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Bauwens PH, Fayard JM, Tatar M, Abid H, Freychet B, Sonnery-Cottet B, Thaunat M. Evaluation of a smartphone application for self-rehabilitation after anterior cruciate ligament reconstruction during a COVID-19 lockdown. Orthop Traumatol Surg Res 2023; 109:103342. [PMID: 35660080 DOI: 10.1016/j.otsr.2022.103342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rehabilitation after surgery is a crucial process that governs the final functional outcome. The self-rehabilitation smartphone application Doct'up (Healing SAS, Lyon, France) is designed for patients who have had anterior cruciate ligament (ACL) reconstruction surgery. In France in the spring of 2020, the lockdown mandated due to the COVID-19 pandemic prevented patients from seeing their physiotherapists for 2 months. The objective of this study was to compare the clinical outcomes in two groups of patients who underwent ACL reconstruction surgery: in one group, surgery performed before the lockdown was followed by standard in-person physiotherapy while, in the other, surgery was done just before the lockdown and rehabilitation was performed by the patients themselves using the phone application. HYPOTHESIS Using a self-rehabilitation smartphone app limits the negative effects of not receiving physiotherapist rehabilitation after ACL reconstruction. MATERIAL AND METHODS We performed a case-control study involving the retrospective analysis of prospectively collected data from two groups of patients who had undergone ACL reconstruction surgery. Patients in the App group had surgery just before the 2-month COVID-19-related lockdown that started in France on March 17, 2020,and used only the smartphone app for rehabilitation. The standard-care group was composed of matched controls who had surgery 1 year before the cases and received rehabilitation therapy during in-person physiotherapist visits. The ACL reconstruction technique was the same in the two groups. The primary outcome measure was extension lag 6 weeks after surgery. The secondary outcome measures were extension lag 3 weeks and 6 months after surgery, quadriceps muscle activation, knee extension locking 3 and 6 weeks after surgery, and the 6-month rate of surgical revision for cyclops syndrome. RESULTS We included 32 cases managed using only self-rehabilitation guided by the phone app, and we identified 101 matched controls managed using standard care. We found no significant between-group difference in extension lag after 6 weeks: 9.4% (28/32) vs. 4.6% (87/101), p=0.39. After 3 weeks, the App group had a higher proportions of patients with quadriceps activation (94% [30/32] vs. 73% [74/101], p=0.015) and extension control using canes (78.1% [25/32] vs. 40.6% [41/101], p=0.0002). None of the other measured outcomes differed significantly between the two groups (extension lag after 3 weeks: 12.5% [4/32] vs. 13.8% 14/101]; extension lag after 6 months: 3.2% [1/32] vs. 1% [1/101]; quadriceps activation after 6 weeks: 97% [31/32] vs. 99% [100/101]; extension locking with canes after 6 weeks: 96.9% [31/32] vs. 93.1% [94/101]; extension locking without canes after 3 weeks: 53.2% [17/32] vs. 47.5% [48/101]; extension locking without canes after 6 weeks: 93.7% [30/32] vs. 82.2% [83/101]; and surgery for cyclops syndrome (3.1% [1/32] vs. 1% [1/101]). DISCUSSION The use of a self-rehabilitation phone app after ACL reconstruction during a COVID-19 lockdown limited the adverse effects of not receiving in-person physiotherapy. The 6-month outcomes were similar to those seen with standard rehabilitation. The study results demonstrate the usefulness of self-rehabilitation after ACL reconstruction surgery. Self-rehabilitation guided by a phone app could be used as a complement to the protocols generally applied by physiotherapists. LEVEL OF EVIDENCE IV, single-centre retrospective case-control study.
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Affiliation(s)
- Paul-Henri Bauwens
- Centre Orthopédique Santy, Lyon, France, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Jean-Marie Fayard
- Centre Orthopédique Santy, Lyon, France, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Maxime Tatar
- Centre Orthopédique Santy, Lyon, France, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Hichem Abid
- Centre Orthopédique Santy, Lyon, France, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Benjamin Freychet
- Centre Orthopédique Santy, Lyon, France, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Lyon, France, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, Lyon, France, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.
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McPherson AL, Schilaty ND, Anderson S, Nagai T, Bates NA. Arthrogenic muscle inhibition after anterior cruciate ligament injury: Injured and uninjured limb recovery over time. Front Sports Act Living 2023; 5:1143376. [PMID: 37025459 PMCID: PMC10072230 DOI: 10.3389/fspor.2023.1143376] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/15/2023] [Indexed: 04/08/2023] Open
Abstract
Introduction It is well documented that marked weakness of the quadriceps is present after knee joint injury. This joint trauma induces a presynaptic reflex inhibition of musculature surrounding the joint, termed arthrogenic muscle inhibition (AMI). The extent to which anterior cruciate ligament (ACL) injury affects thigh musculature motor unit activity, which may affect restoration of thigh muscle strength after injury, is undetermined. Methods A randomized protocol of knee flexion and extension isometric contractions (10%-50% maximal voluntary isometric contraction) were performed for each leg on 54 subjects with electromyography array electrodes placed on the vastus medialis, vastus lateralis, semitendinosus, and biceps femoris. Longitudinal assessments for motor unit recruitment and average firing rate were acquired at 6-month intervals for 1 year post ACL injury. Results The ACL-injured population demonstrated smaller quadriceps and hamstrings motor unit size (assessed via motor unit action potential peak-to-peak amplitude) and altered firing rate activity in both injured and uninjured limbs compared to healthy controls. Motor unit activity remained altered compared to healthy controls at 12 months post ACL reconstruction (ACLR). Discussion Motor unit activity was altered after ACLR up to 12 months post-surgery. Further research is warranted to optimize rehabilitation interventions that adequately address altered motor unit activity and improve safety and success with return to sport after ACLR. In the interim, evidence based clinical reasoning with a focus on development of muscular strength and power capacity should be the impetus behind rehabilitation programming to address motor control deficits.
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Affiliation(s)
- April L. McPherson
- Emory Sport Performance and Research Center, Emory University, Flowery Branch, GA, United States
- Department of Orthopaedics, The Ohio State University, Columbus, OH, United States
- Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
- Correspondence: April L. McPherson
| | - Nathan D. Schilaty
- Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
- Department of Physical Medicine & Rehabilitation, Rochester, MN, United States
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
- Sports Medicine Center, Mayo Clinic, Rochester, MN, United States
- Department of Neurosurgery & Brain Repair, University of South Florida, Tampa, FL, United States
- Department of Medical Engineering, University of South Florida, Tampa, FL, United States
| | - Sarah Anderson
- Department of Physical Medicine & Rehabilitation, Rochester, MN, United States
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
- Sports Medicine Center, Mayo Clinic, Rochester, MN, United States
| | - Takashi Nagai
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
- Sports Medicine Center, Mayo Clinic, Rochester, MN, United States
- United States Army Research Institute of Environmental Medicine, Natick, MA, United States
| | - Nathaniel A. Bates
- Department of Orthopaedics, The Ohio State University, Columbus, OH, United States
- Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
- Sports Medicine Center, Mayo Clinic, Rochester, MN, United States
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Chantrelle M, Menu P, Crenn V, Grondin J, Daley P, Louguet B, Fouasson-Chailloux A, Dauty M. Consequences of anterior knee pain after anterior cruciate ligament reconstruction: A 2015-2020 cohort study. PLoS One 2023; 18:e0280146. [PMID: 36603016 PMCID: PMC9815630 DOI: 10.1371/journal.pone.0280146] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023] Open
Abstract
Anterior cruciate ligament reconstruction (ACLR) using hamstring tendon (HT) graft aims to stabilise the knee, but it may bring some complications like anterior knee (AKP) pain that can have consequences on the functional aspect of this surgery. The aim of this study was to compare isokinetic knee strength and functional outcomes between patients with and without AKP following an ACLR using HT graft during the first-year post-surgery. Three hundred and thirty subjects operated by ACLR using hamstring tendon graft were included in our retrospective cohort and divided into two groups: a group with AKP (AKP+ group) and one without AKP (AKP-group). In our population, 14.8% of the patients had AKP. At 4 post-operative months, subjects with pain had lower isokinetic strength limb symmetry index (LSI) for knee flexors and extensors, and a lower Lysholm score than subjects without pain (p < 0.0001). These differences did not persist at 7 post-operative months, and there was no difference in the one-leg hop test. After multivariate analysis, we highlighted the impact of time on the evolution of these parameters. Yet, the exact definition of AKP after ACLR remains to be clearly defined since an imprecise diagnosis may lead to inappropriate management. Pre-operative information about this type of complication, which evolves favourably with time, could be useful for patients. Indeed, AKP can occur after ACLR, even if a HT graft has been used, compared to other surgical procedures using the knee extensor apparatus as patellar tendon graft (AKP is associated with the donor site morbidity). In case of AKP after ACLR, monitoring the muscle inhibition by isokinetic tests may enable clinicians to adapt the retraining and the return to sport.
