䢇

Research Report

Circulatory Responses to Voluntary

and Electrically Induced Muscle
Contractions in Humans
Background and Purpose. Transcutaneous electrical nerve stimulation
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

(TENS) increases regional blood flow when applied at intensities

sufficient to cause skeletal muscle contraction. It is not known whether
increases in blood flow elicited by TENS differ from those caused by
voluntary muscle contraction. The purpose of this study, therefore, was
to compare the hemodynamic effects of these 2 types of muscle
contraction. Subjects and Methods. Fourteen people with no known
pathology, aged 18 to 49 years (X⫽28, SD⫽8), served as subjects. Calf
blood flow (venous occlusion plethysmography), heart rate (electro-
cardiogram), blood pressure (automated sphygmomanometry), and
force (footplate transducer) were measured during electrically
induced and voluntary contractions. Results. Both modes of exercise
caused rapid, but short-lived vasodilation (calf vascular resistance
[X⫾SEM]: ⫺53%⫾3% for voluntary contractions versus ⫺57%⫾4%
for electrically induced contractions). The vasodilation caused by
electrically induced contractions persisted for at least 15 seconds in the
postexercise period, whereas the vasodilation elicited by voluntary
contractions had resolved by this time point. Conclusion and Discussion.
The hemodynamic changes elicited by voluntary and electrically
induced muscle contractions are similar in magnitude but different in
duration. [Miller BF, Gruben KG, Morgan BJ. Circulatory responses to
voluntary and electrically induced muscle contractions in humans. Phys
Ther. 2000;80:52–59.]

Key Words: Exercise, Regional blood flow, Transcutaneous electrical nerve stimulation.
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

Benjamin F Miller

Kreg G Gruben

Barbara J Morgan

Physical Therapy . Volume 80 . Number 1 . January 2000 53

T
he beneficial effects of transcutaneous electrical
nerve stimulation (TENS) on limb blood flow in
patients with circulatory deficits have been
described in some case reports.1,2 In experimen-
tal animals and humans with no known pathology, TENS
has been shown to increase regional blood flow; how-
ever, the preponderance of evidence indicates that it
does so only at stimulation intensities sufficient to cause
skeletal muscle contraction.3–10 Whether the increased
blood flow found in these previous studies resulted from
the TENS or from the skeletal muscle contraction pro-
duced by the TENS is unknown. It is also unclear
whether electrically evoked muscle contractions offer a
therapeutic advantage over voluntary contractions in
terms of their ability to effect circulatory changes in the
clinical setting.
In 2 studies,6,11 the circulatory responses to electrically
evoked and voluntary muscle contractions in humans
with no known pathology were compared. Walker et al11
studied the effects on blood flow of electrically evoked
versus voluntary contractions of the calf muscles. Isomet-
ric calf muscle contractions at 10% and 30% of the
subjects’ maximal force output were electrically induced.
In another protocol in the same study, voluntary con-
tractions were produced in a rhythmic manner at the
same relative workloads. The authors found that volun-
tary muscle contractions produced increases in popliteal
artery blood flow, whereas electrically evoked contrac-
tions did not. The meaning of this difference is unclear,
however, because of the nonuniform exercise modes
used in the 2 protocols (ie, sustained electrically induced
contractions versus intermittent voluntary contractions).
Sustained and intermittent muscle contractions are
known to produce different effects on blood flow.12–14
In the other study, Kim et al6 examined blood flow in
response to electrically evoked and voluntary contrac-
tions of the quadriceps femoris muscles during one-
legged exercise. Rhythmic contractions were electrically
evoked at the rate of 50 Hz using electrodes positioned
over the vastus medialis and vastus lateralis muscles. In
another protocol used in the same study, the subjects
voluntarily extended their knees at the same work rates,
duty cycles, and exercise bout durations. The authors
found that peak muscle blood flow was the same during
voluntary and electrically induced contractions. It is not
clear, however, whether the active muscle mass was the
same in the 2 protocols (the entire quadriceps femoris
muscle during voluntary contractions versus only the
vastus muscles during electrically induced contractions).
The size of the active muscle mass is likely to be an
important determinant of blood flow because of the
tight coupling known to exist between blood flow and
metabolic rate.15
Because of difficulties in the interpretation of these
previous findings, the question of whether electrically
evoked and voluntary contractions elicit similar
increases in blood flow remains unanswered. The pur-
pose of this study, therefore, was to compare circulatory
responses to electrically induced and voluntary calf
muscle contractions performed with the same force
output, duty cycle, and active muscle mass.
Method
Subjects
Seven men and 7 women (mean age⫽28 years, SD⫽8,
range⫽18 – 49) served as subjects. All subjects, by self-
report, were nonsmokers, were receiving no medica-
tions, and had no history of neuromuscular or cardio-
vascular disease. All subjects provided informed consent.
General Procedures
Subjects were studied in the supine position in a temperature-
controlled (24°–25°C) laboratory (Fig. 1). The subjects
participated in 2 testing sessions: 1 session to become
familiar with TENS and the test environment and 1
session for measurement of responses. Three subjects
were tested an additional time to evaluate reproducibil-
ity of responses. Blood pressure was measured using a

