9th Annual Conference of the International FES Society

September 2004 – Bournemouth, UK

Stimulation parameters for increased muscle force and selectivity of

elbow extensors in chronic stroke subjects
Keller T 1,2, Dewald JPA 3,4
1
Automatic Control Laboratory, Swiss Federal Institute of Technology Zurich, Switzerland
2
Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland
3
Dept. of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago IL,
USA
4
Biomedical Engineering Department, Northwestern University, Evanston IL, USA

E-mail: kellert@control.ee.ethz.ch
Website: www.control.ethz.ch/~fes/

Abstract pulse durations. However, the effects of these

Functional electrical stimulation (FES) has
been shown to be a promising technique to
retrain the grasping ability in subjects with
unilateral brain lesion. In order to extend this
technique to more proximal arm functions for
reaching in subjects with chronic stroke, the
electrical stimulation parameters need to be
carefully chosen. Muscle selectivity and suffi-
cient force generation are crucial for the
development of efficient training paradigms
that augment reaching capabilities. Isometric
torque measurements in the elbow joint and
EMG recordings were performed to evaluate
optimal parameters for commonly used
stimulation patterns. The results from eight
chronic stroke subjects showed that shorter
pulse durations produced higher torques and
stimulated more selectively the target muscle
in brain injured subjects.
1 Introduction
In practical transcutaneous functional electrical
stimulation (FES) applications the stimulation
parameters are often chosen heuristically, con-
sidering an in the FES community established
range for pulse amplitude, pulse duration and
pulse repetition frequency. Muscle fatigue is
minimized by choosing the lowest pulse repeti-
tion frequency that is able to produce smooth
contractions. Commonly frequencies ranging
from 20 to 30 Hz are used [1, 2].
Efficient values for pulse duration and ampli-
tude are more difficult to standardize as they
depend on multiple factors. Muscle and nerve
excitation models consider extracellular poten-
tials to generate action potentials [e.g. 3, 4] in
order to produce muscle force. Due to the
mainly capacitive-resistive electrode-skin junc-
tion, the required potentials can either be
obtained by higher current intensities or longer
parameters are likely to be different as the
results of the presented study show.
A preliminary study with healthy and stroke
subjects indicated that the choice of the stimu-
lation parameters was very crucial for achiev-
able muscle force, muscle selectivity, and
crosstalk to adjacent muscles. In particular,
with stroke subjects we found the maximum
achievable muscle force to be strongly
dependent on the chosen pulse duration.
In the presented study we used an isometric
setup that allowed us to measure forces and
torques in the upper limb. Isometric torques in
the shoulder and elbow joints were measured
during electrical stimulation of the triceps mus-
cle, with amplitude ramps and trapezoidal
stimulation patterns for different pulse dura-
tions.
2 Methods
Eight subjects (5 male and 3 female; age 44-73)
with chronic unilateral brain lesion participated
in the study. All subjects had a moderate to
severe upper limb motor impairment (Fugl-
Meyer assessment scores of 21–36/66), five on
the left side and three on the right side.
The subjects were strapped in a Biodex system
3 chair with the impaired arm attached at the
wrist to 6 DOF load cell (JR3, Model 45E15)
using a fiberglass cast.
The cathode of the stimulation electrode pair
was placed approximately 1 cm below and 2 cm
proximal the lateral head of the triceps muscle
and the anode was placed at the distal end of
the triceps muscle. The cathode position was
optimized to eliminate co-activation in
antagonistic flexor muscles by palpating the
adjacent muscle groups during short non-
fatiguing stimulation trains and by moving the
electrode about its initial position. During the
 9th Annual Conference of the International FES Society
September 2004 – Bournemouth, UK

entire experiment the electrode position
remained the same.
The produced shoulder and elbow torques were
measured with 1 kHz sampling frequency along
with EMG activity antagonistic muscle groups
and the intensity of the electrical stimulation.
In a fist part of the experiment the stimulation
amplitude was linearly increased up to 70 mA
in 10 s and the subject was asked to signalize
his/her tolerable limit. When the limit was
reached the examiner stopped the stimulation
immediately. This procedure (trial) was per-
formed twice in random order for the pulse
durations 150, 200, 300, and 500 µs and a
ject the stimulation was already too uncomfort-
able before antagonistic muscles were
activated.
On average across subjects (n=8) a maximum
EE torque of 7.16 (±4.23) Nm was generated in
the ramp trials with an average stimulation am-
plitude of 53.13 mA. The maximum EE torque
was obtained in three subjects with 150 µs
pulse duration, in four subjects with 200 µs and
one subject generated a maximum EE torque at
300 µs.
Triceps Stimulation, Amplitude Ramp, Pulse Duration = 150 µs
5

AMP [mA]
EE [Nm]
4 EEmax = 5.197 Nm
25 Hz pulse repetition frequency. 3 60
2 40
In the second part of the experiment the ampli- AMP = 54.456 mA
1 20
tude ramps with the different pulse durations 0 0
0 1 2 3 4 5 6 7 8 9 10
were randomly repeated using the maximal am- time [s]
plitudes determined in part one. This time the Triceps Stimulation, Amplitude Ramp, Pulse Duration = 500 µs

10 s stimulation sequence was not interrupted.

