EQUINE VETERINARY JOURNAL
Equine vet. J. (2010) 42 (Suppl. 38) 671-675
doi: 10.1111/j.2042-3306.2010.00180.x
Evaluation of neuromuscular electrical stimulation on fibre
characteristics and oxidative capacity in equine
skeletal muscles evj_180 671..675
A. BERGH*, H. NORDLÖF† and B. ESSÉN-GUSTAVSSON‡
Departments of Anatomy, Physiology and Biochemistry and Department of Animal Environment and Health, and ‡Department of Clinical
Sciences, Swedish University of Agricultural Sciences, Sweden; and †Department of Community Medicine and Rehabilitation, Umeå
University, Sweden.
Keywords: horse; fibre type; fibre area; glycogen; enzyme activity; rehabilitation
Summary
Reasons for performing study: Neuromuscular electrical
stimulation (NMES) is used to increase or maintain muscle
strength during rehabilitation. Human studies investigating
different protocols show that some treatments induce changes
in muscle characteristics. Despite the frequent use of NMES in
horses, no studies have been published describing its efficacy.
Objectives: To investigate the effects of a NMES protocol on
equine fibre types and areas, glycogen concentrations and
enzyme activities.
Methods: NMES was administrated to m. gluteus medius and
m. longissimus dorsi, on one side of 6 healthy Standardbred
horses. The contralateral side of each muscle served as a
nonstimulated control. The horses were stimulated at 50 Hz a
day, with 21–39 mA, for 45–60 min, 5 days a week for 4 weeks.
Needle biopsies were obtained from the muscles on both sides
before and after the experimental period. Muscle samples
were analysed for fibre type proportions and area using
histochemical methods and for glycogen and enzyme activities
(citrate synthase, 3-OH-acyl CoA dehydrogenase, hexokinase
and lactate dehydrogenase) using biochemical methods.
Muscle contractions at the location and depth of the muscle
biopsy were confirmed by diagnostic ultrasound.
Nonparametric tests (Mann-Whitney, Wilcoxon sign-rank)
were used for statistical analysis.
Results: No significant differences were observed in
the percentage of types I, IIA or IIX fibres, fibre areas,
glycogen levels or enzyme activities either when comparing
stimulated and nonstimulated muscles before and after the
NMES treatment, or when comparing the left and right
muscle samples.
Conclusions: The NMES treatment was well tolerated by
the horses, but the present protocol did not induce significant
muscle adaptations. Further studies are needed to describe
the effect of more intense and/or prolonged NMES
treatment protocols on muscles of healthy horses, and to
describe if stimulation protocols induce positive changes in
atrophied muscles.
*Corresponding author email: Anna.Bergh@afb.slu.se
[Paper received for publication 08.01.10; Accepted 30.05.10]
671
Introduction
Physical rehabilitation of equine musculoskeletal injuries is an
expanding field (McGowan et al. 2007). Methods used in man are
often extrapolated to veterinary medicine without sufficient
scientific evidence of their effects. One modality used is
neuromuscular electrical stimulation (NMES), where electrodes
are placed on the skin and contractions in the muscle are produced
by electrical stimulation (Lake 1992). With NMES, it is possible to
induce contraction patterns different from those during voluntary
contraction (Delitto and Snyder-Mackler 1990). It is generally
accepted that NMES first recruits force-producing type II muscle
fibres and then type I fibres, which is the reverse of the muscle
recruitment pattern in a voluntary contraction (Hainaut and
Duchateau 1992; Requena-Sánchez et al. 2005).
The main purpose of using NMES is to improve the maximal
voluntary strength of weakened and/or healthy muscles. Human
reviews report increased muscle strength due to NMES in athletic
training, training during immobilisation and pathology treatments
(Laughman et al. 1983; Gibson et al. 1988; Wigerstad-Lossing
et al. 1988; Hainaut and Duchateau 1992; Parker et al. 2003;
Gondin et al. 2006; Herrero et al. 2006; Colson et al. 2009). It can
be concluded that the effect of NMES on healthy subjects is equal
to but not superior to voluntary strength training, that the protocols
that associate electrostimulation with voluntary muscle
contractions seem to have more effect than electrostimulation
alone, and that NMES is effective in reducing muscle wasting
during immobilisation (Bax et al. 2005; Requena-Sánchez et al.
2005; Vanderthommen and Duchateau 2007). In man, NMES has
been shown to cause fibre type changes towards fewer fast
contracting type II fibres, increased cross-sectional area and
increased citrate synthase (CS) activity indicating a higher
oxidative capacity in the muscle (Gauthier et al. 1992; Thériault
et al. 1994; Pérez et al. 2002; Nuhr et al. 2003, 2004; Del Corso
et al. 2007). The above results are contradicted by other human
studies where no significant differences in muscle strength, muscle
mass, fibre types or CS activity were seen after electrical
stimulation (Eriksson et al. 1981; Arvidsson et al. 1986; Suetta
et al. 2004, 2008).
© 2010 EVJ Ltd
672 Effect of NMES on horses