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Affiliation(s)
- Marie Chantrelle
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Département de Médecine Physique et de Réadaptation, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Pierre Menu
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, Nantes, France
| | - Vincent Crenn
- Clinique Chirugicale Othopédique et Traumatologique, CHU Nantes, Nantes Université, Nantes, France
| | - Jérôme Grondin
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
| | - Pauline Daley
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
| | - Bastien Louguet
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
| | - Alban Fouasson-Chailloux
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, Nantes, France
- * E-mail:
| | - Marc Dauty
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, Nantes, France
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Criss CR, Lepley AS, Onate JA, Simon JE, France CR, Clark BC, Grooms DR. Neural Correlates of Self-Reported Knee Function in Individuals After Anterior Cruciate Ligament Reconstruction. Sports Health 2023; 15:52-60. [PMID: 35321615 PMCID: PMC9808834 DOI: 10.1177/19417381221079339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) rupture is a common knee injury among athletes and physically active adults. Despite surgical reconstruction and extensive rehabilitation, reinjuries are common and disability levels are high, even years after therapy and return to activity. Prolonged knee dysfunction may result in part from unresolved neuromuscular deficits of the surrounding joint musculature in response to injury. Indeed, "upstream" neurological adaptations occurring after injury may explain these persistent functional deficits. Despite evidence for injury consequences extending beyond the joint to the nervous system, the link between neurophysiological impairments and patient-reported measures of knee function remains unclear. HYPOTHESIS Patterns of brain activation for knee control are related to measures of patient-reported knee function in individuals after ACL reconstruction (ACL-R). STUDY DESIGN Cross-sectional study. LEVEL OF EVIDENCE Level 3. METHODS In this multicenter, cross-sectional study, participants with unilateral ACL-R (n = 25; 10 men, 15 women) underwent task-based functional magnetic resonance imaging testing. Participants performed repeated cycles of open-chain knee flexion/extension. Neural activation patterns during the movement task were quantified using blood oxygen level-dependent (BOLD) signals. Regions of interest were generated using the Juelich Histological Brain Atlas. Pearson product-moment correlations were used to determine the relationship between mean BOLD signal within each brain region and self-reported knee function level, as measured by the International Knee Documentation Committee index. Partial correlations were also calculated after controlling for time from surgery and sex. RESULTS Patient-reported knee function was positively and moderately correlated with the ipsilateral secondary somatosensory cortex (r = 0.57, P = 0.005) and the ipsilateral supplementary motor area (r = 0.51, P = 0.01). CONCLUSION Increased ipsilateral secondary sensorimotor cortical activity is related to higher perceived knee function. CLINICAL RELEVANCE Central nervous system mechanisms for knee control are related to subjective levels of knee function after ACL-R. Increased neural activity may reflect central neuroplastic strategies to preserve knee functionality after traumatic injury.
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Affiliation(s)
- Cody R. Criss
- Translational Biomedical Sciences,
Graduate College, Ohio University, Athens, Ohio
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Cody R Criss, W283 Grover
Center, 1 Ohio University, Athens, OH 45701 (
) (Twitter: @criss_cody)
| | - Adam S. Lepley
- Exercise and Sport Science Initiative,
School of Kinesiology, University of Michigan, Ann Arbor, Michigan
| | - James A. Onate
- School of Health and Rehabilitation
Sciences, The Ohio State University, Columbus, Ohio
| | - Janet E. Simon
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Division of Athletic Training, School
of Applied Health Sciences and Wellness, College of Health Sciences and Professions,
Ohio University, Athens, Ohio
| | - Christopher R. France
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Department of Psychology, College of
Arts and Sciences, Ohio University, Athens, Ohio
| | - Brian C. Clark
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Department of Biomedical Sciences,
Ohio University, Athens, Ohio
- Department of Geriatric Medicine, Ohio
University, Athens, Ohio
| | - Dustin R. Grooms
- Ohio Musculoskeletal & Neurological
Institute (OMNI), Ohio University, Athens, Ohio
- Division of Athletic Training, School
of Applied Health Sciences and Wellness, College of Health Sciences and Professions,
Ohio University, Athens, Ohio
- Division of Physical Therapy, School
of Rehabilitation and Communication Sciences, College of Health Sciences and
Professions, Ohio University, Athens, Ohio
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Long T, Fernandez J, Liu H, Li H. Evaluating the risk of knee osteoarthritis following unilateral ACL reconstruction based on an EMG-assisted method. Front Physiol 2023; 14:1160261. [PMID: 37153223 PMCID: PMC10160379 DOI: 10.3389/fphys.2023.1160261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Objective: Anterior cruciate ligament reconstruction (ACLR) cannot decrease the risk of knee osteoarthritis after anterior cruciate ligament rupture, and tibial contact force is associated with the development of knee osteoarthritis. The purpose of this study was to compare the difference in bilateral tibial contact force for patients with unilateral ACLR during walking and jogging based on an EMG-assisted method in order to evaluate the risk of knee osteoarthritis following unilateral ACLR. Methods: Seven unilateral ACLR patients participated in experiments. The 14-camera motion capture system, 3-Dimension force plate, and wireless EMG test system were used to collect the participants' kinematics, kinetics, and EMG data during walking and jogging. A personalized neuromusculoskeletal model was established by combining scaling and calibration optimization. The inverse kinematics and inverse dynamics algorithms were used to calculate the joint angle and joint net moment. The EMG-assisted model was used to calculate the muscle force. On this basis, the contact force of the knee joint was analyzed, and the tibial contact force was obtained. The paired sample t-test was used to analyze the difference between the participants' healthy and surgical sides of the participants. Results: During jogging, the peak tibial compression force on the healthy side was higher than on the surgical side (p = 0.039). At the peak moment of tibial compression force, the muscle force of the rectus femoris (p = 0.035) and vastus medialis (p = 0.036) on the healthy side was significantly higher than that on the surgical side; the knee flexion (p = 0.042) and ankle dorsiflexion (p = 0.046) angle on the healthy side was higher than that on the surgical side. There was no significant difference in the first (p = 0.122) and second (p = 0.445) peak tibial compression forces during walking between the healthy and surgical sides. Conclusion: Patients with unilateral ACLR showed smaller tibial compression force on the surgical side than on the healthy side during jogging. The main reason for this may be the insufficient exertion of the rectus femoris and vastus medialis.
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Affiliation(s)
- Ting Long
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Biomechanics Laboratory, Beijing Sport University, Beijing, China
- *Correspondence: Ting Long, ; Hanjun Li,
| | - Justin Fernandez
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - Hui Liu
- China Institute of Sport and Health Science, Beijing Sport University, Beijing, China
| | - Hanjun Li
- Biomechanics Laboratory, Beijing Sport University, Beijing, China
- *Correspondence: Ting Long, ; Hanjun Li,
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Patel HH, Berlinberg EJ, Nwachukwu B, Williams RJ, Mandelbaum B, Sonkin K, Forsythe B. Quadriceps Weakness is Associated with Neuroplastic Changes Within Specific Corticospinal Pathways and Brain Areas After Anterior Cruciate Ligament Reconstruction: Theoretical Utility of Motor Imagery-Based Brain-Computer Interface Technology for Rehabilitation. Arthrosc Sports Med Rehabil 2022; 5:e207-e216. [PMID: 36866306 PMCID: PMC9971910 DOI: 10.1016/j.asmr.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 11/09/2022] [Indexed: 12/29/2022] Open
Abstract
Persistent quadriceps weakness is a problematic sequela of anterior cruciate ligament reconstruction (ACLR). The purposes of this review are to summarize neuroplastic changes after ACL reconstruction; provide an overview of a promising interventions, motor imagery (MI), and its utility in muscle activation; and propose a framework using a brain-computer interface (BCI) to augment quadriceps activation. A literature review of neuroplastic changes, MI training, and BCI-MI technology in postoperative neuromuscular rehabilitation was conducted in PubMed, Embase, and Scopus. Combinations of the following search terms were used to identify articles: "quadriceps muscle," "neurofeedback," "biofeedback," "muscle activation," "motor learning," "anterior cruciate ligament," and "cortical plasticity." We found that ACLR disrupts sensory input from the quadriceps, which results in reduced sensitivity to electrochemical neuronal signals, an increase in central inhibition of neurons regulating quadriceps control and dampening of reflexive motor activity. MI training consists of visualizing an action, without physically engaging in muscle activity. Imagined motor output during MI training increases the sensitivity and conductivity of corticospinal tracts emerging from the primary motor cortex, which helps "exercise" the connections between the brain and target muscle tissues. Motor rehabilitation studies using BCI-MI technology have demonstrated increased excitability of the motor cortex, corticospinal tract, spinal motor neurons, and disinhibition of inhibitory interneurons. This technology has been validated and successfully applied in the recovery of atrophied neuromuscular pathways in stroke patients but has yet to be investigated in peripheral neuromuscular insults, such as ACL injury and reconstruction. Well-designed clinical studies may assess the impact of BCI on clinical outcomes and recovery time. Quadriceps weakness is associated with neuroplastic changes within specific corticospinal pathways and brain areas. BCI-MI shows strong potential for facilitating recovery of atrophied neuromuscular pathways after ACLR and may offer an innovative, multidisciplinary approach to orthopaedic care. Level of Evidence V, expert opinion.
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Affiliation(s)
- Harsh H. Patel
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Chicago, Illinois
| | - Elyse J. Berlinberg
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Chicago, Illinois
| | - Benedict Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Riley J. Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Bert Mandelbaum
- Department of Orthopaedic Surgery, Cedars-Sinai Kerlan-Jobe Institute, Santa Monica, California, U.S.A
| | | | - Brian Forsythe
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Chicago, Illinois,Address correspondence to Brian Forsythe, M.D., 1611 W. Harrison St, Suite 360, Chicago, IL 60621
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Pinto RF, Birmingham TB, Philpott HT, Primeau CA, Leitch KM, Arsenault DA, Appleton CT. Changes and Associations Between Gait Biomechanics and Knee Inflammation After Aspiration and Glucocorticoid Injection for Knee Osteoarthritis. Arthritis Care Res (Hoboken) 2022. [PMID: 36478406 DOI: 10.1002/acr.25064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/20/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although knee inflammation is thought to adversely affect joint function in patients with knee osteoarthritis (OA), the effects of reducing knee inflammation on gait biomechanics and strength are unknown. Our objectives were to compare ultrasound (US) measures of knee inflammation, gait biomechanics, knee extension and flexion strength, and pain before and after knee aspiration and glucocorticoid injection, and to explore associations among changes. METHODS Forty-nine patients (69 knees) with symptomatic knee OA and synovitis were tested before and 3-4 weeks after US-guided knee aspiration and glucocorticoid injection. At each visit, participants completed US assessments for inflammatory features of knee OA, 3D gait analysis, isokinetic knee extension and flexion strength tests, and Knee Osteoarthritis Outcome Score (KOOS) pain subscales. Linear and polynomial mixed-effects regression models were used to investigate changes and their associations. RESULTS Changes were observed for the synovitis score (unstandardized β [post-injection minus pre-injection] -0.55/9 [95% confidence interval (95% CI) -0.97, -0.12]), effusion depth (-1.05 mm [95% CI -1.07, -0.39]), KOOS pain (unstandardized β 5.91/100 [95% CI 1.86, 9.97]), peak external knee flexion and extension moments (KFM; 3.33 Nm [95% CI 0.45, 6.22]), KEM (-2.99 Nm [95% CI -5.93, -0.05]), and knee extension strength (4.70 Nm [95% CI 0.39, 9.00]) and flexion strength (3.91 Nm [95% CI 1.50, 6.81]). The external KFM increased during 13-38% and 76-89% of stance post-injection. When controlled for time, greater synovitis was associated with lower knee extension strength, while lower pain was associated with increased knee extension and flexion strength. CONCLUSION In patients with knee OA and synovitis, reduced inflammation and pain after aspiration and glucocorticoid injection are associated with changes in knee gait biomechanics and strength.