3
During the trials elbow extension (EE) torque EEmax = 3.499 Nm
EE [Nm]

AMP [mA]
2 40
was recorded in order to determine the stimula-
1 AMP = 40.23 mA 20
tion amplitude that produced the first local
maximum in the EE torque. The local torque 0 0
0 1 2 3 4 5 6 7 8 9 10
maxima were generated by co-activation of time [s]

synergistic extensor and possibly antagonistic
(elbow extensor) muscles.
In the last part of the experiment a trapezoidal
stimulation amplitude pattern (1 s ramps and 5 s
constant) mimicked a typical stimulation pat-
tern used in neuroprosthetic application, e.g. for
finger or wrist movements. The maximal
stimulation amplitudes were adjusted to the
values found in the second part or the experi-
ment. If crosstalk to other muscles was ob-
served during the 1 s ramps (see figure 3) it was
corrected by decreasing the stimulation ampli-
tude and the trial was repeated. This guaranteed
that the maximum stimulation amplitudes were
performed at the level of the first local EE
Figure 1: The upper plot shows 2 typical EE torque
responses for an amplitude ramp with constant pulse
duration of 150 µs and the lower plot of 500 µs.
Note that the plot with 500 µs pulse duration shows
more disturbances from activated adjacent muscles.
The maximum EE torque per stimulated charge
for all subjects was found for the pulse duration
of 150 µs. The average EEtorque/charge for
150 µs was 31.05 (±16.48) Nm/mC, for 200 µs
26.05 (±13.31) Nm/mC, for 300 µs 18.45
(±11.86) Nm/mC, and for 500 µs 11.28 (±8.26)
Nm/mC (n=8).
All subjects
1.8
MaxEE
1.6
Normalized MaxEE

MaxEE/charge
1.4
torque maxima. Each trial randomly used one
1.2
of the four pulse durations. Muscle fatigue was 1.0
minimized by having at least a 1 min pause 0.8
between each trial. 0.6
0.4
3 Results 0.2
Four of eight subjects could be stimulated with 0
150 200 300 500
higher amplitudes than needed to produce the Pulse duration [µs]
maximum EE torque, i.e. although the stimula- Figure 2: Across all subjects the highest EE torques
tion amplitude was further increased the EE were generated with 200 µs pulse duration (dark
torque decreased because antagonistic muscles bars). However, the least charge was needed to pro-
were activated. The EMG recordings confirmed duce the highest EE torques using stimulation pulse
this. trains with 150 µs pulse duration (light bars).
In three subjects this was only the case for the The trials with the trapezoidal stimulation pat-
pulse durations of 300 and 500 µs. In one sub- terns showed comparable results, although the
 9th Annual Conference of the International FES Society
September 2004 – Bournemouth, UK
stimulation amplitudes were adjusted to gener-
ate EE torques without disturbance by adjacent
antagonistic muscles. The shorter pulse dura-
tions on average also generated the higher
maximal torques. Five subjects had their EE
torque maxes at 150 µs, two subjects at 200 µs
and one subject at 300 µs.
3.5
3 38 mA
2.5
2 25 mA
EE [Nm]
1.5
1 21 mA
0.5
0
0 1 2 3 4 5 6 7
time [s]
Figure 3: Stimulation amplitude ramps from a
chronic stroke subject. With shorter pulse durations
higher EE torques could be generated. The lowest
plot (dashed - 500 µs and 21 mA) shows how acti-
vation of adjacent muscles reduced the EE torque
compared to stimulating the triceps muscle with
19 mA (2nd plot from below)
4 Discussion and Conclusions
In all trials the triceps muscle could be
activated more selectively and generated higher
torques using shorter pulse durations. This
result is of clear clinical relevance for most FES
applications the in upper extremity, where
different muscle groups are close together and
have to be stimulated selectively. The optimal
pulse duration was observed between 150 and
200 µs. However, such short pulse durations are
less used in transcutaneous FES applications,
although similar results were published for
implantable electrodes in [5]. Most transcutane-
ous FES applications use longer pulse durations
between 250 and 400 µs because they require
lower amplitudes and therefore are technically
easier to implement.
With longer pulses (300 or 500 µs) maximum
isometric EE torques were reduced through
activation of antagonistic muscles. In subjects
with increased spasticity and significant abnor-
mal torque coupling [6] long pulse durations
combined with low stimulation amplitudes gen-
erated co-activation of the biceps muscle, which
resulted in reduced EE torques and in one sub-
ject even in a net elbow flexion (EF) torque.
Current spread cannot be the only reason for the
early activation of the antagonistic muscles
with long pulse durations, because the ampli-
tudes we used were very low reducing the pos-
sibility of direct muscle nerve activation of the
elbow flexors. It is possible that the activation
of low threshold spindle Ia afferent nerve fibers
may also have contributed to the activation of
the elbow flexor muscles in the more spastic
subjects. The possibility that non-linear electri-
cal properties in human limbs are responsible
for increased current spread of longer pulses
150 µs
when the induced charge stays constant or even
200 µs
30 mA
is decreased should be investigated in the fu-
300 µs ture. This could be implemented with a FEM
model. Currently available transcutaneous mus-
500 µs
19 mA cle models do not explain the presented results.
500 µs
In conclusion for the FES practitioner the cur-
rent study suggests to stimulate muscles with
8
pulse durations shorter than 200 µs using sur-
face electrodes whenever strong torque output
and high muscle selectivity are required. In
addition the current results suggest that chang-
ing the pulse duration in order to modulate the
muscle force output is less suitable for produc-
ing accurate limb movements in upper extremi-
ties of subjects suffering from unilateral brain
lesions. Compared to an amplitude modulated
FES system the non-linearities of a pulse width
modulated FES system are higher.
References
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[2] Popovic MR, Keller T, Pappas IP, et al.
Surface-stimulation technology for grasping
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[3] Rattay F. Modeling the exitation of fibers
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[4] Dorgan SJ, O'Malley MJ. A nonlinear mathe-
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Acknowledgements
This work was supported by the grant No. 823B-
067648 from the Swiss National Science Founda-
tion, Switzerland.