TABLE 1: Amperage interval (mA) for the horses at the beginning and the end of the weeks of (NMES) neuromuscular electrical stimulation treatment

Week 1 Week 2 Week 3 Week 4

Start End Start End Start End Start End

Mean Range Mean Range Mean Range Mean Range Mean Range Mean Range Mean Range Mean Range

M. gluteus 25 28.5 29 33 33.5 34.5 33.5 36

medius 22.5–28 27–30.5 28–30.5 32–34.5 32–35 32.5–36 31.5–36 34.5–39
M. longissimus 22.5 26.5 27 31.5 31.5 32 32 34
dorsi 21–24 25.5–28 26.5–28 30–32.5 30.5–32.5 30.5–34 30.5–33 32.5–36

To the best of our knowledge, there is nothing reported in the
literature on NMES and its effect on horse muscle tissue. Changes
in strength cannot be measured directly in horses as in man, but
alterations in muscle histochemical and fibre type properties can be
studied with the muscle biopsy technique. Therefore, the aim of
present study was to use this technique to investigate if a NMES
protocol has any effect on muscle characteristics in healthy
untrained horses.
Materials and methods
Horses and environment
The study comprised 6 healthy Standardbred trotters (3 mares and
3 geldings), with a mean age of 6 years (range 4–13 years) and a
mean weight of 471 kg (range 420–492 kg). During the treatment
period, the horses were out on pasture for 4–5 h/day. The
experiments were approved by the Ethical Committee on Animal
Experiments in Uppsala, Sweden.
Muscles
The muscles chosen for stimulation were m. gluteus medius and m.
longissimus dorsi on one side, while the muscles on the other side
did not receive any intervention and thereby served as within-
subject controls.
Equipment
Neuromuscular electrical stimulation was performed with the
1
muscle stimulator CEFAR MYO . The electrodes were 50 ¥
100 mm carbon-impregnated rubber electrodes1. Blue Gel1 was
used to create good contact between the electrode and the skin.
Electrode placement: After identifying the motor points (the area
where the motor nerve enters the muscle), the positions of the 4
electrodes (2 for each muscle) were shaved to improve the
contact between the electrodes and the skin and to assist the
investigator in finding the motor point during subsequent
stimulation sessions.
Stimulation protocol: The horses were stimulated once a day,
between 45 and 60 min, 5 days a week for 4 weeks. Both muscles
were stimulated simultaneously. The number of contractions was
increased from 3 ¥ 10 during week 1, 3 ¥ 15 during weeks 2 and 3,
to 3 ¥ 20 contractions week 4. There was a two-minute rest between
the sets of contractions. The stimulation was a biphasic rectangular
pulse form with a frequency of 50 Hz and with a pulse width set to
300 ms. The protocol included a 3 s rise to the full contraction,
© 2010 EVJ Ltd
which was held for 10 s followed by a 2 s decrease to 0 mA. The
total stimulation time was therefore 15 s. In order to achieve a
comparable degree of muscle contraction, the stimulation current
was set individually for each horse (Table 1) with such intensity
that it produced an obvious visual and palpable contraction in the
muscle, without any apparent discomfort for the horse.
Muscle biopsies: Muscle biopsies (Lindholm and Piehl 1974)
were performed with a Bergström biopsy needle2 (external
diameter 5 mm). Biopsy samples were taken by the same
investigator from both the stimulated and nonstimulated m.
gluteus medius and m. longissimus dorsi before and after the
treatment period, at a site halfway between the 2 electrodes for
each muscle. The biopsy needle was inserted to a depth of
4–5 cm and the collected muscle sample was frozen in liquid
nitrogen and then stored at -80°C until analysed. The muscle
sample for histochemical analysis was rolled in talcum powder
before being frozen in liquid nitrogen.
Histochemical analysis: Transverse serial sections (10 mm) of
muscle biopsy specimen were cut in a cryostat at -20°C. These
sections were stained for myosin ATPase after both acid (pH 4.3
and 4.6) and alkaline (pH 10.3) pre-incubation. Muscle fibres were
identified as type I, type II A, type II B or type II C (Brooke and
Kaiser 1970; Essén et al. 1980). Type I fibres stained black, type II
A fibres white and type II B fibres grey or brown after pre-
incubation at pH 4.6. Type II C fibres stained black or grey after
pre-incubation at pH 4.3, 4.6 and 10.3. Type II B fibres identified
with the ATPase staining method will be called type II X fibres in
the present study. The reason for this is to not confuse with the
nomenclature used when 4 fibre types are identified due to different
MHC isoforms (MHCI, MHCIIA, MHCIIX, MHCIIB). Since
MHCIIB fibres, which are expressed in small mammals, do not
exist in horse muscle type II B fibres are more related to MHCIIX
fibres (Rivero and Serrano 1999).
Muscle composition was determined by typing at least 200
fibres. In a few cases, the samples contained a lower number of
fibres (the range was 125–286 fibres). In a computerised image
analysis system (BIO-RAD)3, fibre type distribution (%) and mean
fibre type area (mm2) for each fibre type were investigated. All
measurements were carried out blind, and the codes were broken
only after collection of all the data.
Biochemical analysis: Whole muscle biochemical analyses were
performed on freeze-dried muscle, weighing 1–3 mg, after blood,
fat and connective tissues had been dissected free under a
microscope. One muscle sample was homogenised in ice cooled
0.1 mol/l phosphate buffer at pH 7.3 and the activities of
citrate synthase (CS), 3-OH-acyl-CoA-dehydrogenase (HAD),
hexokinase (HK) and lactate dehydrogenase (LDH) were analysed
A. Bergh et al. 673