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Affiliation(s)
- Ryan F Pinto
- University of Western Ontario and London Health Sciences Centre-University Hospital, London, Ontario, Canada
| | - Trevor B Birmingham
- University of Western Ontario and London Health Sciences Centre-University Hospital, London, Ontario, Canada
| | - Holly T Philpott
- University of Western Ontario and London Health Sciences Centre-University Hospital, London, Ontario, Canada
| | - Codie A Primeau
- University of Western Ontario and London Health Sciences Centre-University Hospital, London, Ontario, Canada
| | - Kristyn M Leitch
- University of Western Ontario and London Health Sciences Centre-University Hospital, London, Ontario, Canada
| | | | - C Thomas Appleton
- St. Joseph's Health Care London and Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Huby CL, Miari I, Hagen M, Verschueren S, Vanrenterghem J, Smeets A. Push-Off Dynamics Reveal Task-Independent Alterations in Athletes Returning to Sport after ACL Reconstruction. Med Sci Sports Exerc 2022; 54:2045-2053. [PMID: 35797624 DOI: 10.1249/mss.0000000000002994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Athletes with an anterior cruciate ligament (ACL) reconstruction (ACLR) show persisting biomechanical and neuromuscular landing alterations. So far, most research focused on the landing phase of dynamic tasks where most ACL injuries occur. This study will assess whether these landing alterations are also present in the propulsion phase, in an attempt to identify generalized movement alterations. METHODS Twenty-one athletes with ACLR (cleared by their surgeon and/or physiotherapist for return-to-sport) and twenty-one controls performed five single-leg hop tasks. Propulsion kinematics, kinetics, and muscle activations were compared between legs and between groups. RESULTS Increased hamstrings activation was found during propulsion when comparing the ACLR limb with both the uninjured limb and the controls. In addition, decreased internal knee extension moments were found in the ACLR limb compared with the uninjured limb. CONCLUSIONS Athletes with ACLR show task-independent alterations that unload the knee during the propulsion phase of single-leg hopping tasks. If longitudinal data deem these alterations to be maladaptive, more emphasis must be placed on their normalization during the propulsion phase, assuming beneficial carryover effects into the landing phase. Normalizing these patterns during rehabilitation may potentially reduce the risk of long-term complications such as reinjuries and posttraumatic osteoarthritis.
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Affiliation(s)
- Claire Louise Huby
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, BELGIUM
| | - Ioanna Miari
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, BELGIUM
| | - Michiel Hagen
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, BELGIUM
| | - Sabine Verschueren
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, BELGIUM
| | - Jos Vanrenterghem
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, BELGIUM
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Diong J, Kishimoto KC, Butler JE, Héroux ME. Muscle electromyographic activity normalized to maximal muscle activity, not to Mmax, better represents voluntary activation. PLoS One 2022; 17:e0277947. [PMID: 36409688 PMCID: PMC9678282 DOI: 10.1371/journal.pone.0277947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022] Open
Abstract
In human applied physiology studies, the amplitude of recorded muscle electromyographic activity (EMG) is often normalized to maximal EMG recorded during a maximal voluntary contraction. When maximal contractions cannot be reliably obtained (e.g. in people with muscle paralysis, anterior cruciate ligament injury, or arthritis), EMG is sometimes normalized to the maximal compound muscle action potiential evoked by stimulation, the Mmax. However, it is not known how these two methods of normalization affect the conclusions and comparability of studies. To address this limitation, we investigated the relationship between voluntary muscle activation and EMG normalized either to maximal EMG or to Mmax. Twenty-five able-bodied adults performed voluntary isometric ankle plantarflexion contractions to a range of percentages of maximal voluntary torque. Ankle torque, plantarflexor muscle EMG, and voluntary muscle activation measured by twitch interpolation were recorded. EMG recorded at each contraction intensity was normalized to maximal EMG or to Mmax for each plantarflexor muscle, and the relationship between the two normalization approaches quantified. A slope >1 indicated EMG amplitude normalized to maximal EMG (vertical axis) was greater than EMG normalized to Mmax (horizontal axis). Mean estimates of the slopes were large and had moderate precision: soleus 8.7 (95% CI 6.9 to 11.0), medial gastrocnemius 13.4 (10.5 to 17.0), lateral gastrocnemius 11.4 (9.4 to 14.0). This indicates EMG normalized to Mmax is approximately eleven times smaller than EMG normalized to maximal EMG. Normalization to maximal EMG gave closer approximations to the level of voluntary muscle activation assessed by twitch interpolation.
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Affiliation(s)
- Joanna Diong
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- * E-mail:
| | - Kenzo C. Kishimoto
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Jane E. Butler
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia
| | - Martin E. Héroux
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia
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Taniguchi M, Fukumoto Y, Yagi M, Motomura Y, Okada S, Okada S, Kobayashi M, Ichihashi N. Enhanced echo intensity in vastus medialis is associated with worsening of functional disabilities and symptoms in patients with knee osteoarthritis: a 3 years longitudinal study. Rheumatol Int 2022; 43:953-960. [PMID: 36394599 PMCID: PMC9672570 DOI: 10.1007/s00296-022-05246-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/09/2022] [Indexed: 11/18/2022]
Abstract
Patients with knee osteoarthritis (OA) experience muscle quality loss, and is characterized by the enhanced echo intensity (EI) of the vastus medialis (VM) muscles and a high extracellular water-to-intracellular water (ECW/ICW) ratio of the thigh. This study aimed to elucidate the association between muscle degeneration and the worsening of functional disabilities and symptoms in patients with KOA over 3 years duration. Thirty-three patients with KOA who completed follow-up over 3 years were included in the analysis. The knee scoring system (KSS) was used to evaluate the functional abilities and symptoms. Based on the 3 years change in KSS scores, patients were classified into progressive or non-progressive groups. Muscle thickness (MT) and EI of the VM were determined using ultrasonography. The ECW/ICW ratio was measured using segmental-bioelectrical impedance spectroscopy. Multivariable logistic regression analyses were conducted with the groups as the dependent variables and VM-MT, VM-EI, and ECW/ICW ratio at baseline as independent variables, including potential confounders. Thirteen (39.4%) patients showed progressive features. VM-EI at baseline was significantly associated with the progression of functional disabilities (adjusted odds ratio [OR] 1.24; 95% confidence interval [CI] 1.03 − 1.50) and symptoms (adjusted OR 1.13; 95% CI 1.01 − 1.25). Enhanced VM-EI was associated with the worsening of functional disabilities and symptoms in patients with KOA over a period of 3 years. Therefore, the assessment of VM-EI using ultrasonography is a useful indicator for predicting the future worsening of KOA.
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Affiliation(s)
- Masashi Taniguchi
- Graduate School of Medicine, Human Health Sciences, Kyoto University, 53-Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Yoshihiro Fukumoto
- Graduate School of Medicine, Human Health Sciences, Kyoto University, 53-Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
- Faculty of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Masahide Yagi
- Graduate School of Medicine, Human Health Sciences, Kyoto University, 53-Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Yoshiki Motomura
- Graduate School of Medicine, Human Health Sciences, Kyoto University, 53-Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
- Department of Orthopaedic Surgery, Kobayashi Hospital, Kyoto, Japan
| | - Sayaka Okada
- Graduate School of Medicine, Human Health Sciences, Kyoto University, 53-Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Shogo Okada
- Graduate School of Medicine, Human Health Sciences, Kyoto University, 53-Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
| | | | - Noriaki Ichihashi
- Graduate School of Medicine, Human Health Sciences, Kyoto University, 53-Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
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Kong DH, Jung WS, Yang SJ, Kim JG, Park HY, Kim J. Effects of Neuromuscular Electrical Stimulation and Blood Flow Restriction in Rehabilitation after Anterior Cruciate Ligament Reconstruction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15041. [PMID: 36429760 PMCID: PMC9690111 DOI: 10.3390/ijerph192215041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 06/16/2023]
Abstract
The present study aimed to examine and compare the effects of a rehabilitation exercise (RE) using neuromuscular electrical stimulation (NMES) and blood flow restriction (BFR) on muscle function and knee functional abilities in patients who underwent anterior cruciate ligament reconstruction (ACLR). A total of 45 patients who underwent ACLR (28.76 ± 0.8 years; 34 males and 11 females) were retrospectively divided into three groups: control (CON, n = 15), NMES (n = 15), and BFR (n = 15). All participants carried out the RE program for 60 min, thrice a week for 12 weeks. The Lysholm score, International Knee Documentation Committee (IKDC) subjective score, thigh circumference at 5 cm from the knee joint, Y-balance posterior medial, and lateral significantly increased in all groups via intervention (p < 0.05). However, NMES showed a higher thigh circumference at 15 cm from the knee joint than CON via intervention (p < 0.05), and the strength and endurance of quadriceps femoris and hamstrings and Y-balance anterior showed a significant increase via intervention in NMES and BFR compared with CON (p < 0.05). In conclusion, we confirmed that RE using NMES and BFR effectively enhances muscle function and balance in ACLR patients.
