Gobbo et al.

Journal of NeuroEngineering and Rehabilitation 2014, 11:17

http://www.jneuroengrehab.com/content/11/1/17 JNER JOURNAL OF NEUROENGINEERING
AND REHABILITATION

COMMENTARY Open Access

Muscle motor point identification is essential for

optimizing neuromuscular electrical
stimulation use
Massimiliano Gobbo1, Nicola A Maffiuletti2, Claudio Orizio1 and Marco A Minetto3*

Abstract
Transcutaneous neuromuscular electrical stimulation applied in clinical settings is currently characterized by a wide
heterogeneity of stimulation protocols and modalities. Practitioners usually refer to anatomic charts (often provided
with the user manuals of commercially available stimulators) for electrode positioning, which may lead to
inconsistent outcomes, poor tolerance by the patients, and adverse reactions. Recent evidence has highlighted the
crucial importance of stimulating over the muscle motor points to improve the effectiveness of neuromuscular
electrical stimulation. Nevertheless, the correct electrophysiological definition of muscle motor point and its
practical significance are not always fully comprehended by therapists and researchers in the field. The commentary
describes a straightforward and quick electrophysiological procedure for muscle motor point identification. It
consists in muscle surface mapping by using a stimulation pen-electrode and it is aimed at identifying the skin area
above the muscle where the motor threshold is the lowest for a given electrical input, that is the skin area most
responsive to electrical stimulation. After the motor point mapping procedure, a proper placement of the stimulation
electrode(s) allows neuromuscular electrical stimulation to maximize the evoked tension, while minimizing the dose of
the injected current and the level of discomfort. If routinely applied, we expect this procedure to improve both
stimulation effectiveness and patient adherence to the treatment.
The aims of this clinical commentary are to present an optimized procedure for the application of neuromuscular
electrical stimulation and to highlight the clinical implications related to its use.
Keywords: Muscle motor point, Motor entry point, Discomfort, Motor unit recruitment, Evoked muscle tension

Introduction effectiveness and utility in clinical practice. The three

Transcutaneous neuromuscular electrical stimulation main limitations of NMES are: 1) considerable discom-
(NMES) involves the application of electrical stimuli to fort; 2) limited spatial recruitment that results in low
superficial skeletal muscles, with the main objective to evoked tension and early occurrence of fatigue; 3) poor
trigger visible and valid muscle contractions due to the ac- control of dosage. These limitations are partly due to
tivation of motor neuron axons or intramuscular axonal non-optimal application of NMES by the end-users,
branches [1]. It is largely adopted in rehabilitation practice who frequently place electrodes in poorly effective loca-
to restore or preserve muscle mass and function in case tions as recently outlined by Doucet et al. [4]. Specific-
of prolonged periods of disuse/immobilization [2], and it ally, the practitioner should consider that benefits are
is also receiving increasing attention as a preoperative strictly modality- and dose-dependent and, as a conse-
strengthening intervention (i.e. “prehabilitation”) [3]. Never- quence, rigorous methods are crucial for optimal NMES
theless, the technique presents some inherent limita- delivery. In this view, muscle motor point (MP) identifica-
tions that foster a lack of general consensus on NMES tion prior to placement of stimulation electrodes represents
a simple, inexpensive and straightforward strategy to im-
* Correspondence: [email protected]
prove NMES use in the context of clinical rehabilitation. In
3
Division of Endocrinology, Diabetology and Metabolism, Department of fact, the position of the stimulation electrodes critically in-
Medical Sciences, University of Turin, Turin, Italy fluences the pathway of the spreading current and therefore
Full list of author information is available at the end of the article

