons than voluntary
exercise, favoring the activation of
large (type II), higher-forceproducing motor units at relatively
low levels of stimulation.-- To date,
most NMES training studies have
focused on people who are healthy
rather than on those with compromised muscle ftinction,^^ yet the
greatest benefits of NMES may be
seen with impaired muscle function,^" such as after TKA.
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and performance gains than lower

intensities. Therefore, the purpose
of this investigation was to determine whether higher NMES training
intensities resulted in greater recovery of quadriceps muscle strength
within the first 6.5 weeks after TKA;
the data were derived from a parent,
prospective randomized clinical trial
of NMES application. We hypothesized that higher NMES training
intensities would be associated with
greater recovery of quadriceps musA substantially limiting factor with cle function after TKA. We further
NMES use is patient tolerance sought to quantify quadriceps musbecause of the discomfort associated cle fatigue and activation immediwith intense stimulation. Therefore, ately after an NMES session. We
evidence that higher training intensi- hypothesized that quadriceps musties translate to greater muscle func- cle activation would improve immetion is necessary to justify the diately after an NMES session,
approach of encouraging patients to despite some acute fatigue of the
undergo the highest tolerable NMES quadriceps muscle.
intensity. Furthermore, the timing of
NMES application during rehabilita- Method
tion (before or after voluntary con- Design Overview
traction-based exercises) depends This investigation was an observaon the degree of acute muscle tional substudy of data derived from
fatigue with NMES use and immedi- a randomized, controlled, parallelate changes in muscle activation. Eor group intervention trial to evaluexample, in the presence of substan- ate the benefits of adding NMES
tial quadriceps muscle fatigue with- to a postoperative TKA rehabiliout improvement in muscle activa- tation program.'"* This substudy
tion, NMES application might be best included only participants randomtimed after other exercises. In con- ized to the NMES intervention
trast, a marked improvement in mus- arm. Participants were assessed 1
cle activation after NMES application to 2 weeks before TKA and at 3.5
without substantial quadriceps mus- and 6.5 weeks after TKA at the
cle fatigue would encourage NMES Clinical and Translational Research
use before the initiation of other Center, University of Colorado.
exercises to take advantage of Informed consent was obtained from
all participants.
enhanced muscle recruitment.

With voluntary muscle strengthening, higher intensities of muscle

overload translate to greater strength
gains.-'' Similarly, the higher the
NMES training intensities, the greater
the strength gains for both
healthy^''^'' and impaired'" muscles.
However, to date, no studies have
evaluated how NMES training intensity is related to the preservation of
quadriceps muscle strength when
NMES is initiated early after TKA.

In our recently published randomized controlled clinical trial, we demonstrated that NMES application to
the quadriceps muscle early after
TKA effectively attenuated quadriceps muscle strength loss and
improved functional performance.'''
However, given the discomfort associated with high NMES training
intensities, it is important to determine whether higher NMES training
intensities produce greater strength

Number 9

Setting and Participants

People who had osteoartliritis and
were undergoing a primary unilateral TKA by 1 of 3 orthopedic
surgeons at the University of
Colorado Hospital were consecutively recmited between June 2006
and June 2010. Volunteers were
recruited by referral or advertisement at preoperative educational
sessions. All participants underwent a similar tricompartmental.
September 2012

Intensity of Quadriceps Muscie Neuromuscuiar Electricai Stimulation and Strength Recovery After TKA

