ORIGINAL RESEARCH| Volume 102, ISSUE 12, P2385-2392, December 2021

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Pilot Study of Enhancing Cardiorespiratory Exercise Response in People With Advanced Multiple Sclerosis With Hybrid Functional Electrical Stimulation


      • Hybrid functional electrical stimulation (FES) exercise combines arm cranking with FES leg cycling.
      • Hybrid FES exercise has not previously been investigated in people with multiple sclerosis (MS).
      • FES intensity during hybrid FES exercise was sufficient to enhance aerobic response.
      • Regular hybrid FES exercise might improve aerobic fitness in people with advanced MS.



      To investigate through a pilot study the acute cardiorespiratory responses during functional electrical stimulation (FES) cycling, arm crank ergometry (ACE), and a combination of ACE and FES cycling (hybrid FES cycling) in people with advanced multiple sclerosis (MS) to provide preliminary guidance for effective aerobic exercise prescription.


      Acute repeated measures.


      Laboratory setting.


      Inclusion criteria was a diagnosis of MS, with Expanded Disability Status Scale (EDSS) 6.0-8.5. Included were 9 participants (N=9; 7 female, age 54.7±8.8y, EDSS 7.2±0.7).


      Participants were assessed on 3 different exercise modalities (FES cycling, ACE, hybrid FES cycling) at 40%, 60%, 80%, and 100% of mode-specific peak workload.

      Main Outcome Measures

      Oxygen consumption and heart rate were measured at each workload.


      Hybrid FES cycling evoked a significantly higher oxygen consumption relative to body weight (V̇o2relative) (mL/kg/min) and heart rate (beats per minute [BPM]) at most workloads compared with ACE or FES cycling. At the 100% workload, heart rate for hybrid FES cycling was 125 BPM (range, 113-148 BPM) and was significantly higher than ACE at 99 BPM (range, 95-119 BPM) (P=.008) and FES cycling at 94 BPM (range, 79-100 BPM) (P=.008). Similarly, at the 100% workload, V̇o2relative for hybrid FES cycling was 11.8 mL/kg/min (range, 7.6-17.6 mL/kg/min) and was significantly higher than ACE at 8.9 mL/kg/min (range, 5.3-12.5 mL/kg/min) (P=.012) and FES cycling at 6.8 mL/kg/min (range, 4.1-9.2 mL/kg/min) (P=.012).


      This pilot study showed that hybrid FES cycling can elicit a greater cardiorespiratory response than ACE or FES cycling in people with advanced MS. Thus, hybrid FES cycling might provide a potent enough stimulus to induce clinically relevant changes in cardiorespiratory fitness. Training studies are warranted to document the magnitude and sustainability of aerobic capacity adaptations to hybrid FES cycling and associated health outcomes in advanced MS.


      List of abbreviations:

      ACE (arm crank ergometry), BPM (beats per minute), EDSS (Expanded Disability Status Scale), FES (functional electrical stimulation), MS (multiple sclerosis), RPM (revolutions per minute), V̇o2 (oxygen consumption), V̇o2max (maximum oxygen consumption), V̇o2relative (oxygen consumption relative to body weight)
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        • Compston A
        • Coles A.
        Multiple sclerosis.
        Lancet. 2008; 372: 1502-1517
        • Kurtzke JF.
        Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).
        Neurology. 1983; 33: 1444-1452
        • Stuifbergen AK.
        Physical activity and perceived health status in persons with multiple sclerosis.
        J Neurosci Nurs. 1997; 29: 238-243
        • Motl RW
        • McAuley E
        • Snook EM.
        Physical activity and multiple sclerosis: a meta-analysis.
        Mult Scler. 2005; 11: 459-463
        • Wens I
        • Eijnde BO
        • Hansen D.
        Muscular, cardiac, ventilatory and metabolic dysfunction in patients with multiple sclerosis: implications for screening, clinical care and endurance and resistance exercise therapy, a scoping review.
        J Neurol Sci. 2016; 367: 107-121
        • Heine M
        • Wens I
        • Langeskov-Christensen M
        • et al.
        Cardiopulmonary fitness is related to disease severity in multiple sclerosis.
        Mult Scler J. 2016; 22: 231-238
        • Marrie RA
        • Hanwell H.
        General health issues in multiple sclerosis: comorbidities, secondary conditions, and health behaviors.
        Continuum (Minneap Minn). 2013; 19: 1046-1057
        • Jadidi E
        • Mohammadi M
        • Moradi T.
        High risk of cardiovascular diseases after diagnosis of multiple sclerosis.
        Mult Scler J. 2013; 19: 1336-1340
        • American College of Sports Medicine
        Riebe D Ehrman JK Liguori G Magal M ACSM's guidelines for exercise testing and prescription. 10 edition. Wolters Kluwer, Philadelphia2018
        • Langeskov-Christensen M
        • Heine M
        • Kwakkel G
        • Dalgas U.
        Aerobic capacity in persons with multiple sclerosis: a systematic review and meta-analysis.
        Sports Med. 2015; 45: 905-923
        • Toomey E
        • Coote SB.
        Physical rehabilitation interventions in nonambulatory people with multiple sclerosis: a systematic review.
        Int J Rehabil Res. 2012; 35: 281-291
        • Dalgas U
        • Stenager E
        • Ingemann-Hansen T.
        Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training.
        Mult Scler. 2008; 14: 35-53
        • Smith C
        • Hale L.
        Arm cranking: an exercise intervention for a severely disabled adult with multiple sclerosis.
        N Z J Physiother. 2006; 34: 172-178
        • Snyder KJ
        • Patsakos E
        • White J
        • Ditor DS.
        Accessible exercise equipment and individuals with multiple sclerosis: aerobic demands and preferences.
        NeuroRehabilitation. 2019; 45: 359-367
        • Skjerbaek AG
        • Naesby M
        • Lutzen K
        • et al.
        Endurance training is feasible in severely disabled patients with progressive multiple sclerosis.
        Mult Scler J. 2014; 20: 627-630
        • Pilutti LA
        • Paulseth JE
        • Dove C
        • Jiang S
        • Rathbone MP
        • Hicks AL.
        Exercise training in progressive multiple sclerosis: a comparison of recumbent stepping and body weight-supported treadmill training.
        Int J MS Care. 2016; 18: 221-229
        • Fornusek C
        • Hoang P.
        Neuromuscular electrical stimulation cycling exercise for persons with advanced multiple sclerosis.
        J Rehabil Med. 2014; 46: 698-702
        • Fornusek C
        • Ektas N
        • Hasnan N.
        Cardiorespiratory metabolism during voluntary and electrical stimulation cycling in persons with advanced multiple sclerosis.
        in: 2014 IEEE 19th International Functional Electrical Stimulation Society Annual Conference (IFESS). IEEE, Kuala Lumpur, Malaysia2014: 1-4
        • Petrofsky JS
        • Phillips CA.
        The use of functional electrical stimulation for rehabilitation of spinal cord injured patients.
        Centr Nerv Syst Trauma. 1984; 1: 57-74
        • Fornusek C
        • Davis GM
        • Sinclair PJ
        • Milthorpe B.
        Development of an isokinetic functional electrical stimulation cycle ergometer.
        Neuromodulation. 2004; 7: 56-64
        • Scally JB
        • Baker JS
        • Rankin J
        • Renfrew L
        • Sculthorpe N.
        Evaluating functional electrical stimulation (FES) cycling on cardiovascular, musculoskeletal and functional outcomes in adults with multiple sclerosis and mobility impairment: a systematic review.
        Mult Scler Relat Disord. 2020; 37101485
        • Hasnan N
        • Ektas N
        • Tanhoffer AIP
        • et al.
        Exercise responses during functional electrical stimulation cycling in individuals with spinal cord injury.
        Med Sci Sports Exerc. 2013; 45: 1131-1138
        • Verellen J
        • Vanlandewijck Y
        • Andrews B
        • Wheeler GD.
        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
        • Raymond MJ
        • Davis RG
        • Climstein RM
        • Sutton RJ.
        Cardiorespiratory responses to arm cranking and electrical stimulation leg cycling in people with paraplegia.
        Med Sci Sports Exerc. 1999; 31: 822-828
        • Edwards T
        • Motl RW
        • Pilutti LA.
        Cardiorespiratory demand of acute voluntary cycling with functional electrical stimulation in individuals with multiple sclerosis with severe mobility impairment.
        Appl Physiol Nutr Metab. 2018; 43: 71-76
        • Latimer-Cheung AE
        • Martin Ginis KA
        • Hicks AL
        • et al.
        Development of evidence-informed physical activity guidelines for adults with multiple sclerosis.
        Arch Phys Med Rehabil. 2013; 94: 1829-1836
        • Edwards T
        • Pilutti LA.
        The effect of exercise training in adults with multiple sclerosis with severe mobility disability: a systematic review and future research directions.
        Mult Scler Relat Disord. 2017; 16: 31-39
        • Kalb R
        • Brown TR
        • Coote S
        • et al.
        Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course.
        Mult Scler. 2020; 26: 1459-1469
        • Fornusek C
        • Gwinn TH
        • Heard R.
        Cardiorespiratory responses during functional electrical stimulation cycling and electrical stimulation isometric exercise.
        Spinal Cord. 2014; 52: 635
        • Krause P
        • Szecsi J
        • Straube A.
        FES cycling reduces spastic muscle tone in a patient with multiple sclerosis.
        NeuroRehabilitation. 2007; 22: 335-337
        • Szecsi J
        • Schlick C
        • Schiller M
        • Pollmann W
        • Koenig N
        • Straube A.
        Functional electrical stimulation-assisted cycling of patients with multiple sclerosis: biomechanical and functional outcome - a pilot study.
        J Rehabil Med. 2009; 41: 674-680
        • Edwards T
        • Motl RW
        • Sebastião E
        • Pilutti LA.
        Pilot randomized controlled trial of functional electrical stimulation cycling exercise in people with multiple sclerosis with mobility disability.
        Mult Scler Relat Disord. 2018; 26: 103-111
        • Ratchford JN
        • Shore W
        • Hammond ER
        • et al.
        A pilot study of functional electrical stimulation cycling in progressive multiple sclerosis.
        NeuroRehabilitation. 2010; 27: 121-128
        • Sterman BA
        • Coyle KP
        • Panasci JD
        • Grimson JR.
        Disseminated abnormalities of cardiovascular autonomic functions in multiple sclerosis.
        Neurology. 1985; 35: 1665-1668
        • Sandroff BM
        • Bollaert RE
        • Pilutti LA
        • et al.
        Multimodal exercise training in multiple sclerosis: a randomized controlled trial in persons with substantial mobility disability.
        Contemp Clin Trials. 2017; 61: 39-47