TABLE 2: Mean ⫾ s.d. for fibre type composition and fibre type areas in m. gluteus medius and m. longissimus dorsi of 6 horses without (control) and
with (NMES) neuromuscular electrical stimulation for 4 weeks

M. gluteus medius M. longissimus dorsi

Before After 4 weeks Before After 4 weeks

Fibre type (%)

I
Control 14 ⫾ 5 13 ⫾ 2 20 ⫾ 5 18 ⫾ 3
NMES 17 ⫾ 5 15 ⫾ 7 21 ⫾ 2 20 ⫾ 3
II A
Control 42 ⫾ 3 43 ⫾ 4 41 ⫾ 3 40 ⫾ 4
NMES 42 ⫾ 8 43 ⫾ 8 43 ⫾ 6 42 ⫾ 6
II X
Control 44 ⫾ 6 44 ⫾ 3 39 ⫾ 4 42 ⫾ 4
NMES 41 ⫾ 10 42 ⫾ 9 36 ⫾ 6 38 ⫾ 5
Fibre area (mm2)
I
Control 2190 ⫾ 457 2075 ⫾ 709 2690 ⫾ 716 2725 ⫾ 841
NMES 2014 ⫾ 339 1787 ⫾ 575 2733 ⫾ 391 2611 ⫾ 327
II A
Control 2635 ⫾ 392 2430 ⫾ 755 2866 ⫾ 623 2786 ⫾ 584
NMES 2772 ⫾ 316 2138 ⫾ 419 2962 ⫾ 470 2999 ⫾ 476
II X
Control 4494 ⫾ 673 4476 ⫾ 1265 5057 ⫾ 1714 5161 ⫾ 984
NMES 4552 ⫾ 1155 3622 ⫾ 1076 5465 ⫾ 989 5357 ⫾ 594
Mean area (mm2)
Control 3446 ⫾ 505 3389 ⫾ 896 3654 ⫾ 922 3799 ⫾ 840
NMES 3436 ⫾ 404 2735 ⫾ 554 3792 ⫾ 557 3819 ⫾ 428