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Affiliation(s)
- Doo-Hwan Kong
- Department of Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, Inje University, 9 Mareunnae-ro, Jung-gu, Seoul 04551, Republic of Korea
- Department of Sports Medicine and Science, Graduate School, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Republic of Korea
| | - Won-Sang Jung
- Department of Sports Medicine and Science, Graduate School, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Republic of Korea
- Physical Activity and Performance Institute, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Republic of Korea
| | - Sang-Jin Yang
- Department of Health and Exercise Management, Tongwon University, 26 Gyeongchung-daero, Gonjiam-eup, Gwangju-si 12813, Republic of Korea
| | - Jin-Goo Kim
- Department of Orthopedic Surgery and Sports Medical Center, Myong-Ji Hospital, 55 Hwasu-ro 14beon-gil, Deogyang-gu, Goyang-si 10475, Republic of Korea
| | - Hun-Young Park
- Department of Sports Medicine and Science, Graduate School, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Republic of Korea
- Physical Activity and Performance Institute, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Republic of Korea
| | - Jisu Kim
- Department of Sports Medicine and Science, Graduate School, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Republic of Korea
- Physical Activity and Performance Institute, Konkuk University, 120 Neungdong-ro, Gwangjin-gu, Seoul 05029, Republic of Korea
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Lin TY, Chung CC, Chen WC, Su CW, Fang HW, Lu YC. Complications following all-inside anterior cruciate ligament reconstruction. INTERNATIONAL ORTHOPAEDICS 2022; 46:2569-2576. [PMID: 35859213 DOI: 10.1007/s00264-022-05515-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/11/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE We conducted a comprehensive analysis of possible perioperative complications following all-inside anterior cruciate ligament reconstruction (ACLR). Additional techniques and tips are proposed to prevent and manage complications. METHODS Complications following all-inside ACLR performed between December 2015 and December 2020 were retrospectively analysed. Altogether, 348 operations were performed and 275 patients were enrolled with a minimum 12-month follow-up period. Only semitendinosus autograft was utilised in most patients, and semitendinosus-gracilis autograft and allograft were used in five and 31 patients, respectively. Simultaneous meniscal repair, partial meniscectomy, and chondral surgery were performed in 29.5%, 21.1%, and 4.4% of patients, respectively. Complications were observed based on the patient's clinical condition, plain film, and magnetic resonance imaging. Clinical outcomes were assessed pre-operatively and at 12 months post-operatively, using the International Knee Documentation Committee form, Lysholm and Tegner activity scores, and KT1000 side-to-side difference. RESULTS Intraoperative and post-operative complications developed in 65 patients (23.6%). The most common complication was cortical button malposition on the femoral side (19.3%). Intra-operative breakage of the retrograde drill was found in two cases (0.73%), with three cases (1.1%) of over-drilling with destruction of the outer cortex. Post-operatively, four (1.5%), 13 (4.7%), and 16 (5.8%) cases of infection, full-thickness re-rupture, and loss of extension, respectively, were recorded. Functional outcome scales showed significant post-operative improvement. CONCLUSION Cortical button malposition was the most common but easily preventable complication. All-inside ACLR could be safe and promising after the suggested additional operative techniques and proper perioperative management which decrease complication rates and improve favourable outcomes.
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Affiliation(s)
- Tsung-Yu Lin
- Department of Orthopedic Surgery, Mackay Memorial Hospital, No.45, Minsheng Rd, Tamsui Dist., New Taipei City, Taiwan, Republic of China
- Mackay Junior College of Medicine, Nursing and Management, No. 42, Sec. 3, Zhongzheng Rd, Sanzhi Dist., New Taipei City, Taiwan, Republic of China
- Chemical Engineering and Biotechnology Department, National Taipei University of Technology, No. 1, Sec. 3, Jhongsiao E. Rd, Da'an Dist., 106344, Taipei City, Taiwan, Republic of China
| | - Cheng-Chun Chung
- Department of Orthopedic Surgery, Mackay Memorial Hospital, No.45, Minsheng Rd, Tamsui Dist., New Taipei City, Taiwan, Republic of China
| | - Wei-Cheng Chen
- Department of Orthopedic Surgery, Mackay Memorial Hospital, No.45, Minsheng Rd, Tamsui Dist., New Taipei City, Taiwan, Republic of China
| | - Che-Wei Su
- Department of Radiation Oncology, Mackay Memorial Hospital, No. 92, Sec. 2, Chung-San North Rd, Zhongshan Dist., 104, Taipei City, Taiwan, Republic of China
| | - Hsu-Wei Fang
- Biomechanics Research Laboratory, Department of Medical Research, Mackay Memorial Hospital, No. 45, Minsheng Rd, Tamsui Dist., New Taipei City, Taiwan, Republic of China
- Chemical Engineering and Biotechnology Department, National Taipei University of Technology, No. 1, Sec. 3, Jhongsiao E. Rd, Da'an Dist., 106344, Taipei City, Taiwan, Republic of China
| | - Yung-Chang Lu
- Department of Orthopedic Surgery, Mackay Memorial Hospital, No.45, Minsheng Rd, Tamsui Dist., New Taipei City, Taiwan, Republic of China.
- Biomechanics Research Laboratory, Department of Medical Research, Mackay Memorial Hospital, No. 45, Minsheng Rd, Tamsui Dist., New Taipei City, Taiwan, Republic of China.
- Department of Medicine, Mackay Medical College, No. 46, Sec. 3, Zhongzheng Rd, Sanzhi Dist., New Taipei City, Taiwan, Republic of China.
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Dauty M, Menu P, Daley P, Grondin J, Quinette Y, Crenn V, Fouasson-Chailloux A. Knee Strength Assessment and Clinical Evaluation Could Predict Return to Running after Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Procedure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13396. [PMID: 36293974 PMCID: PMC9603555 DOI: 10.3390/ijerph192013396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Muscle knee strength is a major parameter that allows return to running. Isokinetic strength parameters may predict return to running 4 months after ACLR using the bone-patellar-tendon-bone procedure. MATERIALS AND METHODS The isokinetic knee strength of 216 patients (24.5 ± 5 years) was measured 4 months after surgery, and progressive return to running was allowed. The effectiveness of return to running was reported at 6 months. Return to running prediction was established using multivariate logistic regression. Predictive parameters were presented with a ROC curve area to define the best cut-off, with sensibility (Se) and specificity (Sp). RESULTS A model was established, including the limb symmetry index (LSI), and 103 patients (47.6%) were able to run between the fourth and the sixth month after surgery. These patients presented significantly fewer knee complications, a better Lysholm score, a better Quadriceps and Hamstring LSI and better quadriceps strength reported for body weight on the operated limb. The best model was established including the Quadriceps and Hamstring LSI at 60°/s and the Lysholm score. The cut-off for Quadriceps LSI was 60% (ROC curve area: 0.847; Se: 77.5%; Sp: 77%), for Hamstring LSI 90% (ROC curve area: 0.716; Se: 65.7%; Sp: 60.2%) and for Lyshom score 97 points (ROC curve area: 0.691; Se: 65%; Sp: 66%). CONCLUSION Four months after ACLR using a bone-patellar-tendon-bone procedure, the Quadriceps and Hamstring LSI associated to the Lysholm score could help make the decision to allow return to running.
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Affiliation(s)
- Marc Dauty
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm UMR 1229, Regenerative Medicine and Skeleton, RMeS, Nantes Université, 44042 Nantes, France
| | - Pierre Menu
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm UMR 1229, Regenerative Medicine and Skeleton, RMeS, Nantes Université, 44042 Nantes, France
| | - Pauline Daley
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France
| | - Jérôme Grondin
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France
| | - Yonis Quinette
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU Nantes, Nantes Université, 44000 Nantes, France
| | - Vincent Crenn
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU Nantes, Nantes Université, 44000 Nantes, France
| | - Alban Fouasson-Chailloux
- Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm UMR 1229, Regenerative Medicine and Skeleton, RMeS, Nantes Université, 44042 Nantes, France
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Henderson FJ, Konishi Y, Shima N, Shimokochi Y. Effects of 8-Week Exhausting Deep Knee Flexion Flywheel Training on Persistent Quadriceps Weakness in Well-Trained Athletes Following Anterior Cruciate Ligament Reconstruction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13209. [PMID: 36293790 PMCID: PMC9602677 DOI: 10.3390/ijerph192013209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
Persistent quadriceps weakness after anterior cruciate ligament (ACL) reconstruction is a common hurdle to efficient rehabilitation. Therefore, we evaluated a new treatment strategy for athletes with ACL reconstruction. Eleven athletes with unilateral ACL reconstruction performed one set of flywheel Bulgarian split squats to exhaustion with a maximum knee extension of 60°, over 16 sessions, on their reconstructed limb. Quadriceps rate of force development (RFD) 0-50 ms (RFD0-50 ms), and 0-150 ms (RFD0-150 ms), maximum voluntary isometric contraction (MVIC), and central activation ratio (CAR) were measured bilaterally on the week before and after the intervention. In the reconstructed limb, the RFD0-50 ms (p = 0.04; Cohen's d = 0.8) and RFD0-150 ms (p = 0.03; d = 0.9) increased after training. Before-after changes in MVIC and CAR were not significant (p > 0.05), but the lower the baseline MVIC, the greater the gain in MVIC (r = -0.71, p = 0.02). The between-leg difference in MVIC changed from large before (p = 0.01; d = 0.8) to small after training (p = 0.04; d = 0.4). One set of deep knee flexion flywheel Bulgarian split squats to exhaustion improved quadriceps deficits in well-trained athletes with ACL-reconstruction, particularly those with relatively low quadriceps force production.