BF Miller, ATC, is currently pursuing a PhD in integrative biology at the University of California–Berkeley, Berkeley, Calif. This work was performed
in partial fulfillment of the degree requirements for Mr Miller’s Master of Science degree in kinesiology at the University of Wisconsin–Madison.

KG Gruben, PhD, is Assistant Professor, Departments of Kinesiology and Biomedical Engineering, University of Wisconsin–Madison.

BJ Morgan, PT, PhD, is Associate Professor, Physical Therapy Program, Department of Surgery, University of Wisconsin–Madison. Address
correspondence to Dr Morgan at 5173 Medical Sciences Center, 1300 University Ave, Madison, WI 53706-1532 (USA) (morgan@surgery.wisc.edu).

Writing and data analysis were provided by Miller, Gruben, and Morgan; concept and research design, by Miller and Morgan; facilities and
equipment, by Gruben and Morgan; and data collection, project management, and subjects, by Miller. Dominic Puleo contributed to the data
analysis and provided expert technical advice and support. Patricia L Mecum provided assistance with preparation of the manuscript, and Dr Peter
Hanson provided consultation (including review of the manuscript before submission).

This study was approved by the Health Sciences Human Subjects Committee of the University of Wisconsin–Madison.

This article was submitted February 9, 1999, and was accepted August 23, 1999.

