Optimisation of a neuromuscular electrical stimulation paradigm for targeted strengthening of an intrinsic foot muscle

The intrinsic foot muscles stabilise and stiffen the foot during posture and locomotion. Since they are placed under continued load, these muscles merit training to meet the weight-bearing demands of everyday activities. Their strengthening is however a largely neglected area and furthermore, the occurrence of common foot-related pathologies is associated with their dysfunction. Indeed, atrophy and dysfunction of the strongest intrinsic foot muscle, abductor hallucis (AbH), is symptomatic to pes planus and Hallux Valgus. AbH’s oblique mechanical action along with an inability for its voluntary activation in many individuals limits the strengthening capacity of existing training modalities. Due to the superficial location of AbH, neuromuscular electrical stimulation (NMES) offers a solution to this problem; however, its efficacy for muscle strength gains relies on high stimulation-intensity protocols, which are uncomfortable and limit participant adherence. Therefore, the purpose of this thesis was to develop an optimised NMES paradigm that is tolerable and efficacious for a targeted strengthening intervention of AbH.
The studies reported in this thesis were undertaken with the overarching aim to systematically establish a tolerable and low stimulation-intensity NMES paradigm to train AbH. With this motivation in mind, four sequential experimental studies were designed to identify the optimal mode of NMES application (muscle vs nerve) and stimulation pulse duration (Chapter 3), pulse frequency and train duration (Chapter 4), training stimulus intensity (Chapter 5), and duty-cycle (Chapter 6), respectively. A major finding from the work undertaken in this thesis was the prevalent inability to voluntary activate AbH that exists in healthy participants. Since this inability also limits the measurement of voluntary force generation following an intervention, this thesis also developed a methodological
approach that overcomes this limitation. Collectively, the studies in this thesis demonstrated that NMES successfully evokes contractions from AbH irrespective of ability for its voluntary activation and can therefore be used as a training modality. The optimised NMES paradigm presented in this thesis targets the motor point of AbH using 22s-trains of 1ms pulses at 20-100-20Hz with an intensity of 200% motor threshold and a 1:4 duty-cycle. This wide-pulse, high-frequency, low-intensity paradigm promotes adherence and has the potential to depolarise sensory axons due to their lower rheobase, and evoke contractions with a contribution of the central nervous system.
When delivered using long trains and an alternating frequency pattern, it can take advantage of post-tetanic potentiation to produce force, which is then preserved across trains using a duty-cycle with long rest periods.
This thesis intended to bind the aforementioned experimental chapters together with a final chapter investigating the effectiveness of the developed NMES paradigm instrengthening AbH following long-term exposure. However, the implementation of this study was not possible in light of the COVID-19 pandemic and is therefore not reportedin this thesis. Nevertheless, future work in this area can benefit from the extensive methodological work undertaken in this thesis and implement a longitudinal study to better understand the clinical implications for targeted AbH strengthening via NMES.