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Affiliation(s)
- Frederick James Henderson
- Department of Health and Sport Management, Osaka University of Health and Sport Sciences, Sennan-gun 590-0496, Japan
| | - Yu Konishi
- Department of Physical Education, National Defense Academy of Japan, Yokosuka 239-8686, Japan
| | - Norihiro Shima
- Department of Sport and Health Science, Tokai Gakuen University, Miyoshi 470-0207, Japan
| | - Yohei Shimokochi
- Department of Health and Sport Management, Osaka University of Health and Sport Sciences, Sennan-gun 590-0496, Japan
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Jakobsen TL, Thorborg K, Fisker J, Kallemose T, Bandholm T. Blood flow restriction added to usual care exercise in patients with early weight bearing restrictions after cartilage or meniscus repair in the knee joint: a feasibility study. J Exp Orthop 2022; 9:101. [PMID: 36192606 PMCID: PMC9530077 DOI: 10.1186/s40634-022-00533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/02/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Blood flow restriction - low load strength training (BFR-LLST) is theoretically superior to traditional heavy strength training when rehabilitating patients who cannot heavily load tissues following surgery. The main purpose of this study was to examine the feasibility of BFR-LLST added to usual care exercise early after cartilage or meniscus repair in the knee joint. METHODS We included 42 patients with cartilage (n = 21) or meniscus repair (n = 21) of the knee joint. They attended 9 weeks of BFR-LLST added to a usual care exercise program at an outpatient rehabilitation center. Outcome measures were assessed at different time points from four (baseline) to 26 weeks postoperatively and included adherence, harms, knee joint and thigh pain, perceived exertion, thigh circumference (muscle size proxy), isometric knee-extension strength, self-reported disability and quality of life. RESULTS On average, patients with cartilage or meniscus repair completed > 84% of the total BFR-LLST supervised sessions. Thirty-eight patients reported 146 adverse events of which none were considered serious. No decrease in thigh circumference or exacerbation of knee joint or quadriceps muscle pain of the operated leg was found in either group during the intervention period. CONCLUSIONS BFR-LLST added to usual care exercise initiated early after cartilage or meniscus repair seems feasible and may prevent disuse thigh muscle atrophy during a period of weight bearing restrictions. Harms were reported, but no serious adverse events were found. Our findings are promising but need replication using a RCT-design. TRIAL REGISTRATION NCT03371901 , preprint (open access): https://www.medrxiv.org/content/10.1101/2022.03.31.22272398v1.
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Affiliation(s)
| | - Kristian Thorborg
- Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Amager and Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Fisker
- Centre of Rehabilitation, City of Copenhagen, Copenhagen, Denmark
| | - Thomas Kallemose
- Department of Clinical Research, Amager and Hvidovre Hospital, Hvidovre, Denmark
| | - Thomas Bandholm
- Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Amager and Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Research, Amager and Hvidovre Hospital, Hvidovre, Denmark.,Department of Orthopedic Surgery, Amager and Hvidovre Hospital, Hvidovre, Denmark
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Molony JT, Greenberg EM, Weaver AP, Racicot M, Merkel D, Zwolski C. Rehabilitation After Pediatric and Adolescent Knee Injuries. Clin Sports Med 2022; 41:687-705. [DOI: 10.1016/j.csm.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bowen W, Frazer AK, Tallent J, Pearce AJ, Kidgell DJ. Unilateral Strength Training Imparts a Cross-Education Effect in Unilateral Knee Osteoarthritis Patients. J Funct Morphol Kinesiol 2022; 7:jfmk7040077. [PMID: 36278738 PMCID: PMC9589957 DOI: 10.3390/jfmk7040077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Worldwide, 86 million individuals over the age of 20 were diagnosed with knee osteoarthritis (KOA) in 2020. Hallmark features of KOA are the loss in knee extensor strength, increasing knee pain severity, and deficits in functional performance. There is a critical need for the investigation into potential cost-effective therapeutic interventions in the treatment of KOA. A potential therapeutic option is the cross-education phenomenon. Methods: This was a non-blinded randomized control trial, with a 4-week intervention, with a pre, post and follow-up assessment (3 months post intervention). Outcome measures of isometric knee extensor strength, rectus femoris muscle thickness and neuromuscular activation were assessed at all-time points. Results: Compared to age-matched KOA controls, 4 weeks of unilateral strength training in end-stage KOA patients increased strength of the untrained affected KOA limb by 20% (p < 0.05) and reduced bilateral hamstring co-activation in the KOA intervention group compared to the KOA control group (p < 0.05). Conclusions: A 4-week-long knee extensor strength training intervention of the contralateral limb in a cohort with diagnosed unilateral KOA resulted in significant improvements to knee extensor strength and improved neuromuscular function of the KOA limb. Importantly, these results were maintained for 3 months following the intervention.
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Affiliation(s)
- Warren Bowen
- School of Exercise and Nutrition Sciences, Deakin University, Melbourne 3125, Australia
- College of Science, Health and Engineering, La Trobe University, Melbourne 3086, Australia
| | - Ashlyn K. Frazer
- Monash Exercise Neuroplasticity Research Unit, Department of Physiotherapy, Monash University, Melbourne 3800, Australia
| | - Jamie Tallent
- Monash Exercise Neuroplasticity Research Unit, Department of Physiotherapy, Monash University, Melbourne 3800, Australia
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester CO4 3SQ, UK
| | - Alan J. Pearce
- College of Science, Health and Engineering, La Trobe University, Melbourne 3086, Australia
| | - Dawson J. Kidgell
- Monash Exercise Neuroplasticity Research Unit, Department of Physiotherapy, Monash University, Melbourne 3800, Australia
- Correspondence: ; Tel.: +61-3-9904-4119
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Lopes TDS, Ballas SK, Santana JERS, de Melo-Carneiro P, de Oliveira LB, Sá KN, Lopes LCD, Silva WDS, Lucena R, Baptista AF. Sickle cell disease chronic joint pain: Clinical assessment based on maladaptive central nervous system plasticity. Front Med (Lausanne) 2022; 9:679053. [PMID: 36203767 PMCID: PMC9530388 DOI: 10.3389/fmed.2022.679053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic joint pain (CJP) is among the significant musculoskeletal comorbidities in sickle cell disease (SCD) individuals. However, many healthcare professionals have difficulties in understanding and evaluating it. In addition, most musculoskeletal evaluation procedures do not consider central nervous system (CNS) plasticity associated with CJP, which is frequently maladaptive. This review study highlights the potential mechanisms of CNS maladaptive plasticity related to CJP in SCD and proposes reliable instruments and methods for musculoskeletal assessment adapted to those patients. A review was carried out in the PubMed and SciELO databases, searching for information that could help in the understanding of the mechanisms of CNS maladaptive plasticity related to pain in SCD and that presented assessment instruments/methods that could be used in the clinical setting by healthcare professionals who manage chronic pain in SCD individuals. Some maladaptive CNS plasticity mechanisms seem important in CJP, including the impairment of pain endogenous control systems, central sensitization, motor cortex reorganization, motor control modification, and arthrogenic muscle inhibition. Understanding the link between maladaptive CNS plasticity and CJP mechanisms and its assessment through accurate instruments and methods may help healthcare professionals to increase the quality of treatment offered to SCD patients.
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Affiliation(s)
- Tiago da Silva Lopes
- Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA, Brazil
- Adventist Neuromodulation and Neuroscience Laboratory, Bahia Adventist College, Cachoeira, Brazil
- NAPEN Network (Nucleus of Assistance, Research, and Teaching in Neuromodulation), São Paulo, SP, Brazil
| | - Samir K. Ballas
- Department of Medicine, Jefferson Medical College, Cardeza Foundation for Hematologic Research, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jamille Evelyn Rodrigues Souza Santana
- Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA, Brazil
- NAPEN Network (Nucleus of Assistance, Research, and Teaching in Neuromodulation), São Paulo, SP, Brazil
- Center for Mathematics, Computation, and Cognition, Federal University of ABC, São Bernardo do Campo, SP, Brazil
| | - Pedro de Melo-Carneiro
- Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA, Brazil
| | - Lilian Becerra de Oliveira
- Adventist Neuromodulation and Neuroscience Laboratory, Bahia Adventist College, Cachoeira, Brazil
- Graduate program of Medicine and Human Health, Bahiana School of Medicine and Public Health, Salvador, BA, Brazil
| | - Katia Nunes Sá
- NAPEN Network (Nucleus of Assistance, Research, and Teaching in Neuromodulation), São Paulo, SP, Brazil
- Graduate program of Medicine and Human Health, Bahiana School of Medicine and Public Health, Salvador, BA, Brazil
| | | | | | - Rita Lucena
- Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA, Brazil
| | - Abrahão Fontes Baptista
- Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA, Brazil
- NAPEN Network (Nucleus of Assistance, Research, and Teaching in Neuromodulation), São Paulo, SP, Brazil
- Center for Mathematics, Computation, and Cognition, Federal University of ABC, São Bernardo do Campo, SP, Brazil
- Graduate program of Medicine and Human Health, Bahiana School of Medicine and Public Health, Salvador, BA, Brazil
- Laboratory of Medical Investigations 54 (LIM-54), Universidade de São Paulo, São Paulo, SP, Brazil
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69
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Conduction Velocity of Spinal Reflex in Patients with Acute Lateral Ankle Sprain. Healthcare (Basel) 2022; 10:healthcare10091794. [PMID: 36141406 PMCID: PMC9498455 DOI: 10.3390/healthcare10091794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
Recent literature has highlighted altered spinal-reflex excitability following acute lateral ankle sprain (ALAS), yet there is little information on the conduction velocity of spinal reflex pathways (CV-SRP) in these patients. Therefore, we aimed to investigate the effects of ALAS on the CV-SRP. We employed a cross-sectional study with two groups: ALAS (n = 30) and healthy controls (n = 30). The CV-SRP of the soleus, fibularis longus, and tibialis anterior was assessed using the H-index method. As secondary outcomes, H-reflex and M-wave latencies were assessed as well as acute symptoms including ankle swelling, pain, and self-reported ankle function. Separate group-by-limb ANOVA with repeated measures revealed a significant interaction for soleus CV-SRP (p < 0.001) and H-reflex latency (p < 0.001), showing significant slower CV-SRP and longer H-reflex latency in the involved limb of the ALAS group compared with both limbs in the control group. However, there was no significant interaction or main effect in any other ankle muscles (p > 0.05). A further correlation analysis showed a significant relationship between CV-SRP and acute symptoms, including ankle swelling (r = −0.37, p = 0.048) and self-reported ankle function (r = 0.44, p = 0.017) in ALAS patients. These results suggest a disrupted functionality of the afferent pathway and/or synaptic transmission following ALAS. Level of Evidence: 4.
