Technology and Health Care 23 (2015) 475–483 475

DOI 10.3233/THC-150913
IOS Press

Effects of interphase interval and stimulation

form on dorsiflexors contraction force

Shmuel Springer
Department of Physical Therapy, Hubert Building, Rm 412, Ariel University, Ariel 40700, Israel
Tel.: +972 58 4572869; E-mail: shmuels@ariel.ac.il

Received 12 January 2015

Accepted 8 March 2015

Abstract.
BACKGROUND: Neuromuscular electrical stimulation (NMES) is commonly used in rehabilitation to restore movement to
patients following orthopedic and neurological injuries. When applying NMES the goal is to induce the strongest contractions
with minimal discomfort.
OBJECTIVE: This study aimed to determine whether introducing an interphase interval (IPI) to 400 µsec biphasic pulses
during stimulation of the dorsiflexor muscles would have the same effect on force production and stimulation discomfort when
stimulation was controlled by constant current (CC) or constant voltage (CV).
METHODS: Eighteen healthy volunteers participated in the study. Each subject participated in one session. Electrically in-
duced contraction (EIC) forces and degree of discomfort were measured during stimulation of the ankle dorsiflexors with 0,
100 and 200 µsec IPI settings with CC or CV.
RESULTS: Compared to IPI = 0 µsec, introduction of a 200 µsec IPI increased force production with CC stimulation without
increasing discomfort. No other enhancements in the EIC force compared to IPI = 0 µsec were found between the IPIs with
CC or CV.
CONCLUSIONS: IPI may increase the effectiveness of biphasic pulse with CC, but not with CV stimulation.

Keywords: Electrical stimulation, muscle force, constant current, constant voltage, inter-phase interva

1. Introduction

Neuromuscular electrical stimulation (NMES) is commonly used in rehabilitation to restore movement

to patients following orthopedic and neurological injuries [1–3]. It is also used for muscle strengthening
in healthy subjects as an adjunct to physical training for sports [4,5]. One of the most common applica-
tions of NMES is peroneal nerve stimulation to treat foot drop, where the ankle dorsiflexor muscles are
stimulated to overcome weakness and paresis to allow functional performance of daily tasks [6].
When applying NMES transcutaneously, a relatively high charge should be used in order to excite the
motor neurons, which lie below the skin and a layer of insulating fat. Yet, current must be kept as low as
possible to avoid pain and damage to the skin [7,8]. The size and placement of the electrodes and stimu-
lation parameters may affect the amount of current required during the delivery of NMES [9,10]. Tradi-
tionally, the pulse parameters most frequently used to optimize the stimulation are duration, frequency
(rate) and amplitude (intensity) [8,11,12]. The most popular stimulus waveform used for electrical stim-
ulation is the symmetrical biphasic pulse, where both the negative and positive phases of the stimulus
involve equal charges [13,14]. The first (stimulating) phase elicits the desired physiological effect such

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476 S. Springer / Effects of IPI and stimulation form on dorsiflexors contraction force

as initiation of an action potential, and the second (reversal) phase is used to reverse the direction of
electrochemical processes that occur during the stimulating phase. The concern with the biphasic wave-
form is that the second phase of the pulse may reverse some of the desired depolarization effects of the
stimulation phase by partially suppressing the action potential. This may cause an increased threshold
for biphasic, relative to monophasic stimulation [10].
The introduction of a short interphase interval (IPI) was suggested as a method to improve the effi-
ciency of the biphasic waveform. The rationale for using an IPI in electrical stimulation is based on the
premise that by introducing an interphase delay between the pulse phases, the threshold for a biphasic
pulse would be similar to that of a monophasic pulse [10,15]. Thus, an IPI may enhance the effectiveness
of biphasic pulse stimulation without imparting the negative electrolytic effects related to monophasic
pulses, such as discomfort and tissue damage [10]. Studies have shown that introducing an IPI may en-
hance the muscle contraction force induced by electrical stimulation without increasing the discomfort
associated with the induced contractions [16–18]. However, phase durations used in these studies were
up to 250 µsec, whereas increased phase durations has been shown to increase motor unit recruitment as
well as to be less painful compared to increasing the current amplitude [11]. Moreover, in some cases,
such as with subjects with high skin impedance, and with partially denervated or large muscles, longer
phase durations are required. It should be also noted that the role of long phase durations in maximiz-
ing muscle force has been overlooked when compared to the attention given to the frequency or the
amplitude characteristics of the NMES [19].
The circuit designs of the devices used for stimulation may be controlled by means of constant cur-
rent (CC) or constant voltage (CV). Both types of stimulation have advantages and disadvantages when
applying NMES [20,21]. A CV transcutaneous NMES system minimizes the risk of high current den-
sities associated with tissue-electrode interface fluctuations; however, variability in muscle stimulation
and inconsistent functional response can result. Conversely, with CC stimulation, the voltage adjusts to
maintain constant current flow, thus, ensuring a consistent physiologic response during treatment. How-
ever, this may cause discomfort and even pain with changes in resistance, such as when an electrode
loses full contact or dries. The question is whether CC and CV generate similar force outputs in spite of
the different methods of transmitting electric charges to the excitable tissue.
Therefore, the primary objective of the present study was to assess whether the IPI effects depend on
the method by which the stimulation is regulated; in other words, to determine whether the IPI effect is
similar when stimulation is controlled by CC or CV. A second aim was to determine the IPI effects in a
biphasic pulse with relatively long phase duration of 400 µsec.