as previously described (Essén et al. 1980; Essén-Gustavsson et al.
1984). CS and HAD were analysed to evaluate the muscle oxidative
capacity, HK to evaluate the capacity for phosphorylation of
glucose and LDH was analysed as a marker for glycolytic capacity
as this enzyme is needed for lactate production. The muscle sample
for glycogen determination was boiled for 2 h in 1 mol/l HCl and
the glucose residues determined fluorometrically (Lowry and
Passonneau 1972).
Additional study on an anaesthetised horse: On one occasion,
one anaesthetised healthy Standardbred trotter was placed in
lateral recumbency and stimulated with the identical programme
as the standing horses. The intensity required to produce
an obvious visual and palpable contraction comparable with
those of the standing horses was 34.5–39.0 mA. During
stimulation, an experienced radiologist confirmed the localisation
and depth of the muscle contraction with a diagnostic
ultrasound (Mindray)4, using a linear probe at the frequency of
7 MHz.
Statistics: SPSS for Windows version 10 was used for data
analysis. The Wilcoxon sign-rank tests were applied for
comparison of the differences between pre- and post values for both
stimulated side and control side. The Mann-Whitney test was used
for comparisons between horses. Statistical significance was set to
P<0.05.
Results
The stimulation intensity to the horses is reported in Table 1, results
on muscle fibre characteristics are shown in Table 2 and results on
enzyme activities and glycogen in Table 3. Type II C fibres were
found in only some samples and, since there were so few fibres,
they were added to the type II A fibre pool, since II C fibre areas
mostly resembled this fibre type. Before the treatment period
started, there were no significant differences in muscle
characteristics between the NMES and the control side. NMES
treatment for 4 weeks did not induce any significant changes in
fibre type composition, fibre area, enzyme activities and glycogen
content in any of the muscles. Furthermore, no differences were
seen in these parameters when comparing the left and right side of
the muscles. No apparent discomfort or skin irritation was detected
in any horse. The result from the evaluation with diagnostic
ultrasound shows a clear visual muscle contraction down to a depth
of 8 cm in the m. gluteus medius muscle and a depth of 6 cm in the
m. longissimus dorsi muscle.
Discussion
Results from the present study demonstrate that daily treatment
with the current NMES-protocol for 5 days a week over 4 weeks
does not cause any significant changes in muscle fibre types, fibre
areas, glycogen content or enzyme activities in healthy horses.
Data on muscle characteristics in the present study are in
good agreement with earlier findings on Standardbred trotters
(Ronéus et al. 1992; Karlström et al. 1994). Data obtained from
the right side of the muscle did not differ from those obtained on
the left side, which also agrees with results from an earlier study
(Essén-Gustavsson et al. 1989). In man, NMES may influence the
muscle properties in both legs, when stimulation was performed
only in one leg (Carrol et al. 2006). However, such a crossover
effect is not likely in the present study as no changes were seen
in either stimulated or nonstimulated side, before or after
stimulation.
Our results diverge from some results found in human studies,
where NMES has been shown to induce fibre type changes. The
amount of type II A fibres increased while the amount of type II X
and type I fibres decreased after electrical stimulation for 30 min, 3
days/week for 6 weeks (Pérez et al. 2002) and stimulation for 10
weeks, 4 h/day and 7 days/week caused a decrease in II X fibres and
© 2010 EVJ Ltd
674
TABLE 3: Mean ⫾ s.d. for citrate synthase (CS), 3-OH acyl CoA dehydrogenase (HAD), lactate dehydrogenase (LDH) and hexokinase (HK) and glycogen
in m. gluteus medius and m. longissimus dorsi activities of 6 horses without (control) and with (NMES) neuromuscular electrical stimulation for 4
weeks
M. gluteus medius
Before
CS (mmol/kg/min)
Control 53 ⫾ 13
NMES 53 ⫾ 10
HAD (mmol/kg/min)
Control 22 ⫾ 5
NMES 23 ⫾ 4
LDH (mmol/kg/min)
Control 1300 ⫾ 174
NMES 1291 ⫾ 95
HK (mmol/kg/min)
Control 3.9 ⫾ 0.7
NMES 4.1 ⫾ 0.8
Glycogen (mmol/kg)
Control 495 ⫾ 62
NMES 493 ⫾ 70
an increase in type I fibres (Nuhr et al. 2003, 2004). These studies
also showed changes in enzyme activities that indicated an
increased oxidative capacity in the muscle.
Other studies have shown increased CS activity after
electrical stimulation; 3 h/day, 6 days/week for 6 weeks (Gauthier
et al. 1992) and after 8 h/day, 6 days/week for 4 weeks (Thériault
et al. 1994). A slight increase in fibre cross-sectional area has
been reported (Pérez et al. 2002; Del Corso et al. 2007).
There are, however, studies that show no changes in enzymes
and muscle fibre characteristics after similar stimulation
(Eriksson et al. 1981; Arvidsson et al. 1986; Suetta et al.
2004, 2008). The influence of NMES on muscle phenotype
