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– Written by Nicola A. Maffiuletti, Switzerland and Grégory Dupont, France

INTRODUCTION AND RATIONALE or sub-tetanic stimulations, whose muscle strength in athletes (for a review
Transcutaneous electrical stimulation clinical/physiological consequences are see Seyri and Maffiuletti1), and to preserve
(ES) consists of delivering small electrical improved neuromuscular function and muscle mass during prolonged periods
pulses via electrodes that are positioned enhanced peripheral blood flow. of inactivity2. Surprisingly, however, the
on the skin, usually around skeletal In reality, this distinction is not growing interest in applied research on
muscle motor points or painful body areas. always respected and considerable tetanic ES observed in the last few years
Depending on electrical current (frequency confusion continues to surround the main corresponds to a reduced use by athletes and
and intensity) and electrode characteristics physiological effects, methodological reduced development by manufacturers.
(size, position), two major ES categories can aspects and clinical/sports applications of At the same time, but with premature
be distinguished: transcutaneous ES. physiological background, subtetanic ES
1. ‘Sensory’ ES (no muscular contractions Some individual and team sport athletes has gained popularity in sportspeople as a
are evoked). Conventionally called use motor ES modalities to complement potentially effective strategy to accelerate
transcutaneous electrical nerve their training/rehabilitation programmes post-exercise recovery.
stimulation. This is mainly delivered for: This review article aims to assess the
using relatively low current intensities 1. improving muscle strength during the effectiveness of motor subtetanic and
(at or below the sensory threshold) in pre-season, sensory ES as a recovery modality for
an attempt to relieve pain via spinal 2. maintaining/improving muscle athletes by following a simplified and
circuitry transmitting pain (gate theory) function while injured/after an injury non-systematic approach. Because the
and endorphin release. and post-exercise decline in physical/sports
2. ‘Motor’ ES. Conventionally called 3. restoring physical performance after performance is due to an impairment in
neuromuscular electrical stimulation. intense exercise (i.e. for accelerating neuromuscular and/or psychomotivational
This elicits visible muscular contractions recovery). function, and because recovery modalities
(stimulations are delivered at or above There is some evidence to suggest that are designed to restore neuromuscular
the motor threshold), using either tetanic motor (tetanic) ES is effective to increase function and/or psychomotivational


Muscle Sensory
contraction feedback

pump effect
Gate Endorphin Placebo
control release effect

Blood flow

Metabolite Substrate Inflammat. Muscle Pain
removal availability response damage

Neuromuscular Psychomotivational
function function



function to the pre-exercise level as the studies as having demonstrated that The rationale for the use of motor ES to
quickly as possible, we provide separate recovery with ES was 'less effective', 'equally promote physiological recovery is based
definitions, analyses and interpretations effective' and 'more effective' compared on the assumption that evoked muscular
for ‘physiological’ and ‘perceptual’ recovery to passive rest and to other recovery contractions are able to enhance
throughout the article. We therefore modalities (submaximal exercise, cold peripheral blood flow mainly due to the
considered original research studies: water immersion, contrast water therapy, muscle pump effect. In turn, this would
1. published in peer-reviewed journals, compression garments and also placebo ES accelerate metabolite removal, improve
2. c omparing the effectiveness of ES- in one study). substrate availability, decrease the
related recovery strategies to passive inflammatory response and reduce muscle
recovery or other recovery modalities DOES ELECTROSTIMULATION IMPROVE damage that could contribute to restoring
(at least two conditions), PHYSIOLOGICAL RECOVERY? the neuromuscular determinants of
3. f ocusing on athletes or healthy subjects, In the context of this article, muscle strength/power and thus physical
4. h aving quantified at least one physiological recovery was considered performance (cf. left portion of Figure 1).
physiological and/or perceptual successful when neuromuscular function, In reality, subtetanic ES of the calf muscles
variable of recovery. as measured objectively (strength, power and of the plantar muscles of the foot are
In order to examine the effectiveness of or physical performance outcomes), able to enhance peripheral blood flow with
ES-related strategies, we arbitrarily classified was fully restored to pre-exercise levels. respect to passive rest conditions, however



Table 1

ES less effective ES equally effective ES more effective

Neric et al 2007 ○ ●
Heyman et al 2009 ○ ●
Cortis et al 2010 ○●
Malone et al 2012 ○ ●
Argus et al 2013 ○ ●
Croci (unpublished data) ○ ●
Table 1: Effects of electrical stimulation-related recovery strategies on blood lactate concentration. ●=vs passive recovery,○=vs other
recovery modalities.