cemented TKA with a medial parapa- comfortable stimulation. Further- during each session, and participants
tellar surgical approach.
more, applying the electrodes were repeatedly encouraged to
over the motor point of the mus- increase the intensity as tolerated.
People were included in the study cle reduces the current threshold The stimulator delivered a biphasic
if they were 50 to 85 years of required. In the present study, large, current with a symmetrical waveage. Exclusion criteria for the study rectangular electrodes were used to form at 50 pulses per second for
were uncontrolled hypertension, maximize treatment tolerance and 15 seconds (including a 3-second
uncontrolled diabetes, a body mass effectiveness.
ramp-up time) and a 45-second off
index greater than 35 kg/m~, signifitime (250-microsecond pulse duracant neurologic impairments, con- Neuromuscuiar electrical stimula- tion). Participants performed 15 contralateral knee osteoarthritis (as tion from the portable electrical tractions per session, 2 sessions per
defined by a pain level of greater stimulator was applied to the resting day, 6 or 7 days per week.
than 4/10 w^ith activity), and other muscle, and the participant w^as
unstable lower-extremity orthopedic instructed to relax during the electri- Participants randomized to the
conditions.
cally induced muscle contraction. NMES intervention group received
Importantly, NMES application with about 9 weeks of standardized rehaNiVIES Intervention
the muscle at rest or NMES appli- bilitation as previously described"
A portable Empi 300PV stimulator cation superimposed on voluntary after TKA in addition to the NMES
(Empi Inc, a DJO Global company, St contraction does not appear to intervention. Initial familiarization
Paul, Minnesota) was used for the influence training-induced strength with the NMES device (Empi 300PV)
NMES intervention because it pro- gains.2o.23,3i-.-i3 Therefore, NMES occurred during preoperative testing
duces comparable levels of average was applied to the muscle at rest to facilitate the application of NMES
peak torque with similar levels of to allow for the quantifieation of early after surgery. Participants used
discomfort as a VersaStim 380 clini- NMES training intensity as a per- the NMES unit a few times at home
cal stimulator (Electro-Med Health centage of quadriceps muscle maxi- before surgery to become familiar
Industries, Miami, Florida), which mal voluntary isometric contraction with the device, a strategy that has
was used in previous NMES investi- strength. The intensity was set to been recommended to increase pargations but is not practical for home the maximal intensity tolerated ticipant tolerance of NMES.-^" Partieuse.'^'27-29 During NMES treatment at
home, the lower limb was secured
with Velero straps (Velero USA Inc,
The Bottom Line
Manchester, New Hampshire) to a
stable chair to allow for approximately 85 degrees of hip flexion and What do we already know about this topic?
60 degrees of knee flexion.'i'^ Selfadherent, flexible rectangular elec- Quadriceps muscle weakness after total knee arthroplasty (TKA) is protrodes (7.6 X 12.7 cm; Supertrodes found and often persists years after surgery. Using neuromuscuiar electri[SME Inc, Wilmington, North Caro- cal stimulation (NMES) early after TKA surgery may enhanee recovery of
lina]) were placed on the distal physical function such as walking.
medial and proximal lateral portions
What new information does this study offer?
of the anterior thigh and marked to
facilitate consistent reapplication by Higher intensities of NMES to the quadriceps muscle after TKA increases
the participant.
muscle strength and activation more than lower intensities.
The size of the electrodes used for
NMES is important because it
directly influences the density of
the current. A high current density
with small electrodes can cause
painful stimulation before a sufficient muscle contraction to allow for
muscle strengthening is reached.'"
Therefore, selecting an appropriate electrode size is important for
September 2012

If you're a patient, what might these findings

mean to you?
Thefindingssuggest that during your rehabilitation after your surgery, you
should make every effort to tolerate the highest intensity of NMES possible
in order to maximize yovir quadriceps muscle strength. Although people
may need a few sessions to get used to the stimulation, they often learn to
tolerate the stimulation well.

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Intensity of Ouadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After TKA

NMES Training Intensity = Avq Torque (N-nn)

x 100
^
Pre-op MVIC Torque (N-m)

Figure 1.
Participant setup for assessment of neuromuscular electrical stimulation (NMES) training intensity at the 3.5- and 6.5-week testing
sessions (left) and sample torque data from a representative participant at the 3.5-week testing session (right). Average (Avg) torque
was the average peak quadriceps muscle torque across 10 electrically elicited contractions during the NMES training intensity
assessment. MVIC=maximal voluntary isometric contraction, Pre-op=preoperative.