54 . Miller et al Physical Therapy . Volume 80 . Number 1 . January 2000


Figure 1.
Experimental setup showing instrumentation for tibial nerve stimulation
and for measuring force, peroneal and tibialis anterior (TA) muscle
electromyographic (EMG) activity, and calf blood flow.
Dinamap 1846 SX/P automated sphygmomanometer.*
Heart rate was measured from the electrocardiogram.
Calf blood flow was measured by venous occlusion
plethysmography (model 271 plethysmograph†). Details
concerning the methods, rationale, and assumptions for
venous occlusion plethysmography have been published
previously.16 –18 The reliability of our plethysmographic
and sphygmomanometric measurements was assessed
by calculating the coefficients of variation (standard
deviation/mean ⫻ 100) for repeated measurements
made under baseline conditions. The mean values for all
subjects’ coefficients of variation were 6.2% for blood
flow measurements and 2.3% for blood pressure
measurements.
Electrical Stimulation
A Theratouch 7.7 point stimulator‡ was used to map the
course of the tibial nerve in the popliteal fossa. A
20.3-cm2 stimulating electrode (Empi series 9000§ was
then placed over the tibial nerve at the point where
maximal plantar flexion of the foot was elicited without
concomitant contraction of the peroneus longus or
tibialis anterior muscle. A 20.3-cm2 dispersive electrode§
was placed on the medial belly of the gastrocnemius
muscle. A sinusoidal waveform with a carrier frequency
of 2,500 Hz and burst frequency of 20 Hz was used. This
burst frequency was chosen because it is within the
reported optimal range for increasing blood flow.7,10
Stimulation intensity was set at a level that elicited the
strongest plantar-flexor contraction that could be toler-
ated by each subject in a series of intermittent contrac-
* Critikon Inc, PO Box 31800, Tampa, FL 33631.
† ††
Parks Medical Electronics Inc, Box 5669, Aloha, OR 97006.
‡ ‡‡
Rich-Mar Corp, Rte 3, Box 879, Inola, OK 74036.
§ §§
Empi Inc, 5999 Cardigan Rd, St Paul, MN 55126.
Physical Therapy . Volume 80 . Number 1 . January 2000
ўўўўўўўўўўўўўўўўўўўўўўўўўўў
tions with a duty cycle of 4 seconds “on” and 4 seconds
“off” (minimum force output⫽68 N).
Force Measurements
Plantar-flexion force was measured using an elevated
footplate coupled to a force transducer (model 13/2443-
08㛳) that was mounted 18 cm distal to the subject’s heel
(Fig. 1). The subject’s foot was strapped to the footplate,
and the footplate was pivoted at the ankle joint so that
the measured force was proportional to ankle torque.
The force transducer was calibrated over the range of 0
to 225 N before and after each testing session by static
weight loading. Output from the force transducer was
amplified (Heath Kit amplifier#), recorded on paper
and on magnetic tape, and directed to an oscilloscope so
that the subject received visual feedback on force gen-
erated with each contraction.
Electromyographic Recordings
To ensure that the same amount of muscle mass was
activated during voluntary and electrically evoked con-
tractions, integrated electromyographic (EMG) activity
of the peroneus longus and tibialis anterior muscles was
recorded (AT 33 electromyograph**). We were con-
cerned that the peroneus longus muscle, a plantar flexor
not innervated by the tibial nerve, might contribute to
the force output during voluntary contractions but not
electrically evoked contractions, thereby creating a dis-
parity in the size of the active muscle mass in the 2
protocols. We were also concerned that the tibialis
anterior muscle might co-contract with the plantar flex-
ors during voluntary exercise as the subject attempted to
match the target force. To guard against these possibil-
ities, the subject was instructed to keep contractions of
these muscles to a minimum during the voluntary exer-
cise protocol, and we monitored the EMG activity of the
muscles to ensure adherence to this instruction. The
subject was given muscle-specific audio feedback of the
EMG activity for the 2 muscles, with the sensitivities set
so that the subject was aware of very small (⬍10%
maximal) contractions.
All measurements except blood pressure were recorded
on a paper chart recorder (model TA4000††). In addi-
tion, analog signals were digitized (model 3000A PCM
recording adapter‡‡) and saved on magnetic tape (mod-
el HR-D860U videocassette recorder§§). The electrocar-
diographic and force output signals were digitized at a
rate of 128 Hz with a 12-bit resolution and saved on
computer disk for subsequent off-line analysis.
㛳
Sensotec, 2080 Arlingate Ln, Columbus, OH 43228.
#
Heath Kit, 455 Riverview Dr, Benton Harbor, MI 49022.
** Autogenic Systems, 620 Wheat Ln, Wood Dale, IL 60191.
Gould Inc, 3631 Perkins Ave, Cleveland, OH 44114.
AR Vetter Co, Box 143, Rebersburg, PA 16872.
JVC Company of America, 41 Slater Dr, Elmwood Park, NJ 07407.
Miller et al . 55
Exercise Protocols
During the TENS protocol, a cycle of 4 seconds “on,”
with a 2-second ramp up to maximum intensity, and 4
seconds “off” was used. During the voluntary exercise
protocol, the subject was instructed to mimic the elec-
trically evoked contractions as closely as possible. A