Table 2

ES less effective ES equally effective ES more effective

Lambert et al 2002 ●
Vanderthommen et al 2007 ●
Bieuzen et al 2012 ●
Neric et al 2007 ○
Table 2: Effects of electrical stimulation-related recovery strategies on serum creatine kinase concentration. ●=vs passive
recovery,○=vs other recovery modalities.

active exercise (voluntary dynamic muscle effective than passive recovery, and equally to active recovery (submaximal concentric
contractions) is even more effective than effective compared to submaximal exercise contractions) was observed following
ES to increase the ejected venous volume3. (Table 2). isokinetic fatiguing exercise in male elite
This observation fits well with recent When evaluating the effectiveness of judo athletes.
recovery studies in which ES was found to ES recovery-related strategies on muscle
be equally or more effective than passive strength/power, physical performance and
rest in reducing post-exercise blood lactate even on the neuromuscular determinants There is no
concentration, while ES was less effective of muscle strength (e.g. muscle activation,
than active recovery modalities such as muscle contractility), only 3 out of 19 studies justification
submaximal swimming and cycling (Table
1). It is nevertheless worth remembering
demonstrated that ES was more effective
than passive recovery (and only for one to expect any
that blood lactate should not be considered
the best indicator of metabolite removal.
variable), while all the other studies were
unable to detect a difference between
Four studies evaluated the changes in the two modalities in healthy active benefit from ES
serum creatine kinase concentration, as an individuals, recreational sportsmen and
objective marker of muscle damage in the professional athletes (Table 3). ES was found for post-exercise
days consecutive to an exhaustive exercise to be equally effective compared to other
bout (including eccentric exercise) and recovery modalities in all but one study, in
demonstrated that ES was equally or more which better effectiveness of ES compared

Table 3

ES less effective ES equally effective ES more effective

Weber et al 1994 ●○
Butterfield et al 1997 ●
Lambert et al 2002 ●
Martin et al 2004 ●○
Lattier et al 2004 ●○
McLoughlin et al 2004 ●
Tourville et al 2006 ●
Vanderthommen et al 2007 ●
Tessitore et al 2007 ●○
Tessitore et al 2008 ●○
Heyman et al 2009 ●○
Cortis et al 2010 ●○
Vanderthommen et al 2010 ●○
Zarrouk et al 2011 ●○
Bieuzen et al 2012 ●
Malone et al 2012 ●○
Finberg et al 2012 ○ ●
Bieuzen et al 2012 ●
Argus et al 2013 ●
Table 3: Effects of electrical stimulation-related recovery strategies on neuromuscular function. ●=vs passive recovery,○=vs other
recovery modalities.

DOES ELECTROSTIMULATION IMPROVE rationale for the use of motor and sensory mechanisms underlying these theories
PERCEPTUAL RECOVERY? ES to promote perceptual recovery is based would be able to attenuate the perception
In the context of this article, perceptual on theoretical models rather than on of pain and tiredness (both locally and
recovery was considered successful when scientific evidence, as the biological basis at a whole-body level), for example by
psychomotivational factors, as measured of the analgesic and psychological effect of reducing exercise-induced muscle soreness,
subjectively (basically, by replying to simple ES is not known. The underlying theories which could ultimately result in recovered
questions such as “what is your level of are the gate control theory, which proposes psychomotivational function and thus
recovery following this intervention?”, that pain transmission through small successful perceptual recovery (Figure 1,
by ranking the perceived effectiveness of afferent fibres would be selectively blocked RHS).
different recovery modalities using scales at the spinal cord level by the ES-induced The effects of ES recovery-related
and scores or by quantifying the perceived activation of large afferents; the endorphin- strategies on delayed onset muscle soreness
level of energy and enthusiasm), were release theory and the placebo theory. In (referred to as muscle pain in some studies)
fully restored to pre-exercise levels. The turn, the neurophysiological/psychological induced by heavy exercise (including



