Table 1 .

Effects of surface neuromuscular (NMES) and FES on body composition in chronological order

References	Purpose	Protocol	Body composition assessment	Results/conclusion
Ragnarsson et al. 37	To determine the effects of FES training on the paralyzed muscles after SCI	Twenty-three males and seven females; age 19–47 years; 11 paraplegic and 19 tetraplegic	CT scans of the mid-shaft of the femurs	• Increased strength, endurance, and bulk of the stimulated knee extensor muscles. Mid-thigh circumference showed increase by 2.1 inches • A greater amount of work on a lower extremity ergometer, both per unit of time and per length of time • Increased aerobic metabolism during the training program
Hjeltnes et al.30	To investigate body composition adaptations after FES-LCE in persons with tetraplegia	Five individuals with tetraplegia (C5–C7) underwent FES-LC training. After a 2-week adaptation period, the subjects performed seven FES-LC sessions per week for 8 weeks	Whole-body DXA and CT scans for lower extremities	• Increase in LBM form 2%, with decrease in whole body fat content by 2% after training • The CSA of quads, hams, gluteus maximus, and gluteus medius muscles, increased by 21% after training
Mohr et al.42	To examine the effect of exercise on SCI individuals	Ten individuals with SCI (6 with tetraplegia and 4 paraplegia; age 27–45 years; time since injury 3–23 years) trained for 1 year using an FES-LC ergometer; 3 days/week, 30 minutes duration	Muscle biopsy and MRI of the CSA of thigh muscles	• Increase in thigh CSA by 12% • A shift towards more fatigue resistant contractile proteins was found after 1 year of training • The percentage of myosin heavy chain (MHC) isoform IIA increased to 61% of all contractile protein and a corresponding decrease to 32% was seen in the fast fatigable MHC isoform IIB
Baldi et al.31	To determine whether FES-CE (loaded) or non-loaded NMES-induced muscle contractions using portable electrical stimulators are capable of preventing disuse atrophy	Three groups FES-CE, NMES-isometric, and control group. FES-CE group rode an Ergys 1 FES bike for 30 minutes three times per week. Load increased by 6 W at 50 rpm	LBM measured at 0, 3, and 6 months using Lunar DXA scanner	• FES-CE training prevented atrophy in all regions after 3 and 6 months when compared to the control group • FES-CE showed increase in lower legs (9.3 ± 3.9%) and trunk (7.7 ± 2.9%) lean body mass (LBM) after 6 months when compared to the NMES isometric group • The LBM increased in the FES-CE group at all body composition regions
Scremin et al.34	To determine the magnitude of changes in muscle mass and lower extremity body composition after regular regimen of FES-induced lower extremity cycling	Thirteen men with neurologically motor and sensory SCI participated in three phases of training – phase 1 quad strengthening, phase 2 cycle progression, phase 3 30 minutes continuous cycling. Average protocol was ∼52.8 weeks	CT scans of legs to assess muscle CSA before, 65 and 98 weeks after starting the program	• Study found a generalized increase in individualized skeletal muscle CSA of thigh • The ratio of muscle to adipose tissue increased significantly in thighs and calves
Dudley et al.33	This pilot study was conducted to determine if intermittent, high force actions could increase lower extremity affected muscle size after SCI	Three males about 46 weeks after complete SCI. Conditioning was twice weekly at the subject's home and lasted 8 weeks. Each session and consisted of four sets of 10 repetitions	MRI scans of the thigh was done 6, 11, 24, 46, and 54 weeks post-injury to determine CSA	• Training evoked a 20% increase in CSA of the quad • This essentially reversed 48 weeks of atrophy • Muscle CSA of knee extensor muscle group at 54 weeks after SCI was about 75% of AB controls and same as week 6 after SCI