metronome was used to cue the subject regarding the
specified duty cycle, and an oscilloscope provided visual
feedback regarding the target force level. The subject
avoided peroneus longus and tibialis anterior muscle
contractions by minimizing the audio EMG feedback
from these muscles. During a 5-minute baseline data
collection period (no exercise), calf blood flow was
measured every 15 seconds. The first exercise protocol
(either voluntary or TENS, order randomly determined)
was then performed for 10 minutes. The intermittent
contractions were interrupted for 25 seconds every 2
minutes for 2 blood flow measurements (1 measurement
done immediately after the cessation of contractions and
1 measurement done 15 seconds after the cessation of
contractions). During a 5-minute recovery period, blood
flow was measured every 15 seconds. Heart rate and
blood pressure were measured at 1-minute intervals
during the baseline, exercise, and recovery periods.
Data Analysis
Force was analyzed by integration of the area under the
force-versus-time curve. The sum of all the force inte-
grals for the entire exercise protocol was determined
as well as the average force per contraction. Trials in
which the force outputs during voluntary and electrically
induced contractions differed by more than 15% were
excluded from analysis. The EMG activity recorded from
the peroneus longus and tibialis anterior muscles during
the voluntary exercise protocol was expressed as a per-
centage of the activity recorded previously during a
maximal voluntary contraction.
Blood flow measurements made during the exercise
protocols were grouped according to whether they were
obtained immediately following the 2-minute series of
contractions or 15 seconds after the cessation of contrac-
tions. The group mean values for immediately postexer-
cise blood flow values for the 5 exercise bouts within
each protocol were compared by analysis of variance to
detect any differences in blood flow responses over time.
This procedure was repeated for the 15-second postex-
ercise values. Because there were no differences over
time (P⬎.05), the data from the 5 exercise bouts within
each exercise protocol were averaged so that each sub-
ject had one value for the immediate postexercise mea-
sure and one value for the 15-second postexercise
measure.
Hemodynamic variables (blood flow, vascular resistance,
heart rate, and mean arterial pressure) measured at 3
56 . Miller et al
time points (baseline, immediately postexercise, and 15
seconds postexercise) during voluntary and electrically
induced contractions were compared by a 2-way (time ⫻
exercise protocol) ANOVA for repeated measures on
the time factor. When the overall F test for time or for
time ⫻ condition (voluntary or electrically induced
contractions) interaction was statistically significant,
paired t tests with Bonferroni corrections for multiple
comparisons were used to detect differences among
means.
Time to recovery was defined as the time required for the
cardiovascular variables to return to within the 95%
confidence interval of the baseline values. Paired t tests
were used to compare times to recovery of hemodynamic
variables and to compare force outputs in the voluntary
and TENS protocols. Except where otherwise noted in
the text and figures, data are presented as means (⫾stan-
dard error of the mean). Probability values of less than
.05 were considered statistically significant.
Results
Baseline Values
Measurements of calf blood flow, calf vascular resistance,
mean arterial pressure, and heart rate were similar in the
baseline periods before the voluntary and TENS proto-
cols (Table).
Force
The average force integral per contraction was compa-
rable for the voluntary and TENS protocols (365⫾27
versus 355⫾27 N䡠s). Likewise, the total force integral for
the voluntary and TENS protocols was similar
(29,106⫾2,146 versus 28,939⫾2,264 N䡠s, P⬎.05). The
average EMG activity for the peroneus longus muscle was
7%⫾2% of that elicited during the subjects’ maximal
voluntary contractions. Analysis of EMG activity of the
tibialis anterior muscle performed for 10 of the 14
subjects revealed an average value of less than 1% of
maximal voluntary contraction.
Effects of Voluntary and Electrically Evoked Contractions
on Hemodynamic Variables
The group mean values for calf blood flow and vascular
resistance during the 2 exercise protocols are shown in
Figure 2. The Table and Figure 3 show that both
voluntary and electrically evoked contractions caused an
increase in calf blood flow and a decrease in calf vascular
resistance that were evident in the immediate postexer-
cise measurements. The increase in blood flow and
decrease in vascular resistance persisted until the 15-
second postexercise measurements during the TENS
protocol only. There was no time ⫻ condition interac-
tion for either blood flow or vascular resistance. Times to
recovery for calf blood flow (84⫾75 versus 138⫾105
Physical Therapy . Volume 80 . Number 1 . January 2000
 ўўўўўўўўўўўўўўўўўўўўўўўўўўў
Table.
Mean (⫾SEM) Hemodynamic Responses to Voluntary and Electrically Evoked Muscle Contractions

