Accepted Manuscript

Mechanomyography responses characterize altered muscle

function during electrical stimulation-evoked cycling in
individuals with spinal cord injury

Md. Anamul Islam, Nur Azah Hamzaid, Morufu Olusola Ibitoye,

Nazirah Hasnan, Ahmad Khairi Abdul Wahab, Glen M. Davis

PII: S0268-0033(18)30550-3
DOI: doi:10.1016/j.clinbiomech.2018.06.020
Reference: JCLB 4563
To appear in: Clinical Biomechanics
Received date: 5 November 2017
Accepted date: 27 June 2018

Please cite this article as: Md. Anamul Islam, Nur Azah Hamzaid, Morufu Olusola Ibitoye,
Nazirah Hasnan, Ahmad Khairi Abdul Wahab, Glen M. Davis , Mechanomyography
responses characterize altered muscle function during electrical stimulation-evoked
cycling in individuals with spinal cord injury. Jclb (2018), doi:10.1016/
j.clinbiomech.2018.06.020

This is a PDF file of an unedited manuscript that has been accepted for publication. As
a service to our customers we are providing this early version of the manuscript. The
manuscript will undergo copyediting, typesetting, and review of the resulting proof before
it is published in its final form. Please note that during the production process errors may
be discovered which could affect the content, and all legal disclaimers that apply to the
journal pertain.
 ACCEPTED MANUSCRIPT

Mechanomyography responses characterize altered muscle function during electrical

stimulation-evoked cycling in individuals with spinal cord injury

Md. Anamul Islama,b, Nur Azah Hamzaida,*, Morufu Olusola Ibitoyea, Nazirah Hasnana,c, Ahmad
Khairi Abdul Wahaba and Glen M Davis, OAMd,a

a
Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, 50603
Kuala Lumpur, Malaysia
b
Department of Physical Therapy, College of Staten Island, City University of New York, New

T
York 10314, USA

IP
c
Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala
Lumpur 50603, Malaysia

CR
d
Clinical Exercise and Rehabilitation Unit, Discipline of Exercise and Sport Science, Faculty of
Health Sciences. University of Sydney, Sydney, 2006 NSW, Australia

US
Corresponding author: Nur Azah Hamzaid (azah.hamzaid@um.edu.my)

(Abstract 250 words)

AN
(Full text 4805 words)
M
ED
PT
CE
AC

1
 ACCEPTED MANUSCRIPT

Abstract

Background: Investigation of muscle fatigue during functional electrical stimulation (FES)-evoked

exercise in individuals with spinal cord injury using dynamometry has limited capability to
characterize the fatigue state of individual muscles. Mechanomyography has the potential to
represent the state of muscle function at the muscle level. This study sought to investigate surface
mechanomyographic responses evoked from quadriceps muscles during FES-cycling, and to

T
quantify its changes between pre- and post-fatiguing conditions in individuals with spinal cord

IP
injury.
Methods: Six individuals with chronic motor-complete spinal cord injury performed 30-min of

CR
sustained FES-leg cycling exercise on two days to induce muscle fatigue. Each participant
performed maximum FES-evoked isometric knee extensions before and after the 30-min cycling

US
to determine pre- and post- extension peak torque concomitant with mechanomyography changes.
Findings: Similar to extension peak torque, normalized root mean squared (RMS) and mean
AN
power frequency (MPF) of the mechanomyography signal significantly differed in muscle
activities between pre- and post- FES-cycling for each quadriceps muscle (extension peak torque
M

up to 69%; RMS up to 80%, and MPF up to 19%). Mechanomyographic-RMS showed

significant reduction during cycling with acceptable between-days consistency (intra-class
ED

correlation coefficients, ICC = 0.51-0.91). The normalized MPF showed a weak association with
FES-cycling duration (ICC = 0.08-0.23). During FES-cycling, the mechanomyographic-RMS
PT

revealed greater fatigue rate for rectus femoris and greater fatigue resistance for vastus medialis
in spinal cord injured individuals.
CE

Interpretation: Mechanomyographic-RMS may be a useful tool for examining real time muscle
function of specific muscles during FES-evoked cycling in individuals with spinal cord injury.
AC

Keywords: FES cycling, muscle fatigue, mechanomyography, spinal cord injury.

2
 ACCEPTED MANUSCRIPT

Introduction

Functional electrical stimulation (FES)-evoked cycling, has reportedly improved muscle fibre

histochemical adaptations and increased muscle strength (Ferrante et al., 2008; Mayson and

Harris, 2014; Sabut et al., 2011). FES cycle training, when purposely embedded into

rehabilitation interventions, led to improved fatigue resistance of human muscles (Decker et al.,

T
2010; Haapala et al., 2008; Thrasher et al., 2013). However, rapid onset of muscle fatigue during

IP
FES exercise often limits its clinical benefits, because neuromuscular fatigue occurs earlier and

CR
more rapidly during FES-evoked contractions in paralyzed or paretic muscles compared to

normally-innervated tissues (Binder-Macleod et al., 1995). In clinical practice, muscle fatigue

US
can be assessed during FES-cycling as a reduction of power output over time, often counteracted
AN
by user real-time modulation of current amplitude or other neuromuscular stimulation parameters

to minimize negative fatigue effects (Pincivero et al., 2001). The development of physical
M

sensors and signal quantification software to monitor real-time fatigue at the muscle level would
ED

improve the deployment of FES systems for practical use by allowing the patient to regulate

neuromuscular stimulus parameters and maintain the quality of a physical activity by reducing
PT

fatigue-related negative sequelae (Haapala et al., 2008). This would be useful both for “closed-
CE

loop” medical devices requiring real-time feedback, as well as “open-loop” systems requiring

muscle status monitoring. To date, fatigue assessment during FES-cycling remains poorly
AC

documented (Estigoni et al., 2011; Haapala et al., 2008).