Murphy, et al.68	To investigate possible changes in skeletal muscle morphology and function, as well as hormonal and metabolic effects, after treatment with a selective beta 2-adrenergic receptor agonist	Thirteen individuals with SCI underwent 2-week treatment with salbutamol (2 mg) or placebo (ascorbic acid, 50 mg) twice a day. Program of functional electronic stimulation (FES) cycling for 30 minutes twice a week	Body weight, three measures of leg circumference, muscle fiber area, and total work output per session	• Body weight increased by 2.30 kg • The CSA of vastus lateralis muscle increased (1374 ± 493 to 2446 ± 1177 µm2) after salbutamol treatment. • Total work output during FES cycling sessions was increased more during salbutamol treatment (64%) compared with training alone (27%)
Donaldson et al.69	To determine whether strength and endurance for recreational cycling by FES are possible following SCI	Single subject with incomplete SCI performed training for an average of 21 minutes/day for 16 months	Near-isometric or cycling exercise measurements	• Training time was 21 minutes/day for 16 months • Subject was able to cycle for 12 km on the level • There was a substantial increase in the measured voluntary strength of the knee extensors
Sköld et al.32	To test the hypothesis that FES-CE alter muscle mass, adipose tissue, and spasticity in individuals with motor complete cervical SCI	Fifteen individuals with tetraplegia underwent FES-CE using Ergys 1 bike, cycle 3X weekly for 6 months. Goal was to maintain a total of 30 minutes/session. Load was added each time the subject was able to ride 30 minutes continuously	Twenty-two CT scans of the whole body and whole-body DXA scan were performed	• No significant change in body composition during the study. • Muscle tissue was increased by about 10% in the training group • Adipose tissue did not change in the abdomen or in the legs
Mahoney et al.26	To determine the effects of 12 weeks of evoked RT using surface NMES of the knee extensor muscle groups	Five individuals with complete SCI (C5–T9) participated in the study. Both thighs were trained 2 days/week for four sets of 10 of dynamic knee extensions for 12 weeks.	Serial MRI scans from hip to the knee joint	• Skeletal muscle CSA increased by 35 and 39% in the right and the left quadriceps femoris, respectively
Clark et al.70	To determine the effects of discontinuous FES to lower limb muscles (15 minute sessions to each leg twice daily, over a 5-day week, for 5 months) on BMD and FM in individuals with acute SCI (AIS A–D)	Twenty-three individuals underwent FES-CE (13 tetra, 28 ± 9 years, C4–T10) and 10 individuals with SCI were assigned to the control group (CON, 31 ± 11 years, C5–T12, four Tetra)	DXA scans were used to measure bone mineral density (BMD) and FM	• FES and CON groups BMD differed significantly at 3 months post-injury. • Regional FM was not different between groups at any time
Liu et al.71	To investigate the change in body composition, leg girths, and muscle strength of patients with incomplete SCI after FES cycling exercises	Eighteen subjects with incomplete SCI were recruited. Each patient received FES three times per week for 30 minutes/session for 8 weeks	Bioelectrical impedance spectroscopy analysis and thigh and calf girth measurements	• A significant increase in bilateral thigh girth after 4 weeks of FES-CE and significant increase in muscular peak torque of knee flexion and extension were found after 8 weeks of training • Besides LBM increased significantly after treatment
Shields and Dudley-Javoroski.5	To determine whether long-term electrical stimulation training of the paralyzed soleus could change this muscle's physiological properties (torque, fatigue index, potentiation index, torque–time integral) and increase tibia BMD	Four men with chronic complete SCI underwent training of one soleus muscle for 30 minutes each day, 5 days/week, for a period of 6–11 months.	DXA scans	• The findings highlight persistent adaptive capabilities of chronically paralyzed muscle, but suggest that preventing musculoskeletal adaptations after acute SCI may be more effective than reversing changes in the chronic condition