Baseline Immediately Postexercise 15 s Postexercise

Calf blood flow (mL/100 mL/min)

Voluntary 4.7⫾0.2 10.3⫾0.3a 5.9⫾0.7
Electrically evoked 4.5⫾0.1 11.1⫾0.3a 6.9⫾0.2a
Calf vascular resistance (arbitrary units)
Voluntary 22.7⫾1.1 10.3⫾0.5a 18.3⫾0.9
Electrically evoked 22.8⫾0.8 9.1⫾0.3a 14.0⫾0.5a
Mean arterial pressure (mm Hg)
Voluntary 82⫾2 85⫾2 84⫾2
Electrically evoked 83⫾2 83⫾2 83⫾2
Heart rate (bpm)
Voluntary 62⫾3 65⫾3 65⫾3
Electrically evoked 62⫾3 64⫾3 64⫾3
a
P ⬍.05, postexercise versus baseline, 2-way repeated-measures analysis of variance (df ⫽2).

2 for the TENS protocol. The respec-

tive values for the 15-second postexer-
cise increases in blood flow were 29%
and 38% for the voluntary exercise
protocol and 72% and 81% for the
TENS protocol.

Discussion
We compared the hemodynamic
responses to voluntary and electrically
induced contraction protocols that
were comparable in terms of duty cycle,
force, and active muscle mass. The
major finding is that the 2 modes of
exercise caused increases in blood flow
and decreases in calf vascular resistance
that were similar in magnitude but dif-
ferent in duration. Both exercise pro-
tocols caused increases in blood flow
and decreases in vascular resistance
Figure 2. that were evident immediately postex-
The effects of voluntary and electrically evoked muscle contractions on calf blood flow and ercise. Only electrically evoked contrac-
vascular resistance. Baseline values are 1-minute averages. The 10-minute exercise period, tions, however, produced vasodilation
indicated by the horizontal bar, was interrupted every 2 minutes so that 2 blood flow
that was maintained above baseline lev-
measurements could be made. Recovery values are 15-second averages. Values are means
(⫾standard error of the measurement). els for 15 seconds postexercise. The
group mean values for blood flow
recovery time were the same with both
protocols; nevertheless, recovery times
seconds) and vascular resistance (86⫾74 versus 118⫾94 were longer after electrically induced contractions in 10
seconds) were comparable in the voluntary and TENS of the 14 subjects. In this regard, it is important to note
protocols (Fig. 4). Neither exercise protocol elicited that the statistical power associated with this particular t
changes in heart rate or mean arterial pressure (Table). test was low (33%), probably due to the size of the
intersubject variability relative to the size of the physio-
We examined day-to-day variability of responses in 3 logic effect.
subjects. The immediate postexercise increases in calf
blood flow, relative to the baseline measurements, were Critique of Methods
137% on day 1 and 149% on day 2 for the voluntary The strain gauge used to register limb circumference
exercise protocol and 230% on day 1 and 191% on day during venous occlusion plethysmography is very sensi-

Physical Therapy . Volume 80 . Number 1 . January 2000 Miller et al . 57


Figure 3.
Comparison of group mean values (⫾standard error of the measure-
ment) for calf blood flow and vascular resistance before and after
voluntary and electrically evoked contractions. Data shown are aver-
ages of the immediate postexercise and the 15-second postexercise
measurements made after all 5 exercise bouts in each exercise protocol.
Asterisk (*) indicates P⬍.05, postexercise versus baseline, 2-way
repeated-measures analysis of variance (df ⫽2).
Figure 4.
Comparison of times to recovery to the baseline values of calf blood
flow and vascular resistance following voluntary and electrically
evoked muscle contractions. Values are means (⫾standard error of the
measurement).
tive to movement artifact; therefore, this technique
cannot be used to measure blood flow during muscle
contraction. Nevertheless, because the postexercise mea-
surements were initiated immediately after relaxation
(within 1 second), we contend that these blood flow
measurements closely approximate the undisturbed flow
rate immediately prior to venous occlusion, that is,
during exercise.16
58 . Miller et al
Venous occlusion plethysmography measures blood flow
in the entire limb; therefore, separate measurements of
blood flow to muscle and to skin cannot be obtained
using this technique. On the basis of our data, we cannot
determine whether the exercise-induced increases in
blood flow occurred primarily in muscle, skin, or both
vascular beds. We consider it unlikely, however, that
changes in skin blood flow contributed importantly to
the observed changes in limb blood flow. The room
temperature was controlled at 24°C, and potential dis-
tractions inherent in the laboratory environment were
kept to a minimum. Thus, fluctuations in skin blood flow
caused by thermoregulatory and arousal responses were
minimized.19
We considered the possibility that the active muscle mass
was larger during voluntary contractions than during
electrically evoked contractions and that this factor
influenced our results. None of our subjects were able to
totally relax the peroneus longus muscle (a plantar
flexor muscle not innervated by the tibial nerve) during
voluntary contractions. The peroneus longus muscle
EMG activity recorded during voluntary contractions was
on average 7% of that recorded during maximal con-
tractions, indicating that this muscle contributed to the
force in a small, but potentially important, way. If so,
similar increases in blood flow despite a smaller active
muscle mass would suggest that TENS is actually more
effective than voluntary exercise in increasing blood flow.
Hemodynamic Responses to Voluntary Versus Electrically
Evoked Contractions
In our subjects, voluntary and electrically evoked con-
tractions of the calf muscles produced nearly identical
increases in calf blood flow. Our findings agree with
those of previous investigators6 who found that voluntary
and electrically evoked contractions of the quadriceps
femoris muscle increased leg blood flow by comparable
amounts. The findings of our study are consistent with
those of the previous study despite the fact that different
exercise protocols were used. Kim et al6 observed blood
flow response to isotonic contractions of a large muscle
mass, whereas we studied blood flow responses to iso-
metric contractions of a relatively small muscle mass. In
the previous study, the size of the active muscle mass may
not have been identical during the TENS and voluntary
protocols (vastus muscles versus entire quadriceps fem-
oris muscle). Nevertheless, the metabolic rates were
probably comparable because the workloads were well
matched.
In contrast, our findings do not agree with those of
Walker et al,11 who found that voluntary contractions
increased blood flow to a greater extent than did elec-
trically evoked contractions. In their study, however,
direct comparison of blood flow changes elicited by
Physical Therapy . Volume 80 . Number 1 . January 2000