© 2014 Gobbo et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited.
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its relative density through the different anatomical struc- showed a large inter-individual variability of the muscle
tures within the current field, namely sensory and motor MP location in lower limb muscles (Figure 3). Together,
branches of the peripheral nerve. As depicted in Figure 1, these findings suggest that muscle MPs should be carefully
stimulation via motor points is likely to involve chiefly searched prior to NMES delivery, thus pursuing a patient-
motor branch excitation, while non-optimal electrode posi- tailored approach that accounts for the specific anatomical
tioning would require higher current levels to reach and ex- morphology of each individual. This approach is supposed
cite the motor branch with concomitant greater excitation to be an essential step in optimizing NMES delivery. In-
of pain afferent fibers. For this reason, the proper place- deed, as demonstrated by Lieber and Kelly [8], the most
ment of stimulation electrodes over the identified MP(s) al- important determinants of the tension evoked by NMES
lows to overcome, at least in part, two of the previously are not electrode size or stimulation current, or any other
described NMES limitations, namely discomfort and lim- external controllable factor, but some intrinsic properties
ited spatial recruitment. of the muscle, e.g., individual patterns of motor nerve
With reference to updated evidence-based knowledge branching.
and through a reappraisal of key physiological concepts, The muscle MP definition relies on its electrophysio-
aims of this commentary are to present a patient-tailored logical identification and has to be distinguished from
approach for optimizing NMES delivery in superficial skel- the anatomical definition of the motor entry point,
etal muscles, namely through individual MP identification, which is actually the location where the motor branch
and to highlight the clinical implications related to its use. of a nerve enters the muscle belly. The motor entry
point is often confused with, and used as synonym for,
Basic concepts the electrophysiologically-identified MP: this common
Skeletal muscle MP is the location of the skin area above misconception may induce end-users to adopt anatomical
the muscle in which an electrical pulse applied transcu- charts with topographical indications of “motor points”
taneously evokes a muscle twitch with the least injected (which are actually motor entry points) as a guide for
current. In other words, it represents the skin area above stimulation electrode positioning. As outlined above, avail-
the muscle where the motor threshold is the lowest for a able published charts presenting “anatomical motor points”
given electrical input [5-7]. are of limited value for administering NMES [6].
Gobbo et al. [6] clearly evidenced that NMES delivered
through individually identified MPs, as opposed to ana- Theory in practice
tomical charts for electrode positioning, is critical to Based on the aforementioned notions, muscle MP loca-
maximize the evoked muscular tension and the related tions cannot simply be inferred from marketed anatom-
metabolic changes while minimizing current intensity ical charts, but a specific electrophysiological procedure
and discomfort (Figure 2). Moreover, Botter et al. [5] based on muscle surface mapping is required for precise
MP identification.
The suggested procedure is feasible and quick: muscle
MPs can be easily identified by scanning the skin surface
with a commercially available stimulation pen-electrode
(“active” or “negative” electrode with a surface of approxi-
non-MP
mately 1 cm2) and with a second electrode (usually called
“reference” or “dispersive” or “positive” or “return” elec-
trode) – larger than the active electrode (around tens of
square centimeters) – that is placed over the antagonist
MP muscle or opposite to the active electrode (monopolar con-
figuration) (Figure 4, panel I).
While stimulating at very low frequency (1 or 2 Hz)
and intensity (starting from 1 mA), using a monophasic
or biphasic wave lasting 100–200 μs for subjects without
neurological problems (longer duration is usually re-
quired in case of denervation or paresis), the operator
Figure 1 Schematic representation of a mixed peripheral nerve
and two stimulation sites. When the active electrode precisely should slightly press the pen-electrode on a specific area
overlies the motor point (MP), less current is required to excite the of the skin overlying the target muscle for 3–5 seconds,
motor axons and thus to elicit the muscle contraction. Alternatively, then the pen-electrode is moved to adjacent locations to
stimulation on the other site (non-MP) requires higher current check for the presence of mechanical responses (“twitch-
intensity to reach the motor branch, with possible excitation of the
ing”). If no location reacts to the chosen level of current,
sensory fibers conveying pain.
the stimulation amplitude is slowly increased (with steps
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Figure 2 Torque traces and oxygenation/deoxygenation profiles during neuromuscular electrical stimulation and recovery. The signals,
recorded from a representative subject during a frequency ramp contraction (from 2 to 50 Hz in 7.5 s) and the subsequent recovery phase, refer
to tibialis anterior muscle stimulation via the motor point (MP stimulation) and stimulation following anatomic reference charts for electrode
placement (conventional stimulation). Note that MP stimulation results in greater mechanical stress and metabolic demand than conventional
stimulation. O2Hb = oxyhemoglobin; HHb = deoxyhemoglobin; TOI = tissue oxygenation index; THI = total hemoglobin index. The bottom panels
are related to subject perception of discomfort evaluated with a numeric rating scale (NRS) and show group mean ± SD values for the two
conditions studied in 10 healthy subjects: MP stimulation induces significantly (* P < 0.05) less discomfort than conventional stimulation. NRS
scores: 0 = no discomfort; 10 = maximum discomfort. (Modified from Gobbo et al. [6]. Copyright © 2011 Springer. Used with permission provided
by Copyright Clearance Center, license number: 2913660233993).

