A Com~arison of Toraue Generatina Capabilities of Three Different Electrical Stimulating Currents

LYNN SNYDER-MACKLER, PT, MS, SCS,' MARK GARRETT, PT, BS,2 MARK ROBERTS, PT, BS3
The purpose of this study was to test the torque generating capabilities of three commercially available neuromuscular electrical stimulators (NMES) having different current characteristics. Twenty healthy adults were positioned in sitting on an isokinetic dynamometer. Maximum voluntary isometric knee extension torque was determined. Subsequently, two 10-sec, maximally tolerated contractions were elicited with each machine. The order of stimulation was randomized and there were 2-minute rest periods between contractions. Electrically elicited torque values were expressed as a percentage of the maximal voluntary isometric torque WMVIT). Analysis of variance with one repeated measure showed a significant difference among %MVIT produced by the stimulators. NMES 2 (Nemectrodyn 7) produced significantly less %MVIT than either NMES 1 (Electrostim 180-2) or NMES 3 (Chattanooga VMS). In all but three cases, NMES 2's maximal current output was reached. Although all three devices were capable of producing %MVIT that has been shown to be sufficient for strengthening, it appears that NMES 2 does not have the capacity to provide "overload" as strength increases.

Electrical stimulation of muscle has been reported to result in significant strength gains in patients with weak muscle as well as in healthy human subjects (3, 5-7, 15, 19). Strength is operationally defined as "the maximal force (or torque) a muscle or muscle group can generate at a specified velocity" (10). Some investigators have reported that certain neuromuscular electrical stimulators (NMES) can be used to elicit muscle contractions measured to be greater than a subject's maximum voluntary isometric torque (MVIT) (1, 11, 12, 19). In select muscle groups, it has been demonstrated that humans are capable of voluntarily contracting all available motor units (1). Others commonly report that only 60-70% of

' Assistant Professor of Physical Therapy. Sargent College of Allied Health Professions. Boston University. Boston. MA 02215. Requests for reprints may be directed to Dr. Snyder-Mackler at this address. Staff physical therapist at the Rehab Hospital of Altoona, 2005 Valley View Blvd.. Altoona. PA 16003. Partner in Physical Therapy and Athletic Training Associates. Inc.. 2205 Forest H~lls Drive. Suite 10. Hanisburg. PA 17112.
0196-601 1/89/1008/0297$02.00/0 OF ORTHOPAED~C AND SPORTS PHYSICAL THERAPY THEJOURNAL Copyright 0 1989 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

available motor units can be activated during voluntary contraction (9, 13, 18). This variable ability to recruit motor units has been attributed to motivational differences, presence of external stimuli, individual level of training, familiarity with the instrumentation, pain tolerance, and muscle group. The relationship between intensity of training contraction and strength gains has not been unequivocally demonstrated, but, in studies where training contraction intensity was measured at each training session, increases in isometric strength were directly proportional to training contraction intensity (3, 19). Significant strength gains have been reported using contraction intensities of only 30-50% of each subject's MVlT (15, 21). In order for a stimulator to be used to augment strength, it must not only be capable of generating electrically elicited torque values equal to 30-50% of the subject's initial MVIT, but to be able to continue to produce 30-50% of the MVlT as the subject's strength increases. Thus, the overload principle of resistance training should hold for electrically stimulated "exercise" as well as for volitional exercise. That is, the stimulator must be capable of increasing the load on the muscle as strength increases in order for continued strength augmentation to occur.
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The torque-generating capabilities of commercially available NMES are of interest then in assessing their potential utility for augmenting strength. Kramer et at. (14), Walmsley et al. (23), Mohr et at. (17), and De Domenico and Strauss (4) tested the torque generating capabilities of a variety of stimulators with differing stimulus characteristics. They reported maximal tolerated contraction intensities of from 37-93% of MVIT. Although statistical analyses were largely inconclusive, a careful scrutiny of this literature suggests that the torque-generating capability of a stimulator is proportional to the phase charge (integrated currentltime plot of the waveform) of the stimulus (22). This study assessed the torque generating capabilities of three commercially available NMES in a relatively electrically naive sample. It was hypothesized that the torque generating capabilities of all three machines tested would be at least at levels that have been previously reported to be sufficient for training and that any differences among these would be attributable to the phase charge (Fig. 1) produced by each NMES.
METHODS Instrumentation