electrically evoked and voluntary contractions is not
possible because sustained muscle contractions were
used in the TENS protocol and intermittent contractions
were used in the voluntary exercise protocol. It is well
known that sustained and intermittent contractions have
widely dissimilar hemodynamic effects.12–14 In addition,
Walker et al11 did not ensure that the same muscle mass
was active in the 2 protocols. It is possible that the
peroneus longus and soleus muscles were activated
along with the gastrocnemius muscle during the volun-
tary exercise protocol, whereas only the gastrocnemius
muscle was active during the TENS protocol. Thus,
blood flow may have increased more in the voluntary
exercise protocol because of the larger active muscle
mass and resultant higher metabolic rate.
Mechanism of the Hemodynamic Changes Caused by
Voluntary and Electrically Evoked Contractions
Because we did not observe systemic cardiovascular
responses to either form of exercise (heart rate and
blood pressure did not change), we assume that the
exercise-induced reductions in calf vascular resistance
were caused mainly by local mechanisms. The “muscle
pump”20,21 and flow-induced vasodilation produced by
local release of endothelial-derived relaxing factors22,23
are potential mechanisms for the observed vasodilation.
What mechanism explains the slightly longer persistence
of the vasodilation produced by TENS versus voluntary
exercise? We speculate that this difference may be
secondary to a basic qualitative difference in electrically
evoked versus voluntary muscle contractions. In electri-
cally evoked contractions, there is at least a partial
reversal in the order in which motor units are recruited
(a large-to-small, as opposed to a small-to-large, order in
voluntary contractions),24,25 and motor units fire syn-
chronously with electrically induced contractions as
opposed to asynchronously with voluntary contrac-
tions.26 –29 Reversal of the recruitment order during
TENS would be expected to alter the proportion of type
I versus type II muscle fibers participating in the con-
traction. Recruitment of more type II fibers during
TENS could lead to an increase in the release of
vasodilatory metabolites such as hydrogen ion, adeno-
sine, or phosphate.30 –32 Previous investigators33 have
observed that leg oxygen consumption is higher during
electrically induced versus voluntary exercise at a given
work rate, which suggests that TENS elicits a less efficient
contraction. In addition, the shorter-lived vasodilation
observed after voluntary exercise could have been
caused, at least in part, by a neural mechanism. “Central
command,” the activation of medullary cardiovascular
neurons in parallel with activation of alpha motoneu-
rons, operative during voluntary exercise but not during
electrically induced exercise, may have caused increases
in sympathetic outflow to skeletal muscle or skin.34,35
Physical Therapy . Volume 80 . Number 1 . January 2000
ўўўўўўўўўўўўўўўўўўўўўўўўўўў
In summary, we demonstrated that voluntary and elec-
trically evoked muscle contractions involving the same
force, duty cycle, and active muscle mass produced
vasodilatory responses that were nearly identical in mag-
nitude. The vasodilation produced by the electrically
induced contractions had a slightly longer duration than
that produced by voluntary contractions; however, the
circulatory effects of both modes of exercise were very