ipants were encouraged to use the electromechanical

dynamometer
stimulator at an intensity that was was used to measure quadriceps
tolerable but slightly uncomfortable, muscle torque. Data were collected
although no minimum intensity was with a Biopac Data Acquisition Sysrequired for participation in the tem (BIOPAC Systems Inc, Goleta,
study protocol. In addition, partici- California) and analyzed with Acqpants were repeatedly instructed to Knowledge software, version 3.8.2
continue to increase the intensity to (BIOPAC Systems Inc). Participants
their maximal tolerance within and were positioned in an electromebetween sessions. Most participants chanical dynamometer with 60
demonstrated safe and proper use of degrees of kneeflexionas previously
the stimulator during their inpatient described (Fig. 1).^'* Participants
stay in the hospital. When there were asked to perform a maximal
were concerns about participant voluntary isometric contraction
implementation or tolerance of (MVIC) of the quadriceps muscles
NMES, a study physical therapist vis- using both visual and verbal feedited the participant at home within back up to 3 times unless the first 2
the first week of discharge to moni- attempts were within 5% of each
tor a home treatment session. Partic- other. The trial with the highest
ipants were given paper logs to track MVIC torque output was then noradherence.
malized to body weight (in kilograms) for data analysis.
Outcome Measures
Isometric quadriceps muscle A Grass S48 stimulator with a Grass
torque and activation testing. model SIU8T stimulus isolation unit
Isometric quadriceps muscle torque (Grass Instruments, West Warwick,
and activation were assessed at the Rliode Island) and self-adherent, flexpreoperative and 3.5- and 6.5-week ible electrodes (7.6 X 12.7 cm;
testing sessions as previously Supertrodes) were used to deterdescribed.'1S4S5 A HUMAC NORM mine voluntary muscle activation as
(CSMi, Stoughton, Massachusetts) previously described.'"* Voluntary
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activation of the quadriceps muscle

was assessed with the doublet interpolation technique, in which a
supramaximal stimulus was applied
to the quadriceps muscle during an
MVIC and again, immediately afterward, to the quadriceps muscle at
rest (stimulus parameters: 2 pulses,
pulse duration of 600 microseconds,
and electrical train of 100 pulses per
second)."^''^' Values of less than
100% represented incomplete motor
unit recruitment or decreased motor
unit discharge rates. ^'*"*^
NMES training intensity and
immediate fatigue assessment.
Neuromuscular electrical stimulation training intensity was assessed
at 3.5 and 6.5 weeks after surgery for
participants in the NMES intervention group because assessment of
training intensity in the home (during treatment) was not feasible.
Wliile seated in the electromechanical dynamometer (Fig. 1), participants were asked to use the NMES
stimulator at the same intensity as
that used at home. Once participants
had reached their typical NMES treatment intensity (usually within the
September 2012

Intensity of Quadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After TKA

first 2 or 3 contractions), the average

electrically elicited (rather than voluntary) torque while the stimulator
^vas on was recorded across 10 contractions. This average torque was
then expressed as a percentage of
the MVIC during the preoperative
session to minimize the potential for
activation deficits to confound
torque measurements.
Changes in quadriceps muscle
torque and activation immediately
after NMES were also assessed at 35
and 6.5 weeks. Methods identical to
those described above were used to
measure quadriceps muscle MVIC
torque and activation immediately
after the NMES training intensity
assessment. Measurements obtained
after an NMES session were compared with measurements obtained
before NMES application to determine whether fatigue or changes in
activation were present after NMES.
Data Analysis

For analyses of NMES training intensity at 35 and 6.5 weeks, quadriceps

muscle torque and activation were
represented as percent changes from
preoperative torque^^ and activation. The NMES training intensities at
35 and 6.5 weeks were represented
as [(average torque/MVIC torque
before surgery) X 100], where average torque w^as the average peak
quadriceps muscle torque across 10
electrically elicited contractions during the NMES training intensity
assessment. Changes in torque and
activation immediately after an
NMES session were represented as
[(value after NMES - value before
NMES)/value before NMES] X 100.
All statistical analyses were performed with SPSS for Windows, version 16.0 (SPSS Inc, Chicago, Illinois). Linear regression was used to
estimate the association between
NMES training intensity and percent
changes in quadriceps muscle
torque and activation at 3.5 and 6.5
September 2012

weeks. Paired sample t tests were

used to assess differences between
quadriceps muscle torque and activation immediately after an NMES
session and quadriceps muscle
torque and activation before the
NMES session at 3.5 and 6.5 weeks.
No adjustment was made for multiple comparisons because this was a
secondary analysis and should be
considered hypothesis generating.