of 1 mA) and skin scanning over the muscle surface is mapping performed by an experienced operator – MAM –
repeated until a clear contraction of the muscle is ob- on the anterior thigh of a healthy subject – MG – who pro-
served or, alternatively, when a mechanical response of vided written informed consent for both execution of the
its tendon is perceived by manual palpation. Thereafter, procedure and image publication). The idea behind this
the stimulation current is decreased to a value providing procedure is to determine the skin area most responsive
a minimal twitching response that should be detectable to electrical stimulation, that is the one where the stimula-
only when the pen-electrode exactly faces the muscle MP. tion electrode provides the greatest muscle response per
Eventually, the position of the identified MP is marked on current dose.
the skin and adopted as the centroid of the stimulation A remarkable consideration pertains to muscle length
electrode placement as represented in Figure 4, panel II during skin mapping: Crochetiere et al. [9] showed that
(that illustrates the procedure of vastus lateralis MP MPs do not remain in the same location but rather move
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Figure 3 Position of the muscle motor points for the quadriceps and gastrocnemii in 53 healthy subjects. The arrows indicate the
average motor point (MP) positions along the respective reference lines. A) Vastus lateralis muscle MPs (blue circles, proximal MP; white circles,
central MP; yellow circles, distal MP). The continuous black line is the reference line for the proximal MP, while the dashed black line is the
reference line for the central and distal MPs. B) Rectus femoris muscle MPs (blue circles, proximal MP; yellow circles, distal MP). C) Vastus medialis
muscle MPs (blue circles, proximal MP; yellow circles, distal MP). The continuous black line is the reference line for the proximal MP, while the
dashed black line is the reference line for the distal MP. D) Medial (blue circles) and lateral (yellow circles) gastrocnemii muscle MPs. (Modified
from Botter et al. [5]. Copyright © 2011 Springer. Used with permission provided by Copyright Clearance Center, license number: 2923641294715).

by about 2–3 cm as the joint is flexed and extended (due to over the proximal and another over the distal part of the
muscle lengthening/shortening). For this reason, muscle muscle). Besides its use for functional electrical stimula-
length should be the same during MP mapping and during tion applications, the asynchronous stimulation delivered
the subsequent NMES session. through a “multi-path” system has recently been applied
to quadriceps rehabilitation in patients after anterior cru-
Can the spatially fixed and incomplete recruitment ciate ligament reconstruction [14,15] and in patients with
be optimized? moderate to severe knee osteoarthritis [16]. The multi-
NMES is usually delivered using one or more active path NMES modality was superior to traditional NMES
electrodes positioned in the proximity to the MPs and performed with two active electrodes positioned over the
one reference electrode closing the stimulation loop [2]. vasti MPs and one dispersive electrode closing the stimu-
This electrode configuration implies that the recruitment lation loop [14] and comparable to volitional resistance
of motor units is not only limited, but also spatially fixed training [16] for the improvement of functional capacity
[10,11]. Therefore, the same muscle units are repeatedly and quadriceps strength. Although preliminary, these find-
activated by the same amount of electrical current, which, ings suggest that spatial recruitment can be maximized
in turn, hastens the onset of muscle fatigue [10,12]. Such through a non-synchronous activation of different muscle
early occurrence of fatigue represents a major limitation volumes. The proper placement of stimulation electrodes
of NMES. In order to maximize the spatial recruitment over the MPs of different muscles (e.g., vastus lateralis and
during NMES, thus minimizing the extent of muscle fa- rectus femoris) or different muscle portions (vastus media-
tigue, it has been recommended to adopt different tricks lis obliquus and vastus medialis longus) within a muscle
during a stimulation session such as altering the length of group is an obvious prerequisite for optimizing the effect-
the stimulated muscle and/or displacing the active elec- iveness of the multi-path paradigm.
trodes [2]. However, a change in the population of activated
fibers could also be obtained through a multichannel stimu- Clinical perspectives
lation technique. Malesević et al. [13] recently showed that The advances attained in NMES application [15] are gener-
asynchronous NMES delivered to the quadriceps of para- ating a comprehensive understanding of the mechanisms
plegic patients via multiple electrodes (one dispersive elec- involved in its effectiveness that are still poorly translated
trode positioned at the distal part of the quadriceps and to clinical practice [4]. Certainly, some of this evidence is
four active electrodes distributed over the quadriceps) de- not easy to access or difficult to integrate in the existing
layed the occurrence of fatigue with respect to single- clinical framework. In clinical settings, a major problem
channel synchronous stimulation (one electrode positioned with NMES is the incorrect placement of stimulation
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Figure 4 Motor point identification procedure. Panel I: schematic representation of monopolar stimulation. The active electrode is placed
over the muscle region of interest and the reference electrode is placed over the antagonist muscle or opposite to the active electrode to close
the stimulation current loop. Panel II: electrophysiological procedure for motor point (MP) identification and proper electrode placement. The
skin surface above the vastus lateralis muscle is mapped with a pen-electrode, the dispersive reference electrode being placed opposite to the
active one; the joint angle should be the one adopted for the subsequent stimulation protocol in order to avoid skin displacement with respect
to the underlying neural and muscular structures. A) The muscle contractile response is not evident when the pen is not facing the MP area. B)
The MP of the target muscle is identified as the specific site where a minimal mechanical response is generated with the lowest current intensity.
C) The identified MP is marked with a felt tip. D) The active electrode is placed exactly over the identified MP.