short-lived (⬍1 minute).
Conclusion
Physical therapy textbooks describe beneficial effects of
TENS on regional blood flow.36,37 Nevertheless, our
study demonstrated that TENS applied using stimulation
characteristics that are reportedly optimal for increasing
blood flow is no more effective than voluntary exercise at
matched force output and duty cycle. These findings
suggest that the muscle contraction, rather than the
stimulation, by itself, is responsible for the vasodilatory
effect of TENS. Therefore, it is unlikely that TENS offers
a therapeutic advantage over voluntary exercise in effect-
ing short-term circulatory improvements, at least in
patients with intact motor control systems. This may not
be the case, however, in patients who are unable to
perform voluntary exercise secondary to neuromuscular
dysfunction.
References
1 Twist DJ. Acrocyanosis in a spinal cord injured patient— effects of
computer-controlled neuromuscular electrical stimulation: a case
report. Phys Ther. 1990;70:45– 49.
2 Kaada B. Vasodilation induced by transcutaneous nerve stimulation
in peripheral ischemia (Raynaud’s phenomenon and diabetic polyneu-
ropathy). Eur Heart J. 1982;3:303–314.
3 Clemente FR, Matulionis DH, Barron KW, Currier DP. Effect of
motor neuromuscular electrical stimulation on microvascular perfu-
sion of stimulated rat skeletal muscle. Phys Ther. 1991;71:397– 406.
4 Currier DP, Petrilli CR, Threlkeld AJ. Effect of graded electrical
stimulation on blood flow to healthy muscle. Phys Ther. 1986;66:
937–943.
5 Heath ME, Gibbs SB. High-voltage pulsed galvanic stimulation:
effects of frequency of current on blood flow in the human calf muscle.
Clin Sci. 1992;82:607– 613.
6 Kim CK, Strange S, Bangsbo J, Saltin B. Skeletal muscle perfusion in
electrically induced dynamic exercise in humans. Acta Physiol Scand.
1995;153:279 –287.
7 Mohr TM, Akers TK, Wessman HC. Effect of high voltage stimulation
on blood flow in the rat hind limb. Phys Ther. 1987;67:526 –533.
8 Randall B, Imig CJ, Hines MH. Effect of electrical stimulation upon
blood flow and temperature of skeletal muscle. Am J Phys Med.
1953;32:22–26.
9 Tracy JE, Currier DP, Threlkeld AJ. Comparison of selected pulse
frequencies from two different electrical stimulators on blood flow in
healthy subjects. Phys Ther. 1988;68:1526 –1532.
10 Wakim K. Influence of frequency of muscle stimulation on circula-
tion in the stimulated extremity. Arch Phys Med. 1953;34:291–295.
Miller et al . 59
11 Walker DC, Currier DP, Threlkeld AJ. Effects of high voltage pulsed 26 Accornero N, Bini G, Lenzi GL, Manfredi M. Selective activation of
electrical stimulation on blood flow. Phys Ther. 1988;68:481– 485. peripheral nerve fibre groups of different diameter by triangular
shaped stimulus pulses. J Physiol (Lond). 1977;273:539 –560.
12 Barcroft H, Dornhorst AC. The blood flow through the human calf
during rhythmic exercise. J Physiol. 1949;109:402– 411. 27 Bellemare F, Garzaniti N. Failure of neuromuscular propagation
during human maximal voluntary contraction. J Appl Physiol. 1988;64:
13 Folkow B, Gaskell P, Waaler BA. Blood flow through limb muscles
1084 –1093.
during heavy rhythmic exercise. Acta Physiol Scand. 1970;80:61–72.
28 Binder-Macleod SA, Snyder-Mackler L. Muscle fatigue: clinical
14 Folkow B, Haglund U, Jodal M, Lundgren O. Blood flow in the calf
implications for fatigue assessment and neuromuscular electrical stim-