50%-80% of prescribed contractions), and 1 participant (3.3%) had

no adherence records but was
included in NMES training intensity
assessments and analyses. At 6.5
weeks, 17 participants (56.7%) were
adherent (completed >80% of prescribed contractions), 6 (20.0%)
were partially adherent (completed
50%-80% of prescribed contractions), 2 (6.7%) were not adherent
(completed <50% of prescribed conRole of the Funding Source
tractions), and 5 (16.6%) had no
This study was supported by the adherence records but were
National
Institute
on Aging included in NMES training intensity
(K23AG029978), an American Col- assessments and analyses. All particlege of Rheumatology New Inves- ipants, regardless of their individual
tigator Award, a Foundation for adherence index, were included in
Physical Therapy Marquette Chal- the analyses. There was no relationlenge Grant, and a Clitiical and ship between NMES adherence and
Translational Science Award Grant change in quadriceps muscle
(ULI RR025780). A peer-reviewed strength or NMES adherence and
research grant from Empi Inc, a DJO change in activation.
Global company, was used to support the purchase of Empi 300PV NMES Training Intensity
electrical stimulators and recniit- The mean stimulation intensities
ment and transportation costs for were 83.7 (SD=3.1) mA at 3.5 weeks
participant visits. None of the spon- and 82.1 (SD=3.3) mA at 6.5 weeks.
sors had any influence on the study These values generally corresponded
design, implementation, or data anal- to a visible muscle contraction that
ysis and interpretation.
was at least equivalent to that
achieved during a straight leg raise.
Results
Ten participants (32.3%) reached the
Participant Characteristics
maximal voltage output of the stimThis substudy included only the ulator (100 mA) during at least 1
NMES intervention group, compris- week of treatment; 3 participants set
ing 30 participants (12 men and 18 the stimulator at 100 mA for all 6
women) who were 65.6 (SD=8.5) weeks of treatment.
years of age and had a body mass
index of 29.0 (SD=5.0) kg/m^.
Overall, NMES training intensity
ranged from 1.6% to 76.7% of the
Adherence to NMES
maximal quadriceps muscle strength
Adherence to NMES treatment was achieved during the preoperative
assessed at the 3.5- and 6.5-week MVIC (X=16.1% [SD=14.8%] at 3.5
time points by use of participant weeks; X=17.7% [SD=11.3%] at 6.5
adherence logs and reported as the weeks). Overall, the results indicated
percentage of expected NMES treat- the presence of a relationship
ment at home (15 contractions per between NMES training intensity and
session, 2 sessions per day, 6 or 7 quadriceps muscle function (Fig. 2).
days per week). At 35 weeks, 23 At 35 weeks, there were significant
participants (76.7%) were adherent associations of NMES training inten(completed >80% of prescribed con- sity with a percent change in torque
tractions), 6 participants (20.0%) from the preoperative value
were partially adherent (completed (adjusted R^ = .6S, P<.001) and actiVolume 92

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Intensity of Quadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After TKA
3.5 wk
9" 150 1

100 -1
80 -

I 100 -

60 CTI
c
nj

50

20 -

u
0 '

CTI

40

-20

-50 -

-40

-a
XI

20

40

60

80

100

-60
0

20

40

60

80

100

Training Intensity (% Pre-op MVIC)

Training Intensity (% Pre-op MVIC)

6.5 wk
?" 150 n

100

^=.25*

<U

ai

50 -

0^

-50 "

ro

a?