Prior research studies have investigated muscle fatigue during FES-cycling by quantifying

cycling duration or cadence, as both of these exercise parameters correlate negatively with

increased muscle fatigue (Chen and Yu, 1997; Fornusek and Davis, 2004). In addition, peak

torque and pedal power output have also been used as proxies of muscle fatigue during FES-

3
 ACCEPTED MANUSCRIPT

cycling. However, these collectively reflect the forces from a group of muscles that are recruited

during cycling, and they are influenced by the knee and ankle angular positions (Haapala et al.,

2008; Szecsi et al., 2014). As such, they do not directly reflect muscle forces associated with

fatigue of individual muscles within a muscle group. Surface electromyography (sEMG) has

been used to characterize fatigue from individual muscles by evaluating motor unit recruitment

T
and firing patterns, such as root mean square (RMS), M-wave amplitude and mean power

IP
frequency (MPF) of the evoked EMG signal during FES (Estigoni et al., 2011; Mizrahi et al.,

CR
1994). While sEMG has been reported to characterize the quality of FES-evoked muscle

contractions (Estigoni et al., 2014; Ibitoye et al., 2014a), its characteristics are highly susceptible

US
to electrical stimulation artefacts. These artefacts lead to sEMG signal’s amplifier saturation, and
AN
while post-processing can eliminate these artefacts, the sEMG has limited use for real-time FES

training (Faller et al., 2009; Haapala et al., 2008). Therefore, researchers have explored
M

alternative means of muscle fatigue measurement during FES exercise. One promising strategy
ED

for assessing muscle fatigue during FES-evoked movements is based on the relationship between

the muscle’s myographic signal and its contraction time, but this fundamental relationship has
PT

not received much research attention to date (Estigoni et al., 2011; Gonzalez-Izal et al., 2010a).
CE

Mechanomyography (MMG) is a mechanical alternative approach to sEMG for assessing muscle

function (Cè et al., 2015; Islam et al., 2013a; Orizio, 1993). It is well documented that the RMS
AC

and MPF of MMG signals are both associated with the contractile properties of muscles during

voluntary isometric and dynamic contractions (Beck et al., 2005; Islam et al., 2013b). Several

previous studies (Faller et al., 2009; Gobbo et al., 2006; Yoshitake et al., 2002) have also used

these MMG signal parameters to investigate muscle fatigue during involuntary contractions.

However, only a limited number of such investigations have used MMG to quantify muscle

4
 ACCEPTED MANUSCRIPT

fatigue during electrically-induced muscle contractions. All of these studies were performed

under isometric exercise conditions in healthy humans, and they collectively concluded that

MMG amplitude was a reliable tool for muscle fatigue assessment. Nevertheless, muscle fatigue

in individuals with SCI as assessed by MMG during electrically-evoked dynamic exercise (e.g.

FES-cycling) remains under-investigated (Ibitoye et al., 2014b; Ibitoye et al., 2014c).

T
The aims of this study were: i) to investigate changes in MMG responses evoked from the

IP
quadriceps muscle group comprising rectus femoris (RF), vastus lateralis (VL), and vastus

CR
medialis (VM) in individuals with chronic motor-complete SCI during FES-cycling; and, ii) to

quantify changes in quadriceps muscles’ MMG signals between pre- and post-fatiguing

US
conditions. We hypothesized that the MMG might be a reliable proxy for examining muscle
AN
function during FES-evoked isometric and cycling exercises, because it is associated with

muscle force output during FES-evoked isometric contraction at different knee angles in SCI
M

individuals with high between days test-retest reliability (Ibitoye et al., 2016) and is immune to
ED

electrical stimulation artefacts during exercise (Beck et al., 2006; Orizio, 1993). In addition, as

sustained FES-cycling is known to induce accelerated muscle fatigue (Agarwal et al., 2003) and
PT

the MMG signal shows decrements during sustained contractions (Orizio et al., 1989), there
CE

might be an association between FES-cycle time and MMG signal parameters.

AC

Methods

Participants

Six volunteers (five males and one female) with motor-complete chronic SCI participated in this

study. Their physical characteristics and clinical data are shown in Table 1. All underwent 2-3

sessions per week of FES-cycle training for muscle strength and conditioning for at least four

5
 ACCEPTED MANUSCRIPT

weeks prior to participating in this study. After oral briefing and provision of written information

concerning the study procedures, they gave their written informed consent to participate, and

these procedures had been approved by the University Malaya Medical Centre Medical Ethics

Committee, University of Malaya Medical Center (Approval No: 1003.14 (1)).

T
IP
[insert Table 1 here]

CR
Study Design

US
The study comprised three phases, as portrayed in Figure 1. In the first phase, each participant
AN
underwent three trials of FES-elicited peak isometric knee extension to quantify the highest

evoked peak torque (ePT) and MMG parameters of the quadriceps muscle group. These were
M

collected at baseline [PRE] conditions. Next, each participant performed 30-min of FES-leg
ED

cycling exercise [FES-LCE] at a sufficient per-subject exercise intensity so as to induce

significant muscle fatigue. In the final phase [POST], FES-elicited peak isometric knee
PT

extensions to elicit the ePT and MMG were repeated, but with a shorter inter-trial recovery
CE

period. In addition, MMG signals during the 30-min FES-cycling phase were collected to

document fatigue responses of the quadriceps muscle group. Each participant underwent
AC

duplicate sessions of the study design, with a minimum of 48 hours between sessions for the

purpose of establishing day-to-day consistency of responses in this small sample population.

[insert Figure 1 here]

Peak Evoked Isometric Torque

6
 ACCEPTED MANUSCRIPT

Participants were comfortably seated on a dynamometer chair (System 4; Biodex Medical

System, Shirley, NY, USA) with a hip angle of approximately 90 deg and 60 deg knee angle, to

assess ePT. During PRE, three trials of peak evoked isometric knee extension were developed

over 4 s for each trial, separated by 5-min of inactive recovery. A further 15-min recovery period

was allowed to obtain sufficient muscle recovery to reduce risk of overuse and thus produce

T
maximum muscle effort during FES-cycling. Following the recovery period participants

IP
performed 30-min of FES-LCE session, and then each participant repeated three trials of peak

CR
isometric knee extension developed over 4 s, but separated by 1-min of recovery period between

trials (Figure 1). During POST, a small (1-min) recovery period was deployed between trials,

US
because previous pilot research had indicated significant recovery of post-fatigue muscle forces
AN
did not adequately characterize the post-fatigue state. For the three trials during PRE and POST,

the mean score of ePT was used to characterize the highest muscle torque during each phase. If
M

the ePT differed by more the 5% between trials, an additional trial was undertaken. To maintain
ED

consistency between PRE and POST-cycling data, the positions of dynamometer chair were

marked, documented and used in the subsequent trials and phases.

