Keith R. Cole, Shauna Dudley-Javoroski, Richard K. Shields

Objective After spinal cord injury (SCI), hybrid stimulation patterns that interpose paired-pulse doublets over a constant-frequency background may enhance the metabolic "work" (muscle torque) performed by paralyzed muscle. This study examined the effect of background stimulation frequency on the torque contribution of the doublet before and after fatigue. Design Cross-sectional study. Setting Research laboratory in an academic medical center. Participants Five men with chronic sensory and motor-complete SCI and ten non-SCI controls (6 males, 4 females). SCI subjects were recruited from a long-term study of unilateral plantar-flexor training; both limbs were tested for the present study. Interventions Subjects underwent plantar flexor stimulation at 5, 7, 9, and 12 Hz. The four background frequencies were overlaid with 6 ms doublets delivered at the start, middle, or at both the start and middle of each train. The 5 Hz and 12 Hz frequencies were analyzed after fatigue. Outcome Measures Mean torque, peak torque, torque fusion index, doublet torque. Results Trains with doublets at both the start and middle yielded the most consistent enhancement of torque (all P < 0.028). Torque contribution of the doublet was greatest at low stimulus frequencies (all P < 0.016). The low relative fusion of untrained paralyzed muscle preserved the efficacy of the doublet even during fatigue. Conclusion Hybrid stimulus trains may be an effective way to increase contractile work in paralyzed muscle, even after fatigue. They may be useful for rehabilitation strategies designed to enhance the metabolic work performed by paralyzed skeletal muscle.