2. Methods

Eighteen healthy volunteers (aged 22–43 years) participated in the study. The average age of the
subjects was 26.2 ± 5.0 years, and 8 subjects (44%) were female. Inclusion criteria were general good
health, no pacemaker, no neurological or cardiovascular disease, no orthopedic impairment affecting
the dominant lower extremity, and no skin breakdown under the stimulating electrodes of the dominant
lower limb. The study was approved by the Institutional Review Board of Ariel University. All subjects
provided signed informed consent prior to participation.

2.1. Test equipment

A custom-designed testing device was used to measure the force of the electrically induced contrac-
tion (EIC) developed in the ankle joint [18]. It was comprised of a strain gauge sensor (1002-k 20 kg;
 S. Springer / Effects of IPI and stimulation form on dorsiflexors contraction force 477

Fig. 1. The testing device (strain gauge sensor transducer labeled with an arrow).

sensitivity = 1.5 mV/V and 1.5 mV/kg; Vishay, Raleigh, NC) for measuring the force (N). All tests were
performed while the subject was seated on a designated chair, with the hip and knee at 90◦ of flexion
and the ankle fitted to the force measuring device (Fig. 1). The subject’s lower leg was stabilized to
ensure that the starting position of the ankle angle would remain the same during the tests, while allow-
ing free movement during stimulation. The force measurement sampling began when the dorsum of the
foot moved up against the strain gauge sensor and applied pressure on the sensor. The force continued
to be measured as long as the foot was in contact with the sensor. When stimulation was stopped, the
foot returned to its starting position (due to gravity) and the force measurement ceased. Data acquisi-
tion rate was 46 Hz. Data were gathered, processed and saved on a personal computer using National
Instruments LabviewTM software.
A clinical stimulator (492 Sonopuls, Enraf-Nonius, Delft, Netherlands) was used for muscle stimu-
lation. This device enables the delivery CC or CV stimulation with various IPIs. Two 5 × 5 cm, self-
adhesive, surface electrodes (Axelgaard, Fallbrook, CA) were used to deliver the electrical stimulation.

2.2. Testing procedure

Each subject participated in a single 1 to 1.5 hour session, which included two assessments, one with
CC and one with CV stimulation. The order was randomized across subjects. Electrode placement was
similar for both conditions; the proximal electrode was located over the common peroneal nerve, just
below the head of fibula, and the second electrode was located over the dorsiflexor muscles belly (Fig. 2).
During all tests, the phase duration was set at 400 µsec, and pulse frequency 35 Hz.
478 S. Springer / Effects of IPI and stimulation form on dorsiflexors contraction force

Fig. 2. Electrode placement – the proximal electrode located over the common peroneal nerve, just below the head of fibula,
and the second electrode located over the dorsiflexor muscles belly.

Stimulation intensity was set initially with the IPI at 0. The intensity was gradually increased until
the force at the ankle joint reached a stable peak of 20 to 30 N. This force was chosen, as within this
range a clearly visible dorsiflexion movement was demonstrated in all subjects, with minimal inversion
or eversion and without discomfort related to stimulation sensation. Therefore, it may represent the
EIC of the dorsiflexors that is used to lift the foot during the swing phase of gait. This intensity was
then used as the current amplitude (in mA) in all subsequent tests with the different IPI durations.
Electrically induced contraction forces were measured with IPI settings of 0, 100 and 200 µsec, which
were presented in random order. During each test, electrical stimulation was delivered for 7 sec (with
ramp up and down of 1 sec), followed by a 53 sec rest period. The isometric force was measured when
the ankle joint reached 0◦ (Fig. 1). Two measurements were taken for each of the three IPI durations
with each of the two stimulation forms. The average force value of the two repetitions was used for
data analysis. In addition, in each test subjects were asked to rate the discomfort related to stimulation
sensation using a numeric rating scale (NRS) ranging from 0 to 10. The average NRS value for each IPI
was used for data analysis.