-100
0

10

20

30

40

50

. Training Intensity (% Pre-op MVIC)

Training Intensity (% Pre-op MVIC)

Figure 2.
Relationship between neuronnuscular electrical stinnulation (NMES) training intensity and percent change in quadriceps (Quad)
nnuscle strength and activation at 3.5 and 6.5 weeks after total knee arthroplasty (TKA). Neuromuscular electrical stimulation (NMES)
training intensity is represented as a percentage of the maximal voluntary isometric contraction (MVIC) at the preoperative (Pre-op)
session. Percent changes in quadriceps muscle strength and activation at 3.5 and 6.5 weeks after TKA were calculated as [(value after
NMES - value before NMES)/value before NMES] X 100. Solid lines represent data at 3.5 and 6.5 weeks after TKA, and dashed lines
represent data without a potential outlier's data point at 3.5 weeks after TKA. Adjusted R^ values are shown on each graph, and
asterisks indicate significance (P<.05).

vation (adjusted J?^=.22, P=.OO6}.

At 6.5 weeks, there was a significant
association of NMES training intensity with a percent change in torque
from the preoperative value
(adjusted R^ = .25, P=.OO3) but not
with activation (adjusted R~=.OO,
P=.31). In 1 participant, low preoperative strength made the postoperative strength relative to training
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intensity appear unusually great.

Therefore, data are presented with
and without this potential outlier.
Muscle Fatigue and Activation
After NMES

Quadriceps muscle fatigue was

apparent immediately after NMES
application, such that quadriceps
muscle torque was significantly

Number 9

lower after NMES application than

before NMES application at 35
weeks (P<.001) and 6.5 weeks
(/'<.OO1) (Fig. 3). There were no significant changes in NMES quadriceps
muscle activation immediately after
NMES application relative to activation before NMES application at 3.5
and 6.5 weeks (P=.67 and P=.55,
respectively).
September 2012

Intensity of Quadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After TKA
Pre NMES
Post NMES
100

3.5 wk

6.5 wk

3.5 wk

6.5 wk

Figure 3.
Immediate changes in normalized quadriceps (Quad) muscle torque and activation after an NMES session. Asterisks indicate
significant differences between values before NMES application (Pre NMES) and values after NMES application (Post NMES) (P<.05,
paired t test).

Discussion
Neuromuscular electrical stimulation offers an effective approach for
mitigating quadriceps muscle central
activation deficits early after TKA
and restores normal quadriceps muscle function more effectively than
voluntary exercise
alone.^'O'
Patients with large quadriceps muscle central activation deficits from a
variety of causes have shown negligible improvements in strength even
after intensive rehabilitation focused
on traditional, voluntary exercise
paradigms.37 It appears that these
patients, including those who have
had TKA, may have difficulty training
their muscles at intensities sufficient
to promote strength gains. Neuromuscular electrical stimulation
appears to help counter these muscle activation deficits and reeducate
the quadriceps muscle to facilitate
the recovery of muscle ftinction
early after TKA. Results from the previously published parent study'''
indicated that, at the 3.5-week visit,
NMES treatment resulted in greater
improvements in quadriceps muscle
strength and a trend toward greater
quadriceps muscle activation than
the control treatment. The results of
September 2012

the present study expanded these

findings by demonstrating that stronger, electrically induced muscle
forces during training resulted in
greater improvements in quadriceps
muscle strength. Importantly, the
relationship between NMES dose
and muscle strength was more
marked at 3.5 weeks than at 6.5
weeks, suggesting that NMES dose
may have a greater impact during
early rehabilitation than during later
rehabilitation after TKA. Furthermore, muscle activation also was
related to training intensity at 35
weeks but not at 6.5 weeks, likely
because activation deficits without
NMES were most pronounced at 3.5
weeks (X=73.6% [SD=17.9%]) and
had substantially diminished by 6.5
weeks (X=86.3% [SD=10.6%]) in
the parent study (ceiling effect). Also
interesting was the finding that muscle activation and NMES training
intensity were not as strongly related
as were muscle strength and NMES
training intensity, possibly because
of more general variability in muscle
activation outcomes than in muscle
strength outcomes. Finally, the relatively high degree of adherence to
NMES may have precluded finding a