PT

For neuromuscular stimulation during the PRE and POST phases, two 9 cm x 15 cm self-
CE

adhesive skin surface electrodes (RehaTrode, HASOMED, Germany) were affixed above and

below the belly of the quadriceps muscle. The distal electrode was placed 6–8 cm proximally to
AC

the patellar border and the proximal electrode was placed approximately 1/3 of the distance

between the inguinal line and the superior patellar border and slightly lateral to the muscle center

line to provide stimulation coverage over the muscle bellies of VL, RF, and VM (Haapala et al.,

2008; Szecsi et al., 2014). Neuromuscular stimulation was delivered at a constant frequency of

30 Hz and a biphasic pulse width of 400 µs to elicit tetanic muscle contractions. The stimulation

7
 ACCEPTED MANUSCRIPT

current amplitude (range: 90-120 mA) was individually selected so that each participant reached

their maximum knee extension torque that was determined via dynamometer.

FES-leg Cycling Exercise [FES-LCE]

All participants performed 30-min of sustained FES-LCE at a constant resistance (8/10 units of

MOTOmed cycle) and a cadence of 50 rev•min-1. The FES-cycling system comprised of six

T
IP
channels of neuromuscular stimulation (Rehastim II, Hasomed GmbH, Magdeburg, Germany)

CR
and motor-resisted cycling trainer (MOTOmed Viva 2, RECK-Medizintechnik GmbH,

Betzenweiler, Germany). The feet and legs of each participant were strapped firmly and held in

US
position by ankle-calf supports. The wheelchair was anchored firmly with the cycling system

during FES-LCE.
AN
During FES-cycling, surface stimulating electrodes were bilaterally affixed over the quadriceps
M

and the hamstring muscles. The placement of electrodes for the quadriceps muscles was similar

to that used for the peak isometric contraction. The electrode placements over the hamstring
ED

muscles were adapted from a previous study (Haapala et al., 2008) as follows: the distal
PT

electrode was placed approximately 6 cm above the superior crease of the posterior aspect of the

knee joint and the proximal electrode a distance of 10 cm above the crease. The neuromuscular
CE

stimulation parameters were biphasic rectangular pulses at a frequency of 30 Hz and a pulse

AC

width of 300µs. Stimulation intensity ranged between 60-120 mA for quadriceps and 58-90 mA

for hamstrings muscle groups adjusted for each participant to maximize initial cycling power

output. The stimulation intensity was gradually increased bilaterally to perform FES-cycling with

a target cadence mentioned above. This was set at the beginning and remained constant for the

30-min cycling phase.

MMG Setup

8
 ACCEPTED MANUSCRIPT

Three MMG sensors (Sonostics VMG BPS II Transducer, operational frequency response = 20-

200 Hz, sensitivity 50V/g) were placed over the bellies of the VL, RF, and VM muscles using

double sided adhesive tape. Quadriceps muscles were elicited during FES-evoked isometric

contraction to identify the bulky position of each muscle, of which the center position was used

to place the MMG sensor and maintained the position for FES-evoked cycling exercise. For VL

T
muscle, the sensor was placed at approximately 66% of the distance from the anterior-superior

IP
iliac spine to the lateral border of the patella. For the RF, the sensor was placed at approximately

CR
50% of the distance from the anterior superior iliac spine to the superior aspect of the patella. For

the VM, the sensor was placed at 70-80% (based on subject’s muscle belly elicited by the

US
stimulation) of the distance from the anterior superior iliac spine to the medial border of the
AN
patella. The greatest thickening of the VM muscle belly was determined through a FES-evoked

isometric contraction. The placements of the MMG sensors over the muscle groups remained
M

unchanged, performed and/or monitored by the same investigator(s), amongst the trials in each
ED

testing day, and between PRE and POST phases to provide consistency of MMG signals.
PT

Data Acquisition and Processing

The raw data of each MMG sensor during isometric muscle contractions and the output of ePT
CE

from the dynamometer were recorded at a sampling rate of 2 kHz and 100 Hz, respectively.
AC

These data were synchronously recorded and stored. Additionally, the output of each MMG

sensor during FES-LCE was recorded at a sampling rate of 2 kHz and the data stored for the

entire 30-min cycling period for later analysis of muscle fatigue during exercise. The acquisition

unit (BP150 and HLT100C, BIOPAC System Inc., USA) and software (AcqKnowledge 4.3.1,

BIOPAC System Inc., USA) were used in both cases to record and store the raw data on a

computer for off-line analyses.

9
 ACCEPTED MANUSCRIPT

The raw data detected by the sensors were digitally bandpass-filtered (fourth-order Butterworth)

at 20-200 Hz to obtain the MMG signals for RMS in the time domain and MPF in the frequency

domain. The lower cut-off of the MMG signal was set so that movement and other low

frequency artefacts could be filtered out (De Luca et al., 2010) and the higher cut-off of the

MMG signal was set to capture greater ‘signal density’ from fast firing motor unit fibers, which

T
are in much higher proportion in muscles of chronic SCI individuals (Burnham et al., 1997;

IP
Higashino et al., 2013). All signal processing was performed with custom programs written in

CR
LabVIEW programming software (Version 12.0, National Instruments, Austin, TX, USA).

US
Data analysis

The MMG signals and ePT of the two isometric conditions (PRE and POST phases on each day)
AN
were extracted for 2 s corresponding to the middle of each 4 s isometric trial to produce the RMS
M

and MPF. MMG signals (RMS and MPF) and ePT during PRE were normalized to their

respective peak values considering all the participants and trials and during POST condition
ED

these signals were normalized to their respective peak values of the PRE condition. The MMG
PT

signals during FES-cycling were partitioned into six consecutive 5-min of cycling epochs. A

middle 10 s of each 5-min epoch was extracted to determine the MMG RMS and MPF for later
CE

analysis. In addition, the first and last 10 s of the entire 30-min of FES-LCE were also included
AC

for analysis to represent early and final response of the muscles. For each of these data segments,

the RMS and MPF were normalized to their respective peak values obtained at PRE condition.