electrodes [4]. As outlined by Gobbo et al. [6], although the and better recovery), less adverse reactions (e.g., skin irrita-
approximate position of MPs for different muscles can be tion), and eventually lower cost-effectiveness ratio com-
easily found in a number of manuals, charts and atlases, pared to conventional NMES with no MP identification.
electrode placement over the approximate MP position is
likely to result in ineffective NMES use, mainly as a conse- Conclusions
quence of low evoked tension and concomitant discomfort. Quick and accurate MP identification prior to NMES has
MP identification prior to NMES delivery, which is com- the potential to minimize the amount of current injected
pleted in less than a minute, is expected to have relevant to the muscle and thus to minimize the sensation of dis-
clinical implications in terms of greater acceptability by pa- comfort, while maximizing spatial recruitment and evoked
tients (discomfort is a major limitation of NMES that may muscle tension.
lead to dropouts or, at the other extreme, to excessive low- In light of the recent evidences, we expect the use of
ering of the stimulus amplitude with ineffective levels of the standard patient-tailored approach described in this
muscle contraction), greater treatment effectiveness (earlier commentary to improve clinical practice by optimizing
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NMES application. Therefore, we recommend the sys- 12. Binder-Macleod SA, Snyder-Mackler L: Muscle fatigue: clinical implications
tematic implementation of the MP mapping procedure for fatigue assessment and neuromuscular electrical stimulation.
Phys Ther 1993, 73:902–910.
into clinical applications of NMES to further attain 13. Malesević NM, Popović LZ, Schwirtlich L, Popović DB: Distributed low-
beneficial outcomes. frequency functional electrical stimulation delays muscle fatigue
compared to conventional stimulation. Muscle Nerve 2010, 42:556–562.
Abbreviations 14. Feil S, Newell J, Minogue C, Paessler HH: The effectiveness of
NMES: Neuromuscular electrical stimulation; MP: Motor point. supplementing a standard rehabilitation program with superimposed
neuromuscular electrical stimulation after anterior cruciate ligament
reconstruction: a prospective, randomized, single-blind study. Am J
Competing interests Sports Med 2011, 39:1238–1247.
The authors declare that they have no competing interests. 15. Paessler HH: Emerging techniques in orthopedics: advances in
neuromuscular electrical stimulation. Am J Orthop 2012, 41(Suppl 5):1–8.
Authors’ contributions 16. Bruce-Brand RA, Walls RJ, Ong JC, Emerson BS, O'Byrne JM, Moyna NM:
MG and MAM conceived the commentary and drafted the manuscript. NAM Effects of home-based resistance training and neuromuscular electrical
and CO contributed to drafting the manuscript and provided critical revision. stimulation in knee osteoarthritis: a randomized controlled trial.
All authors read and approved the final manuscript. BMC Musculoskelet Disord 2012, 13:118.

