Original article| Volume 93, ISSUE 11, P1930-1936, November 2012

Stimulation of Shank Muscles During Functional Electrical Stimulation Cycling Increases Ankle Excursion in Individuals With Spinal Cord Injury

  • Ché Fornusek
    Correspondence to Ché Fornusek, PhD, Clinical Exercise Rehabilitation Unit, Room 103, Building C, Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales 1824, Australia
    Clinical Exercise and Rehabilitation Unit, Exercise Health and Performance Research Group, The University of Sydney, Sydney, Australia
    Search for articles by this author
  • Glen M. Davis
    Clinical Exercise and Rehabilitation Unit, Exercise Health and Performance Research Group, The University of Sydney, Sydney, Australia
    Search for articles by this author
  • Ilhun Baek
    Clinical Exercise and Rehabilitation Unit, Exercise Health and Performance Research Group, The University of Sydney, Sydney, Australia
    Search for articles by this author


      Fornusek C, Davis GM, Baek I. Stimulation of shank muscles during functional electrical stimulation cycling increases ankle excursion in individuals with spinal cord injury.


      To investigate the effect of shank muscle stimulation on ankle joint excursion during passive and functional electrical stimulation (FES) leg cycling.


      Within-subject comparisons.


      Laboratory setting.


      Well-trained FES cyclists (N=7) with chronic spinal cord injuries.


      Two experimental sessions were performed on an isokinetic FES cycle ergometer with a pedal boot that allowed the ankle to plantarflex and dorsiflex during cycling. During the first session, the optimal stimulation timings to induce plantarflexion and dorsiflexion were investigated by systematically altering the stimulation angles of the shank muscles (tibialis anterior [TA] and triceps surae [TS]). During the second session, TA and TS stimulation was included with standard FES cycling (quadriceps, hamstrings, and gluteals) for 6 subjects.

      Main Outcome Measures

      Ankle, knee, and hip movements were analyzed using 2-dimensional video.


      The ankle excursions during passive cycling were 19°±6°. TA and TS stimulation increased ankle joint excursion up to 33°±10° and 27°±7°, respectively. Compared with passive cycling, ankle joint excursion was not significantly increased during standard FES cycling (24°±7°). TA and TS stimulation significantly increased the ankle excursion when applied during standard FES cycling (41°±4°).


      Freeing the ankle joint to rotate during FES cycling was found to be safe. The combination of shank muscle stimulation and repetitive ankle joint movement may be beneficial for improving ankle flexibility and leg conditioning. Further research is required to test and design ankle supports that might maximize the benefits of shank muscle activation.

      Key Words

      List of Abbreviations:

      ASIA (American Spinal Injury Association), FES (functional electrical stimulation), ROM (range of motion), SCI (spinal cord injury), TA (tibialis anterior), TS (triceps surae)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Petrofsky J.S.
        • Phillips C.A.
        • Heaton III, H.H.
        • Glaser R.
        Bicycle ergometer for paralyzed muscle.
        J Clin Eng. 1984; 9: 13-19
        • Fornusek C.
        • Davis G.M.
        Technical design of a novel isokinetic FES bicycle for spinal cord injured individuals.
        J Rehabil Res Dev. 2004; 41: S53
        • Davis G.M.
        Exercise capacity of individuals with paraplegia.
        Med Sci Sports Exerc. 1993; 25: 423-432
        • Davis G.M.
        • Hamzaid N.A.
        • Fornusek C.
        Cardiorespiratory, metabolic, and biomechanical responses during functional electrical stimulation leg exercise: health and fitness benefits.
        Artif Organs. 2008; 32: 625-629
        • Peng C.-W.
        • Chen S.-C.
        • Lai C.-H.
        • et al.
        Review: clinical benefits of functional electrical stimulation cycling exercise for subjects with central neurological impairments.
        J Med Biol Eng. 2011; 31: 1-11
        • Eser P.C.
        • Donaldson N.
        • Knecht H.
        • Stussi E.
        Influence of different stimulation frequencies on power output and fatigue during FES-cycling in recently injured SCI people.
        IEEE Trans Neural Syst Rehabil Eng. 2003; 11: 236-240
        • Janssen T.
        • Glaser R.
        • Almeyda J.
        • Pringle D.
        • Matthews T.
        Improving FES-leg cycle ergometer performance in individuals who have plateaued during long-term training.
        in: Proceedings of the RESNA '96 Proceedings, 1996 June 7-12; Salt Lake City (Utah) RESNA Press, Arlington1996: 112
        • Figoni S.F.
        • Rodgers M.M.
        • Glaser R.M.
        Effects of electrical stimulation of shank musculature during ES-leg cycle ergometry.
        Med Sci Sports Exerc. 1994; 26: S77
        • Harridge S.D.
        • Andersen J.L.
        • Hartkopp A.
        • et al.
        Training by low-frequency stimulation of tibialis anterior in spinal cord-injured men.
        Muscle Nerve. 2002; 25: 685-694
        • Bittar C.K.
        • Cliquet Jr, A.
        Effects of quadriceps and anterior tibial muscles electrical stimulation on the feet and ankles of patients with spinal cord injuries.
        Spinal Cord. 2010; 48: 881-885
        • Grover J.
        • Gellman H.
        • Waters R.L.
        The effect of a flexion contracture of the elbow on the ability to transfer in patients who have quadriplegia at the sixth cervical level.
        J Bone Joint Surg Am. 1996; 78: 1397-1400
        • McDonald M.F.
        • Kevin Garrison M.
        • Schmit B.D.
        Length-tension properties of ankle muscles in chronic human spinal cord injury.
        J Biomech. 2005; 38: 2344-2353
        • Ben M.
        • Harvey L.
        • Denis S.
        • et al.
        Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries?.
        Aust J Physiother. 2005; 51: 251-256
        • Harvey L.A.
        • Herbert R.D.
        • Glinsky J.
        • Moseley A.M.
        • Bowden J.
        Effects of 6 months of regular passive movements on ankle joint mobility in people with spinal cord injury: a randomized controlled trial.
        Spinal Cord. 2009; 47: 62-66
        • Trumbower R.D.
        • Faghri P.D.
        Kinematic analyses of semireclined leg cycling in able-bodied and spinal cord injured individuals.
        Spinal Cord. 2005; 43: 543-549
        • Fornusek C.
        • Davis G.M.
        • Sinclair P.
        • Milthorpe B.
        Development of an isokinetic functional electrical stimulation cycle ergometer.
        Neurology. 2004; 7: 56-64
        • Hakansson N.A.
        • Hull M.L.
        The effects of stimulating lower leg muscles on the mechanical work and metabolic response in functional electrically stimulated pedaling.
        IEEE Trans Neural Syst Rehabil Eng. 2010; 18: 498-504
        • van Soest A.J.
        • Gfohler M.
        • Casius L.J.
        Consequences of ankle joint fixation on FES cycling power output: a simulation study.
        Med Sci Sports Exerc. 2005; 37: 797-806
        • Verellen J.
        • Vanlandewijck Y.
        • Andrews B.
        • Wheeler G.D.
        Cardiorespiratory responses during arm ergometry, functional electrical stimulation cycling, and two hybrid exercise conditions in spinal cord injured.
        Disabil Rehabil Assist Technol. 2007; 2: 127-132
        • Stoner L.
        • Sabatier M.J.
        • Mahoney E.T.
        • Dudley G.A.
        • McCully K.K.
        Electrical stimulation-evoked resistance exercise therapy improves arterial health after chronic spinal cord injury.
        Spinal Cord. 2007; 45: 49-56
        • Harvey L.A.
        • Glinsky J.A.
        • Katalinic O.M.
        • Ben M.
        Contracture management for people with spinal cord injuries.
        NeuroRehabilitation. 2011; 28: 17-20
        • Betz R.
        • Boden B.
        • Triolo R.
        • Mesgarzadeh M.
        • Gardner E.
        • Fife R.
        Effects of functional electrical stimulation on the joints of adolescents with spinal cord injury.
        Paraplegia. 1996; 34: 127-136
        • Akeson W.H.
        • Amiel D.
        • Mechanic G.L.
        • Woo S.L.
        • Harwood F.L.
        • Hamer M.L.
        Collagen cross-linking alterations in joint contractures: changes in the reducible cross-links in periarticular connective tissue collagen after nine weeks of immobilization.
        Connect Tissue Res. 1977; 5: 15-19
        • Friden J.
        • Lieber R.L.
        Spastic muscle cells are shorter and stiffer than normal cells.
        Muscle Nerve. 2003; 27: 157-164
        • van der Salm A.
        • Veltink P.H.
        • Ijzerman M.J.
        • Groothuis-Oudshoorn K.C.
        • Nene A.V.
        • Hermens H.J.
        Comparison of electric stimulation methods for reduction of triceps surae spasticity in spinal cord injury.
        Arch Phys Med Rehabil. 2006; 87: 222-228
        • Krause P.
        • Szecsi J.
        • Straube A.
        Changes in spastic muscle tone increase in patients with spinal cord injury using functional electrical stimulation and passive leg movements.
        Clin Rehabil. 2008; 22: 627-634
        • Kiser T.S.
        • Reese N.B.
        • Maresh T.
        • et al.
        Use of a motorized bicycle exercise trainer to normalize frequency-dependent habituation of the H-reflex in spinal cord injury.
        J Spinal Cord Med. 2005; 28: 241-245
        • Morrissey M.C.
        • Harman E.A.
        • Johnson M.J.
        Resistance training modes: specificity and effectiveness.
        Med Sci Sports Exerc. 1995; 27: 648-660
        • Shields R.K.
        • Dudley-Javoroski S.
        Musculoskeletal plasticity after acute spinal cord injury: effects of long-term neuromuscular electrical stimulation training.
        J Neurophysiol. 2006; 95: 2380-2390
        • Shields R.K.
        • Dudley-Javoroski S.
        • Law L.A.
        Electrically induced muscle contractions influence bone density decline after spinal cord injury.
        Spine. 2006; 31: 548-553
        • Belanger M.
        • Stein R.B.
        • Wheeler G.D.
        • Gordon T.
        • Leduc B.
        Electrical stimulation: can it increase muscle strength and reverse osteopenia in spinal cord injured individuals?.
        Arch Phys Med Rehabil. 2000; 81: 1090-1098
        • Crameri R.M.
        • Cooper P.
        • Sinclair P.J.
        • Bryant G.
        • Weston A.
        Effect of load during electrical stimulation training in spinal cord injury.
        Muscle Nerve. 2004; 29: 104-111
        • Sirinopakul V.
        Design and validation of a lower leg support to promote ankle joint flexibility during functional electrical stimulation cycling exercise.
        ([honours thesis]) University of Sydney, 2010
        • Janssen T.W.
        • Pringle D.D.
        Effects of modified electrical stimulation-induced leg cycle ergometer training for individuals with spinal cord injury.
        J Rehabil Res Dev. 2008; 45: 819-830