Statistical analysis

Linear regression was performed between FES-cycling time and normalized MMG signals to

determine the degree of association between them, and this was the criterion to investigate

fatigue-state of the quadriceps muscle group during FES-LCE. This analysis was based on

10
 ACCEPTED MANUSCRIPT

previous studies that had employed linear regression to estimate measures of muscle fatigue

during dynamic contractions (Gonzalez-Izal et al., 2010a; Gonzalez-Izal et al., 2010b). Due to

the heterogeneous characteristics of the participants, such as sex, age, weight, level and year of

injury that might influence FES-cycling fatigue differently between the muscles, we performed

participant basis regression analysis between MMG signal and FES-cycling duration. Note that

T
the prolonged FES-LCE exercise induced significant muscle fatigue in this cohort, and this

IP
phenomenon was investigated to determine if there was any decrease of MMG signal intensity

CR
during the 30-min FES-LCE exercise. Additionally, the slope and intercept indices of the MMG-

time regression analysis were used for repeated measures one-way ANOVA analyses with LSD

US
post-hoc tests to quantify the fatigue rate of the quadriceps muscle group. According to the
AN
Cohen’s interpretation for behavioral science (<0.14 is poor, between 0.14-0.36 is fair, between

0.37-0.50 is medium and > 0.51 is large), the regression correlation was determined (Cohen,
M

1998). Paired t-tests between PRE and POST FES-cycling phases were performed to determine
ED

fatigue using the MMG signals. The two-way mixed mode intraclass correlation consistency

(ICC) test of the MMG signal and ePT between Day 1 and Day 2 were performed. The between
PT

days ICC categories were defined according to theCicchetti’s interpretation of consistency

CE

correlation (< 0.4 is poor, between 0.4-0.59 is fair, between 0.6-0.74 is good and > 0.75 is high),

(Cicchetti et al., 1994). All statistical analysis was performed using SPSS software (IBM SPSS
AC

Statistics, version 20, New York, USA). Statistical significance was determined at an alpha of

0.05 (p<0.05).

Results

MMG RMS was sensitive to fatigue-induced changes of both static and dynamic FES-evoked

exercise conditions similar to ePT. The knee extension normalized ePT of POST condition

11
 ACCEPTED MANUSCRIPT

revealed significantly smaller values compared to the PRE condition for the duplicate Day1 (by

64%) and Day2 (by 69%) assessments (Figure 2). Similar to ePT, normalized RMS and MPF of

MMG signal decreased significantly between PRE and POST conditions for all the muscles in

both days (P < 0.05).

[insert Figure 2 here]

T
IP
The normalized MMG RMS of post-fatigued muscles decreased significantly from their pre-

CR
fatigued state for all muscle groups both Day 1 and Day 2 repeated assessments with VL by 63%

on Day1; by 46% on Day 2, RF by 80% on Day1; by 60% on Day 2, and VM by 50% on Day1;

US
by 65% on Day 2 (P < 0.05 for all three muscles; Figure 2). In addition, the MMG MPF after

fatigue decreased significantly from the pre-fatigue condition for VL (by 13% on Day 1; by 14%
AN
on Day 2), RF (by 8% on Day 1; by 19% on Day 2), and VM (by 7% on Day 1; by 8% on Day 2)
M

muscle groups. This fatigue measure was further validated by examining the relationship

between changes in ePT and changes in MMG RMS and MPF between PRE and POST
ED

conditions. There were moderate to strong linear relationships between changes in ePT and
PT

changes in MMG RMS between PRE and POST conditions on both days for the three muscles

within the quadriceps group with R2 between 0.24 to 0.68 (VM: 0.34 Day 1, 0.44 Day 2; VL:
CE

0.68 Day 1, 0.24 Day 2; RF: 0.39 Day 1, 0.23 Day 2; all P < 0.05). The linear relationships of
AC

changes in MMG MPF and ePT between PRE and POST conditions were moderate to strong on

Day 1 for all the muscles with R2 from 0.24 to 0.70. However, this relationship was poor on Day

2 for VL (R2 = 0.11) and VM muscles (R2 = 0.11) (Supplementary 1 and2).

Fatigue analysis during FES-LCE presented changes in MMG signals as a function of FES-

cycling time for VL, RF, and VM muscles on Day 1 and Day 2 repeated assessments. Moderate

to high consistency observed between days in case of MMG RMS for VL (ICC = 0.45-0.76), RF

12
 ACCEPTED MANUSCRIPT

(ICC = 0.71-0.84), and VM (ICC = 0.69-0.91) muscles were reported and hence the data for each

participant between Day 1 and Day 2 were pooled to perform the regression analyses between

the MMG RMS and FES-cycle time. Figure 3 shows that the MMG RMS decreased significantly

over time of FES-cycling for all the muscles (P < 0.05). In addition, repeated measures one-way

ANOVA was performed on slope and intercept indices of each muscle to determine the fatigue

T
rate during FES-cycling. There was a significant difference in fatigue rate (slope and intercept)

IP
for the VL, RF, and VM muscles (P < 0.05, Figure 4). LSD post-hoc tests in the VL, VM, and

CR
RF muscles further confirmed that the RF muscle revealed significantly greater slope, implying

faster fatigue rate, followed by the VL and VM muscles. The intercept of VM muscle was

US
significantly smaller than the VL and RF muscles. Although there was no significant difference
AN
between intercepts of RF and VL muscles (P = 0.061), the overall effect size of the significance

was 52%, a high difference.

M

[insert Figure 3]
ED

In contrast to the MMG RMS findings, there were poor consistency observed between days for
PT

MMG MPF during FES-cycling for VL (ICC=0.09-0.13), RF (ICC=0.08-0.09) and VM

(ICC=0.13-0.23) and hence the data for each participant were used separately for Day1 and Day
CE

2 repeated assessments to perform the regression analyses between the MMG MPF and FES-
AC

cycle time. In almost all cases, there was poor relationship (i.e. “flat” or unchanging MPF-time

slope indices) between the MMG MPF and FES-cycle time on both Day1 and Day 2

(Supplementary 3&4).