de Abreu et al.72	To investigate the effect of treadmill gait training with NMES and BWS on the CSA of quadriceps in complete quadriplegics	Two groups (n = 8 NMES) and (n = 7 control) partial BWS (30 and 50% of BWS) Training was performed during 6 months, twice weekly for 20 minute sessions.	MRI scans	• After 6 months of training, a 15% increase in the knee extensor muscle group CSA occurred • Control group showed no change
Griffin et al.59	To conduct a comprehensive analysis of metabolic, body composition, and neurological profiles before and after 10 weeks of FES cycling	FES-CE, Ergys 2 bike, cycling two to three times per week for 10 weeks. Stimulation frequency 50 Hz for all muscle groups. Target 49 rpm. Total time 30 minutes, allowed up to five rides per session to equal 30 minutes total	DXA scans	• Total body weight increased from 153.2 ± 9.32 to 157.76 ± 9.11 lb. • LBM (lb) increased from 96.8 ± 5.61 to 100 ± 5.47 (4%) • Did not see a significant decrease in total body adipose tissue after 10 weeks
Janssen and Pringle41	To determine whether a modified FES-LCE improved exercise performance and responses compared with the standard FES-LCE	Twelve individuals with motor complete SCI were recruited for 6 weeks training program (age 36 ± 16 years C4–T11, time since injury 11 ± 9 years)	FES-LCE Instrumentation	• Power output, metabolic rate, and lower-limb muscle strength increased significantly following training.18% increase in bone mineral density of the proximal femur after 3 months of cycle training • Muscle performance of all muscle groups studied markedly improved
Gorgey and Shepherd57	To determine the effect of unilateral RT for 12 weeks on knee extensor and surrounding muscle groups, intramuscular and subcutaneous adipose tissue	A C5 motor complete individual with SCI participated in training, twice weekly using surface NMES and progressive ankle weights	Serial MRI scans from hip to the knee joint	• The CSA of knee extensor increased by 43% and individual muscle CSAs experience hypertrophy that ranges from 12 to 38% • IMF decreased by 53%
Johnston et al.60	To determine the effects of FES cycling and electrical stimulation on muscle volume and stimulated strength	Thirty children with chronic SCI were randomized to FES cycling, passive cycling, or non-cycling NMES Each group exercised for 1 hour, three times per week for 6 months at home	MRI to measure muscle volume, and electrically stimulated isometric muscle strength testing using a computerized dynamometer	• Six months post-training, quadriceps muscle volume increased significantly for NMES non-cycling and for FES-LCE compared to passive cycling • The increase in the NMES group was greater compared to FES-LCE • Stimulated muscle strength increased in FES-LCE and NMES stimulation compared to passive cycling. The increase was greater in FES-LCE compared with the other two groups
Gorgey et al.55,61	To determine the effect of 12 weeks of RT on aspects of body composition and metabolism after providing dietary recommendations (diet)	Nine individuals with motor complete SCI were randomly assigned into two groups: RT + diet (n = 5) or diet (n = 4)	Serial MRI scans and DXA	• The CSA of knee extensor showed hypertrophy close to 35%, whole thigh by 28%, and hamstring muscle groups by 16% in the RT + diet group • Relative IMF showed decrease by 18% and leg LM increased by 10% in the RT + diet group. • Visceral fat decreased by 25% in the region of L5–S2
Fornusek et al.62	To investigate effects of FES-evoked cycle training cadence on leg muscle hypertrophy and electrically evoked strength	Eight untrained individuals with chronic SCI underwent 6 weeks of training on an FES cycle bike. For each subject, one leg was randomly assigned to cycling at 10 rpm (LOW cadence) for 30 minutes/day, and the other cycling at 50 rpm (HIGH cadence) for 30 minutes/day, 3 days/week	Pre- and post-training measurements of lower limb circumference were performed at the distal and middle position of each thigh	• Mid-thigh girth increased in the LOW-cadence (6.6 ± 1.2%) group was significantly greater than HIGH-cadence (3.6 ± 0.8%) group after 6 weeks of training