Acknowledgements doi:10.1186/1743-0003-11-17
The authors’ work related to this commentary was supported by the bank Cite this article as: Gobbo et al.: Muscle motor point identification is
foundations “Compagnia di San Paolo” of Turin, Italy (Project “Neuromuscular essential for optimizing neuromuscular electrical stimulation use. Journal
Investigation and Conditioning in Endocrine Myopathies”) and “Fondazione of NeuroEngineering and Rehabilitation 2014 11:17.
CARIPLO” of Milan, Italy (Project “Steroid myopathy: Molecular,
Histopathological, and Electrophysiological Characterization”) and by a grant
(ex 60%) from the University of Turin (MAM).

Author details
1
Department of Clinical and Experimental Sciences, University of Brescia;
Laboratory of Neuromuscular Rehabilitation, Clinic “Domus Salutis”, Brescia,
Italy. 2Neuromuscular Research Laboratory, Schulthess Clinic, Zurich,
Switzerland. 3Division of Endocrinology, Diabetology and Metabolism,
Department of Medical Sciences, University of Turin, Turin, Italy.

Received: 6 May 2013 Accepted: 20 February 2014

Published: 25 February 2014

References
1. Hultman E, Sjöholm H, Jäderholm-Ek I, Krynicki J: Evaluation of methods
for electrical stimulation of human skeletal muscle in situ. Pflugers Arch
1983, 398:139–141.
2. Maffiuletti NA: Physiological and methodological considerations for the
use of neuromuscular electrical stimulation. Eur J Appl Physiol 2010,
110:223–234.
3. Walls RJ, McHugh G, O'Gorman DJ, Moyna NM, O'Byrne JM: Effects of
preoperative neuromuscular electrical stimulation on quadriceps
strength and functional recovery in total knee arthroplasty. A pilot
study. BMC Musculoskelet Disord 2010, 11:119.
4. Doucet BM, Lam A, Griffin L: Neuromuscular electrical stimulation for
skeletal muscle function. Yale J Biol Med 2012, 85:201–215.
5. Botter A, Oprandi G, Lanfranco F, Allasia S, Maffiuletti NA, Minetto MA: Atlas
of the muscle motor points for the lower limb: implications for electrical
stimulation procedures and electrode positioning. Eur J Appl Physiol 2011,
111:2461–2471.
6. Gobbo M, Gaffurini P, Bissolotti L, Esposito F, Orizio C: Transcutaneous
neuromuscular electrical stimulation: influence of electrode positioning
and stimulus amplitude settings on muscle response. Eur J Appl Physiol
2011, 111:2451–2459.
7. Mandrile F, Farina D, Pozzo M, Merletti R: Stimulation artifact in surface Submit your next manuscript to BioMed Central
EMG signal: effect of the stimulation waveform, detection system, and and take full advantage of:
current amplitude using hybrid stimulation technique. IEEE Trans Neural
Syst Rehabil Eng 2003, 11:407–415.
• Convenient online submission
8. Lieber RL, Kelly MJ: Factors influencing quadriceps femoris muscle torque
using transcutaneous neuromuscular electrical stimulation. Phys Ther • Thorough peer review
1991, 71:715–721. • No space constraints or color figure charges
9. Crochetiere WJ, Vodovnik L, Reswick JB: Electrical stimulation of skeletal
• Immediate publication on acceptance
muscle - a study of muscle as an actuator. Med Biol Eng 1967, 5:111–125.
10. Bigland-Ritchie B, Jones DA, Woods JJ: Excitation frequency and muscle • Inclusion in PubMed, CAS, Scopus and Google Scholar
fatigue: electrical responses during human voluntary and stimulated • Research which is freely available for redistribution
contractions. Exp Neurol 1979, 64:414–427.
11. Gregory CM, Bickel CS: Recruitment patterns in human skeletal muscle
during electrical stimulation. Phys Ther 2005, 85:358–364. Submit your manuscript at
www.biomedcentral.com/submit