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70
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Hart LM, Izri E, King E, Daniels KAJ. Angle-specific analysis of knee strength deficits after ACL reconstruction with patellar and hamstring tendon autografts. Scand J Med Sci Sports 2022; 32:1781-1790. [PMID: 36062926 DOI: 10.1111/sms.14229] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/05/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
Abstract
After anterior cruciate ligament reconstruction (ACLR) there are differences in the neuromuscular deficits observed in patients with bone-patellar tendon-bone (BPTB) and with hamstring tendon (HT) autografts. Differences in knee extensor and flexor strength are commonly reported, but analyses have largely focused on peak torque metrics despite the requirement to generate torque through range when returning to sport. The aim of this study was to investigate the angle-specific strength and strength asymmetry differences between BPTB and HT around the time of return to play after ACLR. A total of 357 male field sport athletes with either a BPTB (n=297) or an HT (n=60) autograft underwent concentric knee flexor and extensor isokinetic strength testing nine months post-ACLR. Angle-specific torques were compared between grafts and limbs using 1D Statistical Parametric Mapping and discrete-point variables. Inter-limb extensor torque asymmetry was greater in BTPB than HT at knee angles of >30° (p=0.001, peak d=5.53), with flexor torque asymmetry lower in BPTB than HT at flexion angles of >25° (p=0.001, peak d=2.68). Angle of maximum asymmetry and angle of operated limb peak torque differed in knee extension for BPTB (p<0.001, d=0.32) but not HT, whereas knee flexion angle of maximum asymmetry and operated limb peak torque differed in both BTPB (p<0.001, d=0.75) and HT (p<0.001, d=0.43). Graft type affected extensor torque at knee angles of 67-85° and flexor torque at knee angles of 27-85°. Angle-specific strength analysis may inform the rehabilitation process and improve rehabilitation and return-to-play decision making strategies in comparison to the use of peak torque values alone.
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Affiliation(s)
- Luke M Hart
- Sports Medicine Department, Sports Surgery Clinic, Dublin, Ireland
| | - Erwan Izri
- Sports Medicine Department, Sports Surgery Clinic, Dublin, Ireland
| | - Enda King
- Sports Medicine Department, Sports Surgery Clinic, Dublin, Ireland.,Department of Life Sciences, University of Roehampton, London, UK
| | - Katherine A J Daniels
- Sports Medicine Department, Sports Surgery Clinic, Dublin, Ireland.,Department of Sport and Exercise Sciences, Manchester Metropolitan University, UK
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71
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Impaired Modulation of Motor and Functional Performance in Patients after Total Knee Arthroplasty: A Prospective Observational Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4546836. [PMID: 36072468 PMCID: PMC9441351 DOI: 10.1155/2022/4546836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/17/2022] [Indexed: 11/18/2022]
Abstract
Submaximal levels of effort are required for the performance of the most common daily tasks. Inaccuracy in modulating motor outputs during submaximal tasks has been reported as indicator of safety during daily activities in subjects with lower limb musculoskeletal disorders. The study is aimed at investigating performance modulation ability during motor and functional tasks in patients after total knee arthroplasty (TKA). Sixteen patients with end-stage osteoarthritis undergoing TKA and twenty age-matched healthy participants performed isokinetic knee extension, sit-to-stand, and walking tasks at three levels of self-estimated effort (100%, 50%, and 25%) the day before (T0) and 4 days after surgery (T1). Maximum performance in terms of peak torque (PT—knee extension), overshoot (OS—sit-to-stand), and walking speed was evaluated. Subsequently, relative error (RE) between target and observed performance was computed for the submaximal tasks (RE50% and RE25%). Our results showed a decline of maximum performance after surgery, which resulted lower in patients compared to healthy subjects. RE50% and RE25% for knee extension (involved limb) (p < 0.001) and RE25% for sit-to-stand (p < 0.001) increased from pre- to postsurgery. At T0, knee extension RE25% and walking RE50% and RE25% were higher in patients. At T1, RE50% and RE25% were higher in patients for knee extension (involved limb), sit-to-stand, and walking. In conclusion, the ability to modulate motor and functional performance decreased after TKA and resulted impaired when compared to healthy age-matched subjects. Based on relationship between ability to modulate motor outputs and risk of falling, the role of modulation ability as indicator of readiness for discharge and safe return to daily activities deserves further investigations in patients in early phase after TKA.
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72
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Moran TE, Ignozzi AJ, Burnett Z, Bodkin S, Hart JM, Werner BC. Deficits in Contralateral Limb Strength Can Overestimate Limb Symmetry Index After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e1713-e1719. [PMID: 36312704 PMCID: PMC9596901 DOI: 10.1016/j.asmr.2022.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/25/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose To evaluate whether contralateral limb strength represents a dynamic, rather than static, data point after anterior cruciate ligament reconstruction (ACL-R). Methods Patients who underwent isolated ACL-R at a single institution were identified. Patients completed an institutional Lower-Extremity Assessment Protocol (LEAP) testing protocol at 6 and 9 months postoperatively. Extension strength and flexion strength of the ipsilateral and contralateral limbs and limb symmetry index (LSI) were compared between the 6- and 9-month testing outcomes. Subgroup analysis compared patients demonstrating less than or greater than 10% change in contralateral limb flexion and extension strength between 6 and 9 months postoperatively. Results A total of 144 subjects were included in this study. On average, contralateral limb flexion and extension strength increased 2-4% between 6 and 9 months postoperatively. However, the contralateral limb increased >10% from 6 to 9 months in extension and flexion strength in 35/144 (24.3%) and 55/144 (38.2%) of patients, respectively. The cohort with >10% change between 6 and 9 months had significantly weaker contralateral extension and flexion strength at 6 months compared to the cohort that demonstrated <10% change (extension: 2.00 vs 2.39; P < .001; flexion: 0.84 vs 1.08; P < .001), but similar ipsilateral limb performance. Therefore, the >10% change cohort had a significantly greater LSI at 6 months compared to the <10% change cohort (67.3% vs 59.4%; P = .006). No demographic or operative factors correlated with which patients demonstrated >10% flexion or extension strength changes of the contralateral limb. Conclusion A large percentage of patients demonstrate significant changes in their contralateral limb flexion and extension strength between 6 and 9 months postoperatively that result from an initial contralateral limb strength deficit. This may limit the utility of the contralateral limb as a control for comparison to the operative extremity during return to sport assessment.
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73
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Relevant Strength Parameters to Allow Return to Running after Primary Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autograft. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148245. [PMID: 35886096 PMCID: PMC9322324 DOI: 10.3390/ijerph19148245] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 11/20/2022]
Abstract
After anterior cruciate ligament reconstruction (ACLR), a progressive process is followed from rehabilitation to the return to sport including a crucial step known as the return to running. Return to running (RTR) can be predicted by an isokinetic knee strength assessment at 4 months post-surgery. All patients who had primarily undergone ACLR with a hamstring autograft procedure between 2010 and 2020 were included in this study. Four months after surgery, patients were evaluated using an isokinetic knee strength test. Patients were monitored until the 6th month post-surgery to see if they had returned to running. Comparisons were carried out between the two groups—the RTR and the no-RTR. A multivariate logistic regression analysis was used to predict the RTR status from explicative parameters. Receiver Operating Characteristic (ROC) curves were established to identify cutoffs with their characteristics. A total of 413 patients were included and 63.2% returned to running at 4 months post-surgery. The mean Lysholm score, knee complication rate, and isokinetic parameters were statistically different between both groups. Using a multivariate logistic regression model and ROC curves, the best isokinetic parameter to assist with the decision to allow an RTR was the quadriceps limb symmetry index at 60°/s with a cutoff of 65%. The hamstring LSI at 180°/s could be added (cutoff of 80%) to slightly increase the prediction of an RTR. Quadriceps strength normalized to body weight at 60°/s is a useful parameter (cutoff: 1.60 Nm/kg) but measurements on both sides are necessary. Isokinetic parameters are objective parameters to allow a return to running at 4 months after ACLR with a hamstring procedure.