2.3. Statistical analysis

Two separate repeated measures (mixed model) ANOVAs with CC or CV stimulation, IPI duration (0,
100, and 200 µsec), and their interaction were employed to predict force (N) and stimulation sensation
 S. Springer / Effects of IPI and stimulation form on dorsiflexors contraction force 479

Table 1
Force of the electrically induced contractions and stimulation sensation with the different interphase intervals at each stimulation
form, mean (SE)
Interphase interval (µsec)
0 100 200
Electrically induced contraction force (N) CC 27.68 (1.82) 31.81 (2.06) 35.58 (2.78)
CV 29.11 (1.71) 32.29 (1.73) 25.60 (1.60)
Stimulation sensation CC 2.75 (0.44) 3.22 (0.51) 3.33 (0.58)
CV 3.28 (0.59) 3.33 (0.58) 3.31 (0.58)
CC = constant current, CV = constant voltage.

(a) Constant voltage (b) Constant current

Fig. 3. (a,b): Characteristics and waveform shape of the stimulating pulse with 200 µsec IPI in the two control forms. The figure
shows the current and voltage response measured with one subject. The voltage was measured across the two electrodes; the
current was measured over a 10Ω resistor connected in series with one of the electrodes.

(NRS). Post hoc analysis with Bonferroni corrections were used to examine pairwise differences, as
appropriate. A separate t-test was also performed to examine the difference in the current intensity
used with CC or CV stimulation. SPSS (SPSS Inc, Chicago, Illinois) was used for statistical analyses.
Significance level was set at p < 0.05.

3. Results

The mean (SD) stimulation intensity used with the CC and CV stimulations were 23.0 (8.9) mA and
31.2 (6.2) mA, respectively. Figure 3 presents the characteristics and waveform shape of the stimulating
pulse with 200 µsec IPI, measured with one subject, during the stimulation with the two control forms.
The t-test results comparing intensities with the two stimulation forms indicate that a higher intensity
was required with CV compared to CC (p < 0.001).
The EIC forces (mean, SE) and stimulation sensation (mean, SE) with each IPI in both stimulation
forms are summarized in Table 1. The EIC forces are also presented graphically (Fig. 4). The ANOVA
which tested the effect of the CC and CV stimulations and IPI duration (0, 100, and 200 µsec) on
stimulation sensation (NRS), did not yield a significant interaction effect, (F (2,34) = 1.233, p = 0.304).
On the other hand, ANOVA results showed a significant interaction effect for IPI x stimulation form on
the EIC force (F (2,30) = 10.972, p < 0.001).
480 S. Springer / Effects of IPI and stimulation form on dorsiflexors contraction force

Table 2
Summary of pairwise comparison tests
Stimulation form Pairwise comparisons IPI = 100 IPI = 200
CC IPI = 0 NS 0.018
IPI = 100 − NS
CV IPI = 0 NS NS
IPI = 100 − 0.006
CC = constant current, CV = constant voltage, IPI = interphase interval (measured in µsec).

Fig. 4. The electrically induced contractions (EIC) forces means ± SE (n = 18) with each interphase interval (IPI) in both
stimulation forms.

Results of the post hoc pairwise tests are summarized in Table 2. With CC stimulation, the force of
the EIC was significantly lower with IPI = 0 µsec compared to IPI = 200 µsec (p = 0.018). No other
differences in EIC force were found between the IPIs. With CV stimulation, the results indicate that the
force of the EIC was significantly lower with IPI = 200 µsec compared to IPI = 100 µsec (p = 0.006).
No other differences in the EIC force were found between the IPIs.

4. Discussion

The results of the present study indicate that the effect of IPI on force production with 400 µsec bipha-
sic pulses during stimulation of the dorsiflexor muscles depends on the method by which the stimulation
is regulated. When the stimulation was controlled with CC, a 200 µsec IPI enhanced force production
without increasing the degree of discomfort associated with electrical stimulation. In contrast, when the
stimulation was controlled with CV, the introduction of an IPI did not increase force production.
The findings of the present study are consistent with previous studies indicating that introducing an IPI
may enhance the muscle contraction force induced by electrical stimulation. Kaczmarek et al. [17] tested
 S. Springer / Effects of IPI and stimulation form on dorsiflexors contraction force 481