[Insert Figure 4 here]

Discussion

13
 ACCEPTED MANUSCRIPT

The present study was undertaken to examine whether MMG signals (RMS in time domain and

MPF in the frequency domain) derived from VL, RF, and VM of the quadriceps muscle group

changed during FES-cycling induced fatiguing conditions in SCI participants. In addition, the

MMG signals between pre- and post-fatiguing conditions derived from these muscles were

analyzed in relation to the ePT. To the authors’ knowledge, this is the first study that has

T
investigated these MMG relationships during muscle fatigue induced by sustained FES-cycling

IP
in individuals with chronic SCI. Normalized MMG RMS showed a significant association with

CR
the ePT and as such, the normalized MMG RMS was altered significantly between the PRE and

POST conditions for VL, RF and VM on repeated Day1 and Day 2 trials. The normalized MMG

US
MPF of POST condition reduced significantly from the PRE counterpart in Day1 and Day 2 for
AN
all the muscles. However, the association in changes of normalized MMG MPF with the changes

in ePT between PRE and POST was inconsistent between Day1 and Day 2 for the VL and VM
M

muscles. While the MMG RMS showed good promise for measuring the muscle fatigue during
ED

FES-cycling with moderate-to-strong consistency between days for quadriceps, the MMG MPF-

based measures revealed poor day-to-day consistency between days. Clearly, there is a need for
PT

further research on the reliability of muscle fatigue measurement during FES-cycling in this
CE

population.

The knee extension ePT of the post-fatiguing condition was significantly reduced from the pre-
AC

fatiguing state on Day1 and Day 2. These findings are similar to previous studies on able-bodied

volunteers who performed exercise (Cè et al., 2008; Faller et al., 2009), whereby similar

decrements of MMG amplitude for evoked fatiguing muscles contractions was reported. This

reduction in MMG amplitude can be attributed to numerous physiological changes concomitant

with muscle fatigue, such as muscle fusion and deoxygenation that could likely alter the

14
 ACCEPTED MANUSCRIPT

mechanical properties (Hogan et al.,1994) and hence the MMG RMS, which reflects the

dimensional changes of muscle fibres. We found significant association between changes of

MMG RMS with reduced ePT between the PRE and POST conditions for the three muscles in

Day 1 and Day 2 trials. This finding also concurs with previous studies that have revealed a

significant relationship between the ePT and MMG RMS from leg muscles (medial

T
gastrocnemius and soleus) in healthy volunteers (Yoshitake and Moritani, 1999) and RF in SCI

IP
individuals at different knee angles (Ibitoye et al., 2016). Another study (Faller et al., 2009),

CR
however, reported no significant alterations of MMG frequency between pre- and post-fatiguing

conditions of electrically stimulated muscle of able-bodied participants. The authors performed

US
sustained stimulated isometric contraction of 120 s in healthy population, which may be one of
AN
the factors that might explain the difference in MMG MPF results between pre- and post-

fatiguing conditions in their study and ours. The reduction in ePT, MMG RMS and MPF
M

between pre-and post-conditions in SCI individuals was possible because the electrically
ED

stimulated sustained contraction impairs both low- and high-threshold motor units contributing

to the muscle force and firing frequency and also lose the ability to return muscle’s initial level
PT

even after long recovery time (150 min) following sustained FES-evoked contractions in SCI
CE

(Shinohara and Sogaard, 2006). The changes in MMG MPF showed significant association with

the changes in ePT between the PRE and POST conditions for the RF muscle in Day 1 and Day
AC

2 duplicate trials.

During FES-cycling, the MMG RMS reduced significantly with FES-cycling time for the VL,

RF, and VM muscles in individuals with motor-complete SCI with a moderate to strong

consistency between Day 1 and Day 2. This is possible because FES motor recruitment is

synchronous thus muscle fibres are activated in reverse recruitment order (Binder-Macleod et al.,

15
 ACCEPTED MANUSCRIPT

1995). This causes rapid reduction of muscle force which was reflected in the MMG RMS during

sustained FES-cycling. This finding is similar to other works (Faller et al., 2009;Heasman et al.,

2000), in which the MMG amplitude reduced with continuous FES stimulation. The decline in

MMG amplitude may have occurred due to the development of muscle fusion where the high

discharge rate of motor units greatly decreased the dimensional changes in muscle fibres. The

T
increased discharge rate of motor units with sustained contraction of FES-cycling under fatigue

IP
might naturalize the occurrence of fusion and thus would decrease the MMG amplitude

CR
(Yoshitake et al., 2002). Another potential factor other than a motor unit strategy that could also

alter the MMG signal is an increase in the intramuscular pressure during sustained electrically

US
evoked contraction. The sustained fatiguing contraction impairs the oxygenation of muscle,
AN
which changes the intramuscular pressure of muscle fibres. This phenomenon indirectly alters

the mechanical properties that reduce muscle force and consequently declines the MMG signal
M

(Shinohara and Sogaard, 2006).

ED

The MMG RMS revealed that the RF muscle showed significantly greater fatigue rate followed

by the VL and VM muscles. This observation is also in line with another study (Camata et al.,
PT

2011) that found the greater fatigue rate in RF muscle followed by VL and VM muscles detected
CE

by the EMG signal during able-bodied cycling. The RF muscle consists of the greatest

proportion of fast-twitch type II fibers that is recruited first during FES-evoked contraction,
AC

which may cause faster fatigue in RF muscle during prolonged contraction. Moreover, the RF is

one of the biarticular muscles, which dictates the torque between joints during a task, and has

major contribution in the hip flexion during the recovery phase of the pedaling cycle (Takaishi et

al., 1998). The greater the contribution of the uniarticular muscle group (VL and VM) and the

hip extensor muscles are, the greater activity RF requires to re-coordinate torque and power

16
 ACCEPTED MANUSCRIPT

distribution between joints during cycling exercise (So et al., 2005). There is also evidence that

this re-coordination strategy may be triggered by the central nervous system that is impaired by

SCI population thereby causing more impact on the RF muscle to be active during FES-LCE

(Dorel et al., 2009). Collectively, these factors may contribute to a greater exertion of the RF

muscle, leading to early recruitment of the fast-twitch type II fibers during FES-LCE and hence

T
causing faster fatigue.

IP
This study showed that the relationships between the MMG MPF and sustained FES-cycling

CR
duration were very week in most cases for the VL, RF and VM muscles in Day1 and Day2.