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74
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Husted RS, Troelsen A, Husted H, Grønfeldt BM, Thorborg K, Kallemose T, Rathleff MS, Bandholm T. Knee-extensor strength, symptoms, and need for surgery after two, four, or six exercise sessions/week using a home-based one-exercise program: a randomized dose-response trial of knee-extensor resistance exercise in patients eligible for knee replacement (the QUADX-1 trial). Osteoarthritis Cartilage 2022; 30:973-986. [PMID: 35413476 DOI: 10.1016/j.joca.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/28/2022] [Accepted: 04/05/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate firstly the efficacy of three different dosages of one home-based, knee-extensor resistance exercise on knee-extensor strength in patients eligible for knee replacement, and secondly, the influence of exercise on symptoms, physical function and decision on surgery. METHOD One-hundred and forty patients eligible for knee replacement were randomized to three groups: 2, 4 or 6 home-based knee-extensor resistance exercise-sessions per week (group 2, 4 and 6 respectively) for 12 weeks. PRIMARY OUTCOME isometric knee-extensor strength. SECONDARY OUTCOMES Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6-min walk test, stair climbing test, exercise adherence and "need for surgery". RESULTS Primary analysis: Intention-to-treat analysis of 140 patients did not find statistically significant differences between the groups from baseline to after 12 weeks of exercise in isometric knee-extensor strength: Group 2 vs 4 (0.003 Nm/kg (0.2%) [95% CI -0.15 to 0.15], P = 0.965) and group 4 vs 6 (-0.04 Nm/kg (-2.7%) [95% CI -0.15 to 0.12], P = 0.628). Secondary analysis: Intention-to-treat analyses showed statistically significant differences between the two and six sessions/week groups in favor of the two sessions/week group for Oxford Knee Score: 4.8 OKS points (15.2%) [1.3 to 8.3], P = 0.008) and avg. knee pain last week (NRS 0-10): -1.3 NRS points (-19.5%) [-2.3 to -0.2], P = 0.018. After the 12-week exercise intervention, data were available for 117 patients (N = 39/group): 38 (32.5%) patients wanted surgery and 79 (67.5%) postponed surgery. This was independent of exercise dosage. CONCLUSION In patients eligible for knee-replacement we found no between-group differences in isometric knee extensor strength after 2, 4 and 6 knee-extensor resistance exercise sessions per week. We saw no indication of an exercise dose-response relationship for isometric knee-extensor strength and only clinically irrelevant within group changes. For some secondary outcome (e.g., KOOS subscales) we found clinically relevant within group changes, which could help explain why only one in three patients decided to have surgery after the simple home-based exercise intervention. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02931058. Preprint: https://doi.org/10.1101/2021.04.07.21254965.
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Affiliation(s)
- R S Husted
- Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark; Clinical Orthopedic Research Hvidovre (CORH), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - A Troelsen
- Clinical Orthopedic Research Hvidovre (CORH), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - H Husted
- Clinical Orthopedic Research Hvidovre (CORH), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - B M Grønfeldt
- Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - K Thorborg
- Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark; Sports Orthopaedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - T Kallemose
- Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - M S Rathleff
- Center for General Practice at Aalborg University, Aalborg, Denmark; Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark; Department of Health Science and Technology, Aalborg University, Denmark.
| | - T Bandholm
- Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark; Clinical Orthopedic Research Hvidovre (CORH), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark.
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75
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Achens JT, Victor VSR, Joseph JK. Early Activation of Quadriceps With Pressure Biofeedback for the Prevention of Arthrogenic Muscle Inhibition Following Lower Limb Orthopedic Surgeries: A Proof of Concept Clinical Trial. J Chiropr Med 2022; 21:296-304. [DOI: 10.1016/j.jcm.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 05/17/2022] [Accepted: 05/30/2022] [Indexed: 10/16/2022] Open
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Chakravarthy K, Lee D, Tram J, Sheth S, Heros R, Manion S, Patel V, Kiesel K, Ghandour Y, Gilligan C. Restorative Neurostimulation: A Clinical Guide for Therapy Adoption. J Pain Res 2022; 15:1759-1774. [PMID: 35756364 PMCID: PMC9231548 DOI: 10.2147/jpr.s364081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/26/2022] [Indexed: 11/23/2022] Open
Abstract
In this review, we present a comprehensive clinical approach to restorative neurostimulation, a novel form of stimulation for refractory chronic mechanical low back pain, targeting impaired neuromuscular control and degeneration of the multifidus muscle. We focus on patient identification, technique guidance, and review of the scientific background and clinical evidence. As our understanding of back pain grows, there is clear evidence that impaired neuromuscular control and consequent degeneration of the multifidus muscle contribute to mechanical low back pain development and maintenance. We provide clinical guidance regarding an implantable restorative neurostimulation system that targets impaired neuromuscular control. Supported by results from a randomized, active-sham-controlled clinical trial with long-term follow-up, we provide clinicians with a comprehensive overview and practical clinical guidance for the adoption of this therapy modality.
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Affiliation(s)
- Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - David Lee
- Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Jennifer Tram
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA
| | | | | | - Smith Manion
- Advent Health Pain Specialists, Merriam, KS, USA
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA
| | - Kyle Kiesel
- Department of Physical Therapy, University of Evansville, Evansville, IN, USA
| | - Yousef Ghandour
- Physical Rehabilitation Network (PRN), University of St. Augustine, San Diego, CA, USA
| | - Christopher Gilligan
- Division of Pain Medicine, Brigham & Women's Hospital/Harvard Medical School, Boston, MA, USA
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77
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Spinal Reflex Excitability of Lower Leg Muscles Following Acute Lateral Ankle Sprain: Bilateral Inhibition of Soleus Spinal Reflex Excitability. Healthcare (Basel) 2022; 10:healthcare10071171. [PMID: 35885698 PMCID: PMC9315602 DOI: 10.3390/healthcare10071171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 12/22/2022] Open
Abstract
Neural changes in the ankle stabilizing muscles following ankle sprains are thought to be one contributing factor to persistent ankle dysfunction. However, empirical evidence is limited. Therefore, we aimed to examine spinal reflex excitability of lower leg muscles following acute ankle sprains (AAS). We performed a case-control study with 2 groups consisting of 30 young adults with AAS and 30 aged-matched uninjured controls. Hoffmann reflex (H-reflex) testing was performed to estimate spinal reflex excitability of lower leg muscles: soleus, fibularis longus (FL), tibialis anterior (TA). Maximal H-reflex (Hmax) and motor responses (Mmax) were determined by delivering a series of electrical stimuli at the sciatic nerve. Hmax/Mmax ratios were calculated to represent normalized spinal reflex excitability. Separate group-by-limb analyses of variance (ANOVA) with repeated measures found there were no significant interactions for any of the muscles (SL: F1,56 = 0.95, p = 0.33, FL: F1,51 = 0.65, p = 0.42, TA: F1,51 = 1.87, p = 0.18), but there was a significant main effect of group in the soleus (F1,56 = 6.56, p = 0.013), indicating the Hmax/Mmax ratio of soleus in the AAS group was significantly lower bilaterally (AAS = 0.56 ± 0.19, control = 0.68 ± 0.17, p = 0.013), with no significant group differences in the other muscles (FL: F1,51 = 0.26, p = 0.61, TA: F1,51 = 0.93, p = 0.34). The bilateral inhibition of the soleus spinal reflex excitability following AAS may be significant in that it may explain bilateral sensorimotor deficits (postural control deficits) following unilateral injury, and provide insights into additional therapies aimed at the neural change.
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78
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Labanca L, Bonsanto F, Raffa D, Orlandi Magli A, Benedetti MG. Does adding neuromuscular electrical stimulation to rehabilitation following total knee arthroplasty lead to a better quadriceps muscle strength recovery? A systematic review. Int J Rehabil Res 2022; 45:118-125. [PMID: 35256573 DOI: 10.1097/mrr.0000000000000525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients undergoing total knee arthroplasty (TKA) show postsurgical quadriceps weakness. Neuromuscular electrical stimulation (NMES) has been shown to be an effective treatment for muscle strength recovery in a number of orthopaedic conditions. The aim of this review is to investigate whether adding NMES to TKA rehabilitation leads to a better quadriceps strength recovery in comparison with standardized rehabilitation. A second aim is to investigate which are the most commonly used NMES pulse settings and their effectiveness. A systematic review of literature was conducted on PubMed, Cochrane, Scopus and Web-of-Science. Intervention studies evaluating the effects of a rehabilitation intervention based on quadriceps NMES in patients undergoing TKA were retrieved. Methodological quality was assessed using the risk of bias-2 Cochrane tool. Features of NMES rehabilitation and technical data on NMES settings were extracted from the studies. Four studies met the inclusion criteria. Due to the limited number and the heterogeneity of the selected studies, it was not appropriate to carry out a meta-analysis. All the studies reported higher quadriceps strength in patients undergoing quadriceps NMES, particularly early after TKA. The addition of NMES or traditional strength training shows similar long-term effects. Short duration and low-intensity NMES have limited effects on quadriceps strength. Heterogeneity was found on NMES methodologies and pulse settings. In conclusion, NMES is effective for quadriceps strength recovery following TKA. NMES intensity and duration are essential for good NMES outcomes on quadriceps strength. Further studies on NMES methodologies, pulse features and settings are required to address the gaps in knowledge on NMES following TKA.