relationship between NMES adherence and changes in quadriceps muscle strength or activation.
Few studies have explored how
NMES training intensity is related to
muscle strength gains,^''^^ especially
in patients.^ Although NMES effectiveness is strongly influenced by the
intrinsic neuromuscular properties
of the tissue, such as motor nerve
branching,2"''-^9 results from the
few studies investigating NMES training intensity have found that NMESinduced strength gains are positively
correlated with NMES training intensity. In particular, Snyder-Mackler et
aF^ found that the recovery of quadriceps muscle strength after anterior
cruciate ligament reconstruction
was positively correlated with NMESinduced contraction intensity. They
also found that there was a minimum threshold for NMES training
intensity to elicit an increase in quadriceps muscle strength (10% of the
MVIC of the uninvolved quadriceps
muscle). Seikowitz-*' explored NMES
in the quadriceps muscle in people
who were healthy using maximally
tolerable isometric contractions 3
days per week for 4 weeks. Seiko-

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Intensity of Quadriceps Muscle Neuromuscuiar Electrical Stimulation and Strength Recovery After TKA

witz also found that the relative

strength improvement with NMES
was positively and signicantly correlated with the training contraction
intensity.
An increasitig body of literature has
explored mechanisms that tiiight
explain how larger, electrically elicited muscle contractions confer
greater strength gains. These studies
have suggested that NMES appears to
influence motor performance by
influencitig motor cortex excitabj ^ 40-43 Smith et al'*"' found a relationship between quadriceps muscle
NMES intensity and activation of sensorimotor cortex regions of the
brain, such that higher current intensities increased cortical activity.
Adams et al''' mapped patterns of
muscle activation after repeated
NMES-evoked isometric contractions
and found that with increasing intensity, the number of motor units activated also increased and contributed
to greater force output. Furthermore, the NMES-evoked contractions were able to recruit muscle
fibers deep within the muscle even
at lower training intensities because
the muscle fibers innervated by the
nerves stimulated by the transcutaneous application of NMES are distributed throughout the muscle.
Nevertheless, evidence more generally suggests that NMES at the stimulation intensities achieved in the
present study largely targets superficial nerves more than deep ones
because of proximity to the stimulating electrodes, especially at lower
training intensities.^" However, even
lower levels of stitnulation that target peripheral afferent nerves can
induce prolonged changes in the
excitability of the human motor cortex.^2 Subthreshold peripheral stimulation of the afferent nerves of the
hand resulted in an increase in the
functional magnetic resonance imaging signal intensity in the primary
and secondary motor and somatosensory areas of the cortex.*"
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In addition to the limitation of relatively superficial recruitment of

nerve bers with NMES, another lirnitation of NMES is muscle fatigue,
although muscle fatigue is thought to
be a necessary stimulus for muscle
hypertrophy. Muscle fatigue with
NMES occurs because of the great
metabolic demand on the muscle,
wliich results in greater muscle
fatigue than would occur with voluntary contractions.20-i-^'^-^' This
increased muscle fatigue may be a
result of several factors. In part, muscle fatigue with NMES occurs more
rapidly than muscle fatigue with volitional exercise because of the
repeated contractile activity within
the same musclefiberswith NMES.'''
Muscle fatigue also may be influenced by the less orderly recn.iitment of motor units with electrically
elicited muscle contractions than
with voluntary muscle contractions. 2'
Electrically elicited muscle contractions allow for the activation of a
larger proportion of type II muscle
fibers than volitional exercise at a
comparable intensity.^*-'" Type II
muscle fibers are larger than type I
fibers but also are more fatigable;
therefore, greater activation of these
fibers maximizes force produetion,
but at the expense of increased muscle fatigue.^'' With volitional exercise, type II fibers are typically activated only during high-intensity
voluntary contractions.'" This activation pattern occurs with voluntary
contractions as a result of a more
orderly recruitment of motoneurons
because smaller motoneurons have
lower activation thresholds than
larger motoneurons; therefore,
smaller motoneurons (which innervate type I muscle fibers) are
recruited before larger motoneurons
(which innervate type II muscle
fibers).'" With eleetricaUy elicited
muscle contractions, a less orderly
recruitment of motor units occurs
because factors such as the size of