Although there were some cases where the MMG MPF declined with the FES-cycling duration,

US
this result did not show consistency between Day1 and Day2. While one previous study showed
AN
a reduction in the MMG MPF with sustained contraction time for the biceps brachii muscle

(Madeleine et al., 2006), the authors did not report the correlation between the MMG MPF and
M

contraction time. The present study observed a week correlation between the MMG MPF and
ED

FES-cycling time for all the electrically evoked muscles in almost all participants. This was also

reported by another study that claimed a very low correlation between the MMG MPF and
PT

sustained evoked contraction time (Faller et al., 2009). Hence, the explanation for the use of
CE

MMG MPF in assessing muscle fatigue during FES-cycling would require further investigation.

Our results have practical implications as these showed the sensitivity on MMG responses to
AC

muscle function during FES-cycling and isometric contractions for individuals with motor-

complete SCI. The MMG RMS based approach showed good promise as a proxy to monitor the

mechanical aspects of the muscle performance in rehabilitation.

The limitation of this study was that this study was performed on six SCI participants amongst

whose two could not perform FES-cycling in Day2. As two of them only participated in one trial,

17
 ACCEPTED MANUSCRIPT

their data did not contribute to the reliability calculation. The difference of participation in

duplicate days may not have altered our main findings as the analysis was performed on

participant by participant basis. This study however recommends further comprehensive

investigation with higher number of SCI individuals under various types of contractions i.e.

static and dynamic. This study had to permit a small inter-trial time (≤ 5 min) in determining

T
fatigue after FES-cycling as transferring time of each participant from FES-cycling to FES-

IP
isometric condition (Figure 1). This could be an issue for the quantitative measure of MMG

CR
signals difference between the pre-and post-fatiguing conditions. In addition, while this study

allowed a small recovery time after FES-cycling, other studies suggested that even long recovery

US
time (up to 150 min) cannot improve muscle force after sustained electrically stimulated
AN
contractions (Blangsted et al., 2005; Shinohara and Sogaard, 2006). Our results also showed that

there was a significant difference in MMG signals between the pre-and post-fatiguing conditions
M

for the quadriceps muscle group.

ED

Conclusion
PT

This study demonstrated MMG signals (RMS and MPF), similar to ePT, were significantly

altered between the pre- and post-fatiguing states in SCI individuals after FES-evoked cycle
CE

exercise. The MMG RMS showed good promise in determining muscle function between pre-
AC

and post-fatigue FES-evoked conditions as well as in characterizing muscle fatigue during FES-

cycling with an acceptable consistency between days. However, the MMG MPF based measures

warrant additional research in assessing muscle function during FES-cycling. One potential

observation in this study is the RF muscle showed greater fatigue rate compared to the VL and

VM, which may play a vital role in limiting FES-cycling in SCI individuals.

18
 ACCEPTED MANUSCRIPT

Acknowledgements

The study was financially supported by the Ministry of Higher Education, Malaysia and the

University of Malaya through HIR Grant No. UM.C/625/1/HIR/MOHE/ENG/39 and UMRG

grant RP035A-15HTM. The authors thank the SCI study volunteers for their time and

participation. The authors also thank the physiotherapists for their support in training the SCI

T
participants for muscle conditioning.

IP
CR
Competing interests

There is no competing interest to declare.

US
AN
References

Agarwal, S., Kobetic, R., Nandurkar, S., Marsolais, E.B., 2003. Functional electrical stimulation
M

for walking in paraplegia: 17-year follow-up of 2 cases. The journal of spinal cord medicine 26,
ED

86-91.

Beck, T.W., Housh, T.J., Cramer, J.T., Weir, J.P., Johnson, G.O., Coburn, J.W., Malek, M.H.,
PT

Mielke, M., 2005. Mechanomyographic amplitude and frequency responses during dynamic
CE

muscle actions: a comprehensive review. Biomedical engineering online 4, 67.

Beck, T.W., Housh, T.J., Johnson, G.O., Cramer, J.T., Weir, J.P., Coburn, J.W., Malek, M.H.,
AC

2006. Comparison of the fast Fourier transform and continuous wavelet transform for examining

mechanomyographic frequency versus eccentric torque relationships. Journal of neuroscience

methods 150, 59-66.

Binder-Macleod, S.A., Halden, E.E., Jungles, K.A., 1995. Effects of stimulation intensity on the

physiological responses of human motor units. Medicine and science in sports and exercise 27,

556-565.

19
 ACCEPTED MANUSCRIPT

Blangsted, A.K., Sjøgaard, G., Madeleine, P., Olsen, H.B., Søgaard, K., 2005. Voluntary low-

force contraction elicits prolonged low-frequency fatigue and changes in surface

electromyography and mechanomyography. Journal of Electromyography and Kinesiology 15,

138-148.

Burnham, R., Martin, T., Stein, R., Bell, G., MacLean, I., Steadward, R., 1997. Skeletal muscle

T
fibre type transformation following spinal cord injury. Spinal cord 35, 86-91.

IP
Camata, T.V., Altimari, L.R., Bortolotti, H., Dantas, J.L., Fontes, E.B., Smirmaul, B.P., Okano,

CR
A.H., Chacon-Mikahil, M.P., Moraes, A.C., 2011. Electromyographic activity and rate of muscle

fatigue of the quadriceps femoris during cycling exercise in the severe domain. J Strength Cond

Res 25, 2537-2543.

US
AN
Cè, E., Paracchino, E., Esposito, F., 2008. Electrical and mechanical response of skeletal muscle

to electrical stimulation after acute passive stretching in humans: A combined electromyographic

M

and mechanomyographic approach. Journal of Sports Sciences 26, 1567-1577.

ED

Cè, E., Rampichini, S., Esposito, F., 2015. Novel insights into skeletal muscle function by

mechanomyography: from the laboratory to the field. Sport Sciences for Health, 11, 1-28.
PT

Chen, J.J., Yu, N.Y., 1997. The validity of stimulus-evoked EMG for studying muscle fatigue
CE

characteristics of paraplegic subjects during dynamic cycling movement. IEEE transactions on

rehabilitation engineering : a publication of the IEEE Engineering in Medicine and Biology

AC

Society 5, 170-178.

Cicchetti, Domenic V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and

standardized assessment instruments in psychology. Psychological Assessment 6, 284–290.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed. ). Hillsdale,

NJ: Erlbaum.