the effect of six IPI durations (ranging from 0 to 2000 µsec) on gastrocnemius muscle contractions.
The authors concluded that the introduction of an IPI may generate stronger contraction forces than
stimulation with standard biphasic pulses (IPI = 0 µsec). Laufer [16] demonstrated that introduction of
IPIs ranging between 0 and 250 µsec significantly enhanced the EIC force of the quadriceps muscle,
without increasing the discomfort associated with the contraction. A recently published report showed
that an IPI increased the force production of the dorsiflexors when the stimulation was delivered through
the common peroneal nerve; contrary, when both electrodes were located at the muscle motor point, the
introduction of an IPI did not affect force production [18]. Similarly with this latter report, the present
study also tested the dorsiflexors muscles with one electrode located at a nerve placement. Yet, the
current research is the first to document the positive effect of IPI with relatively long phase duration, and
the different effects of CC and CV.
A possible reason for the different results between the CC and CV stimulations may relate to the
difference in current delivery between these two control methods. With CC, the current is constant
throughout the pulse, whereas with CV stimulation the current reaches its maximum at the beginning of
the pulse and decreases throughout the pulse (see Fig. 3). Consequently, it may be assumed that in CV
stimulation, most of the depolarization occurs in the beginning of the pulse; thus, it is less likely that the
second phase of the pulse may suppress the action potential. Accordingly, introducing an IPI will not
affect the efficiency of the stimulation.
Previous studies have found that an IPI of 100 µsec or less may be sufficient to prevent the suppressing
effect of the reversal phase and to increase force when using biphasic stimulation [16,18]. The findings
of the present study, showed an increase in force production with CC, only when the IPI was 200 µsec.
This discrepancy is probably related to the difference in the phase durations between the studies. While
previous studies applied phase duration of up to 250 µsec [16–18], the phase duration used in present
study was 400 µsec. It may be assumed that there is some correlation between the phase duration and
the optimal IPI to maximize force production. Another important question that should be explored is the
duration in which the IPI saturates. It has been shown that longer phase durations may resulted in greater
torque and increased tolerated maximum voluntary isometric contraction as compared to shorter phase
durations [11,19,22]. Thus, further research that will continue to explore the characteristics of electrical
stimulation with longer phase durations is warranted.
The findings indicated that when the IPI was zero, the current intensity that was required to elicit a
contraction when using CC was 26% lower than with CV stimulation. This may be explained by the
bioelectric properties of the skin and the relatively long phase duration (400 µsec) used in the current
study. When using transcutaneous electrical stimulation, the combination of electrodes and tissue can
be modeled by a resistor capacitor combination. With a long phase duration and CV stimulation, the
capacitors charge at the beginning of the phase and the current quickly drops to resistive current flow
only. This means that the current may drop to a very low value [23]. Thus, higher current intensity is
needed to elicit a contraction.
The most common clinical application of FES is to the ankle dorsiflexors. Optimizing stimulation pa-
rameters is particularly significant in this application, because it involves multiple stimulation repetitions
over long periods. The fact that the electrodes are in a fixed location throughout the day increases the
tendency to develop skin irritation [24]. In addition, some patients may not benefit from this application
as they cannot tolerate the required stimulation intensity [25,26]. This study indicates that with CC, in-
troducing an IPI can enhance force production without the need to increase stimulation intensity. This
eliminates possible undesirable side effects such as skin irritation and reduces the discomfort associated
with higher pulse charges.
482 S. Springer / Effects of IPI and stimulation form on dorsiflexors contraction force

It is important to recognize some limitations of the present study. The participants were able-bodied
individuals and the sample size was relatively small. Thus, future research should examine the effects
of IPI on EIC force in individuals with various pathological upper motor neuron conditions. In addition,
further studies are necessary to substantiate the results with other stimulation parameters, particularly
with shorter phase durations. Finally, this study evaluated the acute response of the IPI effect with CC
and CV. Additional studies are needed to determine the cumulative training effects of IPI, such as on
functional performance and gait.

5. Conclusions

The study showed that introducing of a 200 µsec interval between the two phases of 400 µsec constant
current biphasic pulse enhanced the ability to induce stronger muscle contractions without having to
increase the amplitude of the current and without affecting the degree of discomfort associated with
the stimulation. On the other hand, stimulation with constant voltage did not improve force production
regardless of selected IPI.
The findings of this study suggest that the application of IPI modulation together with constant current
control method may improve the efficiency of neuromuscular electrical stimulation treatments. This
benefit should be utilized when electrical stimulation technology is applied. While further studies are
necessary to confirm the results on different muscle groups, the present study, which tested the ankle
dorsiflexors, may help to optimize the stimulation settings used during peroneal FES, thus, eliminating
possible undesirable side effects such as skin irritation and discomfort associated with higher pulse
charges.

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