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Affiliation(s)
- Luciana Labanca
- Physical Medicine and Rehabilitation Unit, IRCCS - Istituto Ortopedico Rizzoli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Fabio Bonsanto
- Physical Medicine and Rehabilitation Unit, IRCCS - Istituto Ortopedico Rizzoli
| | - Debora Raffa
- Physical Medicine and Rehabilitation Unit, IRCCS - Istituto Ortopedico Rizzoli
| | | | - Maria Grazia Benedetti
- Physical Medicine and Rehabilitation Unit, IRCCS - Istituto Ortopedico Rizzoli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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79
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Hipsley A, Hall M, Saxby DJ, Bennell KL, Wang X, Bryant AL. Quadriceps muscle strength at 2 years following anterior cruciate ligament reconstruction is associated with tibiofemoral joint cartilage volume. Knee Surg Sports Traumatol Arthrosc 2022; 30:1949-1957. [PMID: 34997247 DOI: 10.1007/s00167-021-06853-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Quadriceps strength deficits following anterior cruciate ligament reconstruction (ACLR) are linked to altered lower extremity biomechanics, tibiofemoral joint (TFJ) space narrowing and cartilage composition changes. It is unknown, however, if quadriceps strength is associated with cartilage volume in the early years following ACLR prior to the onset of posttraumatic osteoarthritis (OA) development. The purpose of this cross-sectional study was to examine the relationship between quadriceps muscle strength (peak and across the functional range of knee flexion) and cartilage volume at ~ 2 years following ACLR and determine the influence of concomitant meniscal pathology. METHODS The involved limb of 51 ACLR participants (31 isolated ACLR; 20 combined meniscal pathology) aged 18-40 years were tested at 2.4 ± 0.4 years post-surgery. Isokinetic knee extension torque generated in 10° intervals between 60° and 10° knee flexion (i.e. 60°-50°, 50°-40°, 40°-30°, 30°-20°, 20°-10°) together with peak extension torque were measured. Tibial and patellar cartilage volumes were measured using magnetic resonance imaging (MRI). The relationships between peak and angle-specific knee extension torque and MRI-derived cartilage volumes were evaluated using multiple linear regression. RESULTS In ACLR participants with and without meniscal pathology, higher knee extension torques at 60°-50° and 50°-40° knee flexion were negatively associated with medial tibial cartilage volume (p < 0.05). No significant associations were identified between peak concentric or angle-specific knee extension torques and patellar cartilage volume. CONCLUSION Higher quadriceps strength at knee flexion angles of 60°-40° was associated with lower cartilage volume on the medial tibia ~ 2 years following ACLR with and without concomitant meniscal injury. Regaining quadriceps strength across important functional ranges of knee flexion after ACLR may reduce the likelihood of developing early TFJ cartilage degenerative changes. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anthony Hipsley
- Department of Medicine Dentistry and Health Sciences, Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, VIC, Australia.
| | - Michelle Hall
- Department of Medicine Dentistry and Health Sciences, Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - David J Saxby
- School of Allied Health Sciences, Griffith University, Gold Coast, Australia.,Core Group for Innovation in Health Technology, Menzies Health Institute Queensland, Gold Coast, Australia.,Gold Coast Orthopaedic Research and Education Alliance, Gold Coast, Australia
| | - Kim L Bennell
- Department of Medicine Dentistry and Health Sciences, Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Xinyang Wang
- Department of Medicine Dentistry and Health Sciences, Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, VIC, Australia.,Department of Orthopaedic Surgery, Beijing Chao-Yang Hospital, Beijing, China
| | - Adam L Bryant
- Department of Medicine Dentistry and Health Sciences, Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, VIC, Australia
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Chantrelle M, Menu P, Gernigon M, Louguet B, Dauty M, Fouasson-Chailloux A. Consequences of Patellar Tendinopathy on Isokinetic Knee Strength and Jumps in Professional Volleyball Players. SENSORS (BASEL, SWITZERLAND) 2022; 22:3590. [PMID: 35591280 PMCID: PMC9105239 DOI: 10.3390/s22093590] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
Patellar tendinopathy (PT) in professional volleyball players can have an impact on their careers. We evaluated the impact of this pathology in this specific population in terms of isokinetic strength and jumping performances. Thirty-six professional male volleyball players (mean age: 24.8 ± 5.2) performed isokinetic knee assessments, single-leg countermovement jumps and one leg hop test. They filled out the Victorian Institute of Sport Assessment-Patella (VISA-P) score. Two groups were assessed: “PT group” (n = 15) and “control group” (n = 21). The VISA-P score was lower in the PT group (p < 0.0001). No difference was found between the isokinetic strength limb symmetry index and the jump performance limb symmetry index. The healthy legs of the control group were compared with the affected (PT+) and the unaffected legs (PT−) of the PT group. Compared with the healthy legs, both PT+ and PT− legs showed decreased values of quadriceps and hamstring strengths. Only PT+ legs scored lower than healthy legs in countermovement jumps and hop tests. No differences were found between PT+ and PT− legs for muscle strengths and jumps. A low correlation existed between quadriceps strength and jumping performances (r > 0.3; p < 0.001). Volleyball players with PT showed a decrease in the isokinetic knee strength. This strength deficit was found both on the symptomatic legs and the asymptomatic ones. Jumps were only significantly altered on the pathological legs. Highlighting that the unaffected limbs were also impaired in addition to the affected limbs may help provide a better adaptation of the rehabilitation management.
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Affiliation(s)
- Marie Chantrelle
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.C.); (P.M.); (M.D.)
- Département de Médecine Physique et de Réadaptation, Centre Hospitalier Universitaire d’Angers, 49000 Angers, France
| | - Pierre Menu
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.C.); (P.M.); (M.D.)
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- Institut Régional de Médecine du Sport (IRMS), 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, 44042 Nantes, France
| | - Marie Gernigon
- CIAMS, Complexité, Innovation, Activités Motrices et Sportives, Université Paris-Saclay, 91405 Orsay, France;
- CIAMS, Complexité, Innovation, Activités Motrices et Sportives, Université d’Orléans, 45067 Orléans, France
| | - Bastien Louguet
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- Institut Régional de Médecine du Sport (IRMS), 44093 Nantes, France
| | - Marc Dauty
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.C.); (P.M.); (M.D.)
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- Institut Régional de Médecine du Sport (IRMS), 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, 44042 Nantes, France
| | - Alban Fouasson-Chailloux
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, 44093 Nantes, France; (M.C.); (P.M.); (M.D.)
- Service de Médecine du Sport, CHU Nantes, Nantes Université, 44093 Nantes, France;
- Institut Régional de Médecine du Sport (IRMS), 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, 44042 Nantes, France
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Ruspi A, Temporiti F, Adamo P, Mina F, Traverso F, Gatti R. Neuromuscular activation of quadriceps bellies during tasks performed in the same biomechanical condition in patients undergoing total knee arthroplasty. J Electromyogr Kinesiol 2022; 64:102659. [DOI: 10.1016/j.jelekin.2022.102659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/28/2022] Open
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Rehabilitation of Patients with Moderate Knee Osteoarthritis Using Hyaluronic Acid Viscosupplementation and Physiotherapy. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12063165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Knee osteoarthritis (KOA) is one of the most common public health problems which cannot be cured and ultimately leads to disability. Current management is largely limited to the treatment of the symptoms. To avoid the late stages of KOA that lead to knee replacement, the key point is to control and reduce destructive processes using efficient pharmacological products combined with physiotherapy (PT). Herein, we perform a monocentric observational study to compare the effect of combining a multi-modal physiotherapy regime and intra-articular (IA) injection with hyaluronic acid (HA) on the non-surgical treatment of KOA. Patients with mild KOA were randomly assigned to two groups to receive an HA injection with PT or an HA injection only. The assessment tools for pain, clinical disease severity, and disability were the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (scores range from 0 to 96, with higher scores indicating worse pain, function, and stiffness), knee range of motion (ROM), pain on the visual analog scale (VAS), and muscle strength testing (MST). All tests were evaluated every 3 months up to 1 year from the baseline. The study enrolled 52 patients with ages between 47 and 61 years who were divided into two groups. Thirty-seven (n = 37) patients were randomized in the pilot group (PG) and received IA injections with the viscoelastic hyaluronic acid product (HA) combined with a multi-modal PT regime. The PT program included 10 sessions of transcutaneous electrical nerve stimulation, low-level laser therapy, ultrasound, physical exercise, and cryotherapy. Fifteen patients (n = 15) from the control group (CG) received the IA HA injections only. All patients were confirmed with mild KOA of Kellgren–Lawrence grade 2 on radiographs at the beginning of the treatment. The baseline characteristics, including the severity of pain and level of disability, were similar in the two groups. At baseline, the mean (±SD) WOMAC scores reported were 64.6 ± 4.08 in the CG and 64.5 ± 2.99 in the PG. Notably, at only 3 months into the study, the mean scores were significantly improved to 56.7 ± 5 in the CG and 48.27 ± 2.13 in the PG (mean between-group difference = 16.19 points; 95% confidence interval), finding favor for the combination of HA injections and physiotherapy. At the study’s endpoint (12 months), the scores were improved in both groups, with the mean between-group difference remaining significant (7.08 points, 95% confidence interval). A decrease in pain, as evaluated by the VAS scale, was reported for both groups, with the PG reporting a better VAS score that decreased from 5.7 to 2 when compared to the CG, which decreased from 5.7 to 3. The physical assessment parameters (ROM and MST) followed the same trend, with a rapid improvement in the ROM in the PG, changing from 98° to 115° in the first 3 months, and a slower and more steady evolution in the CG group, changing from 100° to 112° in 9 months. Herein, we report on the combination therapy of an intra-articularly administered HA viscoelastic product and a multi-modal physiotherapy regime, which can play a key role in the non-surgical treatment of KOA, effectively controlling pain, stiffness, and the ROM value and improving patients’ quality of life.
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Bilateral muscle atrophy after anterior cruciate ligament reconstruction in rats: Protective effects of anti-inflammatory drug celecoxib. Knee 2022; 35:201-212. [PMID: 35381572 DOI: 10.1016/j.knee.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/17/2022] [Accepted: 03/21/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Muscle atrophy after anterior cruciate ligament (ACL) reconstruction occurs bilaterally and contributes to a decrease in muscle strength. However, effective treatment strategies for ACL reconstruction-induced muscle atrophy have not been established. We examined the effects of anti-inflammatory drug on muscle atrophy after ACL reconstruction. MATERIALS AND METHODS Rats were divided into groups according to treatment received: untreated control (n = 4), arthrotomy (n = 6), ACL transection (n = 7), ACL reconstruction (n = 8), and ACL reconstruction plus anti-inflammatory drug celecoxib (CBX; 50 mg/kg/day) administration (n = 8). At one