20
 ACCEPTED MANUSCRIPT

De Luca, C.J., Gilmore, L.D., Kuznetsov, M., Roy, S.H., 2010. Filtering the surface EMG signal:

Movement artifact and baseline noise contamination. Journal of Biomechanics 43, 1573-1579.

Decker, M.J., Griffin, L., Abraham, L.D., Brandt, L., 2010. Alternating stimulation of synergistic

muscles during functional electrical stimulation cycling improves endurance in persons with

spinal cord injury. Journal of electromyography and kinesiology : official journal of the

T
International Society of Electrophysiological Kinesiology 20, 1163-1169.

IP
Dorel, S., Drouet, J., Couturier, A., Champoux, Y., Hug, F., 2009. Changes of pedaling

CR
technique and muscle coordination during an exhaustive exercise. Medicine and science in sports

and exercise 41, 1277-1286.

US
Estigoni, E.H., Fornusek, C., Hamzaid, N.A., Hasnan, N., Smith, R.M., Davis, G.M., 2014.
AN
Evoked EMG versus muscle torque during fatiguing functional electrical stimulation-evoked

muscle contractions and short-term recovery in individuals with spinal cord injury. Sensors 14,
M

22907-22920.
ED

Estigoni, E.H., Fornusek, C., Smith, R.M., Davis, G.M., 2011. Evoked EMG and muscle fatigue

during isokinetic FES-cycling in individuals with SCI. Neuromodulation : journal of the

PT

International Neuromodulation Society 14, 349-355; discussion 355.

CE

Faller, L., Nogueira Neto, G.N., Button, V.L.S.N., Nohama, P., 2009. Muscle fatigue assessment

by mechanomyography during application of NMES protocol. Brazilian Journal of Physical

AC

Therapy 13, 422-429.

Ferrante, S., Pedrocchi, A., Ferrigno, G., Molteni, F., 2008. Cycling induced by functional

electrical stimulation improves the muscular strength and the motor control of individuals with

post-acute stroke. Europa Medicophysica-SIMFER 2007 Award Winner. European journal of

physical and rehabilitation medicine 44, 159-167.

21
 ACCEPTED MANUSCRIPT

Fornusek, C., Davis, G.M., 2004. Maximizing muscle force via low-cadence functional electrical

stimulation cycling. Journal of rehabilitation medicine 36, 232-237.

Gobbo, M., Ce, E., Diemont, B., Esposito, F., Orizio, C., 2006. Torque and surface

mechanomyogram parallel reduction during fatiguing stimulation in human muscles. European

journal of applied physiology 97, 9-15.

T
Gonzalez-Izal, M., Malanda, A., Navarro-Amezqueta, I., Gorostiaga, E.M., Mallor, F., Ibanez, J.,

IP
Izquierdo, M., 2010a. EMG spectral indices and muscle power fatigue during dynamic

CR
contractions. Journal of electromyography and kinesiology : official journal of the International

Society of Electrophysiological Kinesiology 20, 233-240.

US
Gonzalez-Izal, M., Rodriguez-Carreno, I., Malanda, A., Mallor-Gimenez, F., Navarro-
AN
Amezqueta, I., Gorostiaga, E.M., Izquierdo, M., 2010b. sEMG wavelet-based indices predicts

muscle power loss during dynamic contractions. Journal of electromyography and kinesiology :
M

official journal of the International Society of Electrophysiological Kinesiology 20, 1097-1106.

ED

Haapala, S.A., Faghri, P.D., Adams, D.J., 2008. Leg joint power output during progressive

resistance FES-LCE cycling in SCI subjects: developing an index of fatigue. Journal of

PT

neuroengineering and rehabilitation 5, 14.

CE

Heasman, J.M., Scott, T.R., Vare, V.A., Flynn, R.Y., Gschwind, C.R., Middleton, J.W.,

Rutkowski, S.B., 2000. Detection of fatigue in the isometric electrical activation of paralyzed
AC

hand muscles of persons with tetraplegia. IEEE transactions on rehabilitation engineering : a

publication of the IEEE Engineering in Medicine and Biology Society 8, 286-296.

Higashino, K., Matsuura, T., Suganuma, K., Yukata, K., Nishisho, T., Yasui, N., 2013. Early

changes in muscle atrophy and muscle fiber type conversion after spinal cord transection and

peripheral nerve transection in rats. Journal of neuroengineering and rehabilitation 10, 46.

22
 ACCEPTED MANUSCRIPT

Hogan, M. C., Richardson, R .S., Kurdak, S. S., 1994. Initial fall in skeletal muscle force

development during ischemia is related to oxygen availability.77, 2380-2384.

Ibitoye, M.O., Estigoni, E.H., Hamzaid, N.A., Wahab, A.K., Davis, G.M., 2014a. The

effectiveness of FES-evoked EMG potentials to assess muscle force and fatigue in individuals

with spinal cord injury. Sensors 14, 12598-12622.

T
Ibitoye, M.O., Hamzaid, N.A., Hasnan, N., Abdul Wahab, A.K., Islam, M.A., Kean, V.S., Davis,

IP
G.M., 2016. Torque and mechanomyogram relationships during electrically-evoked isometric

CR
quadriceps contractions in persons with spinal cord injury. Medical engineering & physics 38,

767-775.

US
Ibitoye, M.O., Hamzaid, N.A., Zuniga, J.M., Abdul Wahab, A.K., 2014b. Mechanomyography
AN
and muscle function assessment: a review of current state and prospects. Clin Biomech 29, 691-

704.
M

Ibitoye, M.O., Hamzaid, N.A., Zuniga, J.M., Hasnan, N., Wahab, A.K., 2014c.
ED

Mechanomyographic parameter extraction methods: an appraisal for clinical applications.

Sensors 14, 22940-22970.

PT

Islam, M.A., Sundaraj, K., Ahmad, R.B., Ahamed, N.U., 2013a. Mechanomyogram for Muscle
CE

Function Assessment: A Review. PLoS ONE 8, e58902.

Islam, M.A., Sundaraj, K., Ahmad, R.B., Ahamed, N.U., Ali, M.A., 2013b. Mechanomyography
AC

Sensor Development, Related Signal Processing, and Applications: A Systematic Review.

Sensors Journal, IEEE 13, 2499-2516.