The Nemectrodyn 7 (NMES 2) delivers two different alternating currents and was set to provide currents of 4000 and 4050 Hz, which gives an amplitude modulation frequency of 50 beatslsec and a phase duration of 125 psec (Fig. 1).
Subjects

Twenty healthy adults111 male, 9 female), ranging in age from 21-40 (X = 28.7) and without a history of right lower extremity pathology, gave informed consent and were included in the study. Approximately threequarters of the subjects were electrically naive (i.e., not previously exposed to electrical stimulation.)
Procedure

The Electrostim 180-2 (Electrostim USA Ltd., 333 Hammes Ave., Joliet, IL 60435), the Chattanooga VMS (Chattanooga Corp, P.O. Box 4287, Chattanooga, TN 37405), and the Nemectrodyn 7 (Nemectron Medical Inc, 28069 Diaz Rd., Unit A, Temecula, CA 92390) electrical stimulators were used. The Electrostim 180-2 (NMES 1) delivers a 2500 Hz alternating current (200 psec phase duration) with a 10 msec:lO msec duty cycle, providing 50, 10 msec bursts of current per second (Fig. 1). The Chattanooga VMS (NMES 3) delivers a symmetrical biphasic square wave that was set at a frequency of 50 pulses per second (pps) and a phase duration of 200 psec (Fig. 1).

Each subject was assigned to be tested sequentially using the three NMES. All testing was performed in a single session. The subjects were positioned in an isokinetic dynamometer (CYBEX, Division of Lumex, Inc, 2100 Smithtown Ave., Ronkonkoma, NY 11779) with the backrest inclined to 70 and the right knee flexed to 60 (13). Stabilization was provided using the pelvic and thigh straps and the subjects were instructed to hold onto the side of the table during contractions (8). The axis of rotation of the dynamometer was aligned with the axis of the knee joint. The distal end of the shin pad was placed just proximal to the medial malleolus. The knee was fixed and the dynamometer speed selector was set at 0 Olsec. Cybex It@ dual-channel recorder was used to record undamped, peak torque for voluntary and electrically stimulated isometric contractions (20). A measure of each subject's maximum voluntary isometric torque (MVIT) was taken in order to serve as a baseline for comparison among the three electrical stimulators. Subjects were instructed (with verbal encouragement throughout the contraction) to extend the knee as forcefully as possible and hold for 10 sec. In order to ensure
NMES 3

NMES 2

Figure 1. Waveform shapes and phase durations for each NMES. NMES 1 represents the Electrostim 180-2; NMES 2 represents the Nemectrodyn 7; NMES 3 represents the Chattanooga VMS. 298

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that the maximum value was recorded, three trials were taken with a 2-minute rest period between each trial (2,16) and the highest value of the three trials peak torque was used as the MVIT. The three electrical muscle stimulators used in this study were designated as follows: the Electrostim 180-2 (NMES I ) , the Nemectrodyn 7 (NMES 2), and the Chattanooga VMS (NMES 3). The order of use of the three machines was then determined. Six possible orders of stimulation existed and the subjects were assigned to an order via a Latin Square. For NMES 1 and 3, two 3 inch x 5 inch electrodes were used. One of the electrodes was placed on the proximal anterior thigh just lateral to the femoral triangle; the other electrode was placed on the distal anteromedial thigh (Fig. 2). NMES 2 uses the interference of two different alternating current circuits and necessitates the use of four electrodes oriented so the currents intersect at or near the motor point of the muscle. Four 3 inch x 5 inch carbon electrodes were placed as shown in Figure 3. All electrodes were mounted on or within a sponge that had been soaked in water. The electrodes were secured in place with elastic straps. After placing the electrodes on the subject's

Figure 3. Electrode configuration of NMES 2 (Nemectrodyn 7).