depends primarily on the total number of impulses delivered and
is less dependent on the stimulation frequency (Salmons 2009).
The fact that neither fibre type and fibre area changes nor
any alterations in enzymes were observed in the present study
may be related to the fact that NMES was used for 4 weeks in
contrast to the longer durations employed in the previously
described studies.
An important methodological question is whether the muscle
specimens obtained with the biopsy needle had actually been
activated. The depth of biopsy corresponded to the depth taken in
human studies on m. quadriceps, which shows that a depletion of
glycogen and phosphagen stores occurs in the muscle after
electrical stimulation (Eriksson et al. 1981; Söderlund et al. 1992).
Further, the evaluation with diagnostic ultrasound on the
anaesthetised horse showed a clear visible contraction in the
muscles at the depth of the muscle biopsy, thus indicating muscle
activation. The intensity used on the anaesthetised horse produced
contractions of the same degree as those in standing horses,
estimated by visualisation and palpation.
Training studies on horses show that changes can occur in fibre
characteristics and oxidative capacity in muscles, evaluated by
muscle biopsies taken at the same depth as in the present study. No
changes in fibre type composition but an increase in CS activity and
a decrease in type II A fibre area was seen after 5 weeks training
(Essén-Gustavsson et al. 1989). Fibre type changes with a
reduction in type II X fibres and a concomitant increase in type II A
fibres, as well as an increase in oxidative capacity and glycogen
levels has been shown in horses after 3 months of endurance
training (Serrano et al. 2000). This indicates that changes in fibre
© 2010 EVJ Ltd
Effect of NMES on horses
M. longissimus dorsi
After 4 weeks Before After 4 weeks
52 ⫾ 10 54 ⫾ 12 49 ⫾ 9
53 ⫾ 13 53 ⫾ 15 51 ⫾ 13
24 ⫾ 4 32 ⫾ 5 30 ⫾ 5
24 ⫾ 4 28 ⫾ 3 31 ⫾ 5
1284 ⫾ 189 2015 ⫾ 177 1887 ⫾ 114
1258 ⫾ 59 1936 ⫾ 95 1991 ⫾ 95
3.6 ⫾ 0.6 2.7 ⫾ 0.7 3.2 ⫾ 1.3
3.9 ⫾ 0.6 2.7 ⫾ 0.5 2.6 ⫾ 1.3
500 ⫾ 101 522 ⫾ 84 535 ⫾ 57
500 ⫾ 93 546 ⫾ 41 567 ⫾ 50
types occurred after a longer duration of training, while metabolic
changes occurred earlier.
Although the NMES protocol used in the present study was
designed to simulate strength-training with an increasing number
of contractions over the experimental period, it was used on the
back muscles of healthy horses - muscles that are more or less
constantly engaged where an animal stands for 18–22 h/day
(Dallaire 1986). It is likely that the stimulation level given to the
healthy horses in the present study may have been lower than their
normal work load and therefore not sufficient to induce any
significant changes in muscle characteristics.
One of the limitations of NMES is the lack of evidence-based
knowledge on how to maximise elicited torque output and to
quantify optimal parameter settings. It has been indicated that an
increase in current amplitude and pulse duration increases both
the maximum voluntary isometric torque, as well as the
percentage of muscle group activated (Han et al. 2007; Gorgey
and Dudley 2008). However, a rise of stimulus duration was
connected to an increase in patient discomfort (Kaczmarek et al.
2009). The stimulation characteristics of the present NMES
protocol were selected according to previous recommendations
(Hainaut and Duchateau 1992). It was chosen to mimic strength
training used in clinical practices. It is generally accepted
that the skin produces resistance to current flow by patient
dependent capacitive impedance (Dorgan and Reilly 1999).
Therefore, the current intensity was individually set in
order to create the comparable highest work load and muscle
contraction possible, without causing serious discomfort. If the
protocol had used the same intensity for each horse, there had
been a major risk of having some horses not showing any
muscle contractions and some experiencing discomfort during
the stimulation.
On the basis of present results, it may be of little clinical use
to stimulate a healthy horse less than according to the
protocol described. In conclusion, healthy horses tolerated the
NMES protocol used in the present study and no changes in
muscle characteristics were seen after 4 weeks. If muscle
adaptations occur after more intense and/or longer stimulation
periods needs to be investigated in future studies and also if
there is an effect of NMES in rehabilitation of horses with
muscle hypotrophy.
A. Bergh et al.
Acknowledgements
The authors wish to express their sincere gratitude to AB Trav och
Galopp (ATG) for financial support, Cefar Medical AB for the use
of equipment, Dr Nostell for taking the muscle biopsies and Dr
Uhlhorn for ultrasound evaluation.
Manufacturers’ addresses
1
Cefar Medical AB, Lund, Sweden.
2
Dixons surgical instruments Ltd, Wickford, Essex, UK.
3
Scan-Beam, Hadsun, Denmark.
4
Scandivet AB, Enköping, Sweden.
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