Kirshblum, S.C., Burns, S.P., Biering-Sorensen, F., Donovan, W., Graves, D.E., Jha, A.,

Johansen, M., Jones, L., Krassioukov, A., Mulcahey, M.J., Schmidt-Read, M., Waring, W., 2011.

23
 ACCEPTED MANUSCRIPT

International standards for neurological classification of spinal cord injury (Revised 2011). The

journal of spinal cord medicine 34, 535-546.

Madeleine, P., Ge, H.Y., Jaskolska, A., Farina, D., Jaskolski, A., Arendt-Nielsen, L., 2006.

Spectral moments of mechanomyographic signals recorded with accelerometer and microphone

during sustained fatiguing contractions. Medical & biological engineering & computing 44, 290-

T
297.

IP
Mayson, T.A., Harris, S.R., 2014. Functional electrical stimulation cycling in youth with spinal

CR
cord injury: A review of intervention studies. The journal of spinal cord medicine 37, 266-277.

Mizrahi, J., Levy, M., Ring, H., Isakov, E., Liberson, A., 1994. EMG as an indicator of fatigue in

US
isometrically FES-activated paralyzed muscles. Rehabilitation Engineering, IEEE Transactions
AN
on 2, 57-65.

Orizio, C., 1993. Muscle sound: bases for the introduction of a mechanomyographic signal in
M

muscle studies. Critical reviews in biomedical engineering 21, 201-243.

ED

Orizio, C., Perini, R., Veicsteinas, A., 1989. Changes of muscular sound during sustained

isometric contraction up to exhaustion. Journal of applied physiology (Bethesda, Md. : 1985) 66,
PT

1593-1598.
CE

Pincivero, D.M., Gear, W.S., Sterner, R.L., 2001. Assessment of the reliability of high-intensity

quadriceps femoris muscle fatigue. Medicine and science in sports and exercise 33, 334-338.
AC

Sabut, S.K., Sikdar, C., Kumar, R., Mahadevappa, M., 2011. Functional electrical stimulation of

dorsiflexor muscle: effects on dorsiflexor strength, plantarflexor spasticity, and motor recovery

in stroke patients. NeuroRehabilitation 29, 393-400.

Shinohara, M., Sogaard, K., 2006. Mechanomyography for studying force fluctuations and

muscle fatigue. Exercise and sport sciences reviews 34, 59-64.

24
 ACCEPTED MANUSCRIPT

So, R., Ng, J., Ng, G., 2005. Muscle recruitment pattern in cycling: A review. Phys Ther Sport 6,

89-96.

Szecsi, J., Straube, A., Fornusek, C., 2014. A biomechanical cause of low power production

during FES cycling of subjects with SCI. Journal of neuroengineering and rehabilitation 11, 123.

Takaishi, T., Yamamoto, T., Ono, T., Ito, T., Moritani, T., 1998. Neuromuscular, metabolic, and

T
kinetic adaptations for skilled pedaling performance in cyclists. Medicine and science in sports

IP
and exercise 30, 442–449.

CR
Thrasher, T.A., Ward, J.S., Fisher, S., 2013. Strength and endurance adaptations to functional

electrical stimulation leg cycle ergometry in spinal cord injury. NeuroRehabilitation 33, 133-138.

US
Yoshitake, Y., Moritani, T., 1999. The muscle sound properties of different muscle fiber types
AN
during voluntary and electrically induced contractions. Journal of electromyography and

kinesiology : official journal of the International Society of Electrophysiological Kinesiology 9,

M

209-217.
ED

Yoshitake, Y., Shinohara, M., Ue, H., Moritani, T., 2002. Characteristics of surface

mechanomyogram are dependent on development of fusion of motor units in humans. Journal of

PT

applied physiology (Bethesda, Md. : 1985) 93, 1744-1752.

CE
AC

25
 ACCEPTED MANUSCRIPT

List of Figure Captions

Figure 1: Study design portraying baseline evoked isometric knee extension trials (Phase 1),

FES-evoked cycling to induce muscle fatigue (Phase 2) and post-fatiguing trials of evoked

isometric knee extension (Phase 3).

T
IP
CR
Figure 2: Normalized ePT, RMS and MPF responses of MMG signal during FES-evoked

isometric contraction between PRE and POST conditions for the VL, RF, and VM muscles in

US
Day 1 and Day 2. * indicates p<0.05. AN
Figure 3: Relationships between the MMG RMS and FES-cycle time for the VL, RF and VM in
M

each SCI individual muscle. Each row presents data of all three muscles for each participant
ED

presented in Table 1. Note that participants 3 and 4 performed the FES-LCE in Day1 only.
PT

Figure 4: Repeated measures One-way ANOVA followed by LSD post-hoc tests of the fatigue
CE

rate (slope and intercept) in the VL, RF, and VM muscles during FES-LCE in SCI individuals.

Common symbols indicate statistical siginificance between them (p < 0.05).

AC

26
 ACCEPTED MANUSCRIPT

Table 1: Physical Characteristics and SCI-related data of the participants.

Participant Age (y) Sex Height Weight Neurological ASIA Time

(cm) (kg) Level of Impairment
since
Injury Scale (AIS)
injury
* (y)
P1 47 F 162 82.0 T4 B 24
P2 28 M 171 62.4 C7 B 14
P3 49 M 174 79.6 T1 A 11

T
P4 44 M 179 71.6 C6 B 3
P5 33 M 171 61.0 C6 A 13

IP
P6 34 M 170 75.9 C6 A 17
Mean 39.2 172.8 74.3 13.6

CR
SD 7.86 4.2 7.7 6.5
* A – Complete SCI (Motor and sensory); B – Incomplete SCI (Motor complete, sensory
sparing); ASIA – American Spinal Injury Association (Kirshblum et al., 2011).

US
AN
M
ED
PT
CE
AC

27
 ACCEPTED MANUSCRIPT

Highlights
 Mechanomyography and torque reduced after electrically stimulated cycling.
 Rectus femoris fatigues faster while Vastus Medialis had greater fatigue resistance.
 Root mean square is more reliable and sensitive compared to mean power frequency.

T
IP
CR
US
AN
M
ED
PT
CE
AC

28
Figure 1
Figure 2
Figure 3
Figure 4