Number 9

the axonal branches and their

orientation toward the current field
influence motor unit recruitment,
such that a larger proportion of
motor units that are activated only
during high-level voluntary muscle
contractions may be recruited earlier
during electrically elicited muscle
contractions.^2,46.51,52 Additionally,
less fatigue occurs during voluntary
muscle contractions because muscle
force is sustained through modulation of the rates of firing of active
motor units'"* or through alternate
recn.iitment of new motor units
when active motor units become
fatigued.^" In contrast, electrically
elicited contractions rely on sustained recruitment of the same
(ie, spatially fixed) motor units at
a fixed rate that is temporally
synchronous.^"
With the myriad factors that contribute to increased muscle fatigue with
NMES, it is not surprising that quadriceps muscle fatigue immediately
after NMES application was found in
the present study, even though the
average NMES training intensity was
relatively low compared with that in
a previous investigation.'^ More surprising was the lack of improvement
in quadriceps muscle activation
immediately after a single session of
NMES. One possible explanation is
that the consistent use of NMES after
TKA facilitated a trend toward
greater overall quadriceps muscle
activation in the parent study (11%
more activation; P=.O9),'* such that
a single session of NMES ^vas not
sufficient to further boost quadriceps muscle activation. Nevertheless, in the presence of substantial
quadriceps muscle fatigue without a
concurrent increase in muscle activation, NMES application may be
best timed after other exercises prescribed for rehabilitation for patients
using NMES daily.
One of the most substantial limitations for NMES use is patient tolSeptember 2012

Intensity of Quadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After TKA

erance, especially at higher intensities, because electrical current

application through the skin results
in the activation of nociceptive
receptors.5-^ Although there is considerable inter-individual variability
in tolerance of NMES, the results
of the present study provide support for using various strategies
to maximize patient tolerance of
NMES. One important factor was the
use of large electrodes to decrease
current density and increase participant comfort. In addition, participant familiarization with NMES
application before surgery increased
comfort with NMES use after surgery, although in many settings it is
not always possible to see patients
before surgery. Even with participants who tolerated only low training intensities during the first few
sessions, continued familiarization
with NMES generally led to greater
tolerance of NMES over time.
When familiarization before surgery
is not possible, aUowing patients a
few sessions after surgery to become
accustomed to NMES application
often allows them to gi-adually tolerate Wgher levels of NMES. Also,
^vhen patients have control over the
intensity of NMES and understand
the importance of increasing the
stimulation intensity as much as is
tolerable, they appear to increase the
stimulation intensity more readily
than when a physical therapist has
control over the stimulator. Adherence to NMES treatment is influenced by patient tolerance of NMES.
In the present study, all participants
were included in the analyses,
regardless of adherence to NMES, to
allow for more generalizability of the
results in clinical settings.
Despite the strong association
between NMES training intensity and
quadriceps muscle function after
TKA, especially for the first few
weeks after TKA, we were unable to
determine a minimum threshold
September 2012

for NMES application. A reasonable

guideline for NMES application may
be the presence of a visible muscle contraction, yet evidence suggests that even subthreshold peripheral stimulation of afferent nerves
results in increased activity of the
primary and secondary motor and
somatosensory areas of the cortex.""'
Therefore, even lower training intensities could result in altered motor
unit recruitment and corresponding
improvements in quadriceps muscle function. Additional investigation is necessary to better establish
a minimum threshold for NMES
application.

tional Science Award Crant (ULI RR025780).

A peer-reviewed research grant from Empi
Inc, a DJO Clobal company, was used to
support the purchase of Empi 300PV electrical stimulators and recruitment and transportation costs for participant visits.
This work was part of a clinical trial
with ClinicalTrials.gov registry number
NCT00800254.
DOI: 10.2522/ptj.20110479

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