Table 4

ES less effective ES equally effective ES more effective

Weber et al 1994 ●○
Butterfield et al 1997 ●
Lambert et al 2002 ●
Martin et al 2004 ●○
McLoughlin et al 2004 ●
Tourville et al 2006 ●
Vanderthommen et al 2007 ●
Tessitore et al 2007 ●○
Tessitore et al 2008 ●○
Cortis et al 2010 ●○
Vanderthommen et al 2010 ●○
Bieuzen et al 2012 ●
Table 4: Effects of electrical stimulation-related recovery strategies on delayed onset muscle soreness. ●=vs passive recovery,○=vs
other recovery modalities.

eccentric exercise) have been compared • unlikely beneficial for improving considerable confusion, particularly with
to other recovery modalities in 12 studies. physiological recovery compared to respect to the multitude of parameters,
Subsensory (micro-current ES), sensory and both passive rest (including a placebo protocols and potential applications –
subtetanic ES has been found to be more condition in one study) and other their choice is often based on convenience.
effective than passive rest in three studies recovery modalities; We believe that, in order to ensure solid
(a placebo ES condition was used in one • likely beneficial for improving credibility of newly developed units,
instance), and more effective than active perceptual recovery compared to their physiological (and eventually also
water exercise in only one study, while in all passive rest, and possibly beneficial perceptual) effectiveness should be
the other instances ES was equally effective for improving perceptual recovery scientifically demonstrated at all levels
compared to both passive and active compared to other recovery of our simplified model (Figure 1) e.g. by
recovery modalities (Table 4). interventions. showing that ES is able to increase blood
More interestingly, ES recovery-related In other words, there is no justification flow using ultrasonography, to accelerate
strategies have been found to be more to expect any physiological benefit from ES metabolites removal by quantifying blood
effective than passive rest for restoring for post-exercise recovery purposes, while lactate concentration and to improve
psychomotivational factors in three out of restoration of some psychomotivational neuromuscular function by evaluating
four studies conducted on highly-trained factors – likely mediated by a placebo effect muscle strength/power and eventually
cyclists and team sport athletes. In the of ES4 – appear to be enhanced when ES sport-related performance (rather than only
same way, ES has been demonstrated to be is used as a recovery modality compared one of these mechanisms as it is the case for
more effective compared to other recovery to several passive and active recovery currently available units).
modalities (submaximal exercise, contrast strategies. Based on subjective belief rather than on
water therapy and compression garments) Medical device manufacturers scientific evidence we propose that in order
for perceptual recovery in three out of five continuously introduce new electrical to maximise potential physiological benefits
studies (Table 5). stimulators on the market with futuristic of ES for recovery purposes (with respect to
current characteristics, claiming superior passive rest), the following methodological
CONCLUSIONS AND CONSIDERATIONS effectiveness compared to previous systems, precautions should be observed:
We conclude that ES-related recovery but with no preliminary physiological • ES would be better combined with
strategies are: validation. ES users are therefore faced with submaximal voluntary dynamic

Table 5

ES less effective ES equally effective ES more effective

Tessitore et al 2008 ●○
Cortis et al 2010 ●○
Finberg et al 2012 ●○
Argus et al 2013 ○ ●
Beaven et al 2013 ○
Table 5: Effects of electrical stimulation-related recovery strategies on psychomotivational function. ●=vs passive recovery,○=vs other
recovery modalities.

contractions (such as toe curls) • ES would be better delivered with low reluctant to apply ES to their muscles mainly
whenever possible, in order to maximise doses but for long-term periods (such as because of the discomfort induced by the
blood flow increase, overnight)6, during travel or by means of electrical current, and therefore its use
• ES would be better applied distally (to electrostatically charged self-adhesive for recovery purposes should be proposed
the calf or foot muscles and eventually membranes7). on an individual basis (and according to
to the common peroneal nerve5) rather ES-related recovery interventions repre- expectations). There is limited research
than proximally (to the quadriceps sent an alternative and potentially useful in this area, particularly on upper limb
muscle belly) to maximise the muscle way of restoring sports performance after muscles and in female athletes, and further
pump effect, intense exercise because they are practical, efforts are required to demonstrate the
• ES would be better used in weight- relatively cheap and quite beneficial for physiological effectiveness, the biological
bearing and contact sports to reduce promoting perceptual (not physiological) basis of the analgesic and psychological
signs and symptoms of muscle damage, recovery. Many athletes are, however, still effect of ES.



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