thigh as described above, the subject was instructed to allow the NMES to produce the greatest muscle contraction possible within the subject's pain tolerance, (e.g., the maximum tolerated contraction or MTC). The subjects were instructed not to assist in the muscle contraction and to instruct the experimenter when the contraction level was intolerable. The machines were oriented so as to obscure the subject's view of the ampmeter. Each machine was used to produce two contractions of 10 sec duration with a minimum of 2 minutes rest between contractions (2, 16). The peak torque produced in each pair of trials was compared to each subject's MVIT.
DATA ANALYSIS The peak MTC for each NMES was expressed as a percentage of pretest MVIT and a one-way analysis of variance with one repeated measure was used to analyze these torque data. Duncan's post hoc tests were used to further distinguish among the groups. RESULTS
Figure 2. Electrode configuration of NMES. NMES 1 (Electrostim 180-2); NMES 3 (Chattanooga VMS). JOSPT February 1989

The mean %MVIT produced by NMES 2 (40.05%) was much lower than the other ma299

COMPARISON OF ELECTRICAL TORQUE

TABLE 1
Analysis of variance with one repeated measure for differences in %MVIT among stimulators

TABLE 2
Means and standard deviations for each stimulator
OhMVIT Machine

ii.
61.6 40.05 54.1

SD

NMES 1 NMES 2 NMES 3

32.04 21.84 27.85

chines and statistical analysis of the %MVIT each machine produced revealed that a difference existed among the groups ( p < 0.0001) Duncan's post hoc analysis revealed that NMES 2 produced significantly less torque than NMES 1 (t = 19.05, p c 0.01) and NMES 3 (t = 12.55, p < 0.05) and that there was no significant difference between torques produced by NMES 1 and NMES 3 (t = 6.50, NS). Statistical analysis and descriptive statistics are summarized in Tables 1 and 2.
DISCUSSION

The results of this study support the contention that, within the constraints of this study, the difference among the torque-generating capabilities of these three types of NMES is proportional to the phase charge. The mean %MVIT produced by NMES 2 was significantly less than the mean %MVIT of the other two machines. The pulse duration of NMES 2 is approximately half that of the other two stimulators and in all but three of the subjects, the maximum excursion of the amplitude potentiometer was obtained before intolerance was reached. In no case was the maximum excursion of the amplitude potentiometer permitted by subjects on either of the other two stimulators. There was extreme variability in the subjects' responses to the stimuli as demonstrated by the large standard deviations in Table 1. This variability has been noted in the past by others and explanations have included electrical naivete and pain tolerance (4). An ANOVA with one repeated measure of these data by trial, showed no significant difference in torque among trials. This would indicate that no stepwise adaptation to electrical stimulation with a resultant increase in tolerance to stimulation occurred over the six contractions. All three machines, when employed in the manner described, were capable of producing initial electrically stimulated %MVITs that have
300

been reported to be sufficient for augmenting muscle strength. However, the NMES 2 %MVIT of 48.55% is at the very low range of O/oMVIT that has been shown to increase isometric strength in healthy subjects. Also, the percentages reported in this study appear to approximate the maximum capability of NMES 2 as in all but three subjects, the maximal current output of the machine was tolerated. This suggests that NMES 2 would have a limited ability to produce the necessary "overload" as muscle strength increases. NMES 3 delivers considerably less total average current (22) and yet has a similar torquegenerating capability to NMES 1. (NMES 1 delivers 25 cycles for each pulse delivered by NMES 3 with no appreciable increase in torque generating capability.) It may not be necessary, therefore, to deliver the additional current generated by NMES 1. Therapists are faced daily with decisions about which types of devices to purchase and use. If the augmentation of muscle strength is a therapeutic goal, maximal torque generating capability of the device should be taken into consideration. The stimulator should be capable of generating at least 30-50% of the subject's MVlT throughout training. Clinically, the results of this study may be used to allow practitioners to choose among these types of currents based on their ability to produce desired treatment outcomes.

CONCLUSIONS

The authors conclude that there is a difference in the torque generating capabilities of the three machines tested: that the Nemectrodyn 7 (NMES 2) produced significantly less torque than either the Chattanooga VMS (NMES 3) or the Electrostim 180-2 (NMES 1). Although all machines produced initial torque values that have been demonstrated to be sufficient for training, the Nemectrodyn 7 appears to have limited capability of increasing electrically elicited torque values above initial values. Although the Electrostim 180-2 delivers significantly more total average current than the VMS, this has no significant effect on torque generating capability. It also appears that torque-generating capability varies directly with phase charge. 0
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COMPARISON OF ELECTRICAL TORQUE