muscle of man during heavy rhythmic exercise. Acta Physiol Scand.
ulation. Phys Ther. 1993;73:902–910.
1971;81:157–163.
29 Folkow B, Halicka H. A comparison between “red” and “white”
15 Corcondilas A, Koroxenidis T, Shepherd JT. Effect of a brief
muscle with respect to blood supply, capillary surface area, and oxygen
contraction of forearm muscles on forearm blood flow. J Appl Physiol.
uptake during rest and exercise. Microvasc Res. 1968;1:1–14.
1964;19:142–146.
30 Hilton SM, Hudlicka O, Marshall JM. Possible mediators of func-
16 Greenfield ADM, Whitney RJ, Mowbray JF. Methods for the inves-
tional hyperemia in skeletal muscle. J Physiol (Lond). 1978;282:131–147.
tigation of peripheral blood flow. Br Med Bull. 1963;19:101–109.
31 Proctor KG. Reduction of contraction-induced arteriolar functional
17 Whitney RJ. The measurement of volume changes in human limbs.
vasodilation by adenosine deaminase or theophylline. Am J Physiol.
J Physiol. 1953;121:1.
1984;247(2 pt 2):H195–H205.
18 Indergand HJ, Morgan BJ. Effects of high-frequency transcutaneous
32 Laughlin MH, Korthuis RJ, Duncker DJ, Bache RJ. Control of blood
electric nerve stimulation on limb blood flow in healthy humans. Phys
flow to cardiac and skeletal muscle during exercise. In: Rowell LB,
Ther. 1994;74:361–367.
Shepherd JT, eds. Handbook of Physiology, Section 12: Exercise: Regulation
19 Delius W, Hagbarth KE, Hongell A, Wallin BG. Manoeuvres affect- and Integration of Multiple Systems. New York, NY: Oxford University
ing sympathetic outflow in human skin nerves. Acta Physiol Scand. Press; 1996:705–769.
1972;84:177–186.
33 Strange S, Secher NH, Pawelczyk JA, et al. Neural control of
20 Laughlin MH. Skeletal muscle blood flow capacity: role of muscle cardiovascular responses and of ventilation during dynamic exercise in
pump in exercise hyperemia. Am J Physiol. 1987;253(5 pt 2):H993– man. J Physiol (Lond). 1993;470:693–704.
H1004.
34 Victor RG, Secher NH, Lyson T, Mitchell JH. Central command
21 Sheriff DD, Rowell LB, Scher AM. Is rapid rise in vascular conduc- increases muscle sympathetic nerve activity during intense intermittent
tance at onset of dynamic exercise due to muscle pump? Am J Physiol. isometric exercise in humans. Circ Res. 1995;76:127–131.
1993;265(4 pt 2):H1227–H1234.
35 Vissing SF, Scherrer U, Victor RG. Stimulation of skin sympathetic
22 Pohl U, Holtz J, Busse R, Bassenge E. Crucial role of endothelium nerve discharge by central command: differential control of sympa-
in the vasodilator response to increased flow in vivo. Hypertension. thetic outflow to skin and skeletal muscle during static exercise. Circ
1986;8:37– 44. Res. 1991;69:228 –238.
23 Rubanyi GM, Romero JC, Vanhoutte PM. Flow-induced release 36 Nelson RM, Currier DP. Clinical Electrotherapy. 2nd ed. East Norwalk,
of endothelium-derived relaxing factor. Am J Physiol. 1986;250 Conn: Appleton & Lange; 1991:188 –191.
(6 pt 2):H1145–H1149.
37 Robinson AJ, Snyder-Mackler L. Clinical Electrophysiology. 2nd ed.
24 Binder-Macleod SA, Halden EE, Jungles KA. Effects of stimulation Baltimore, Md: Williams & Wilkins; 1995:313–317.
intensity on the physiological responses of human motor units. Med Sci
Sports Exerc. 1995;27:556 –565.
25 Feiereisen P, Duchateau J, Hainaut K. Motor unit recruitment order
during voluntary and electrically induced contractions in the tibialis
anterior. Exp Brain Res. 1997;114:117–123.

60 . Miller et al Physical Therapy . Volume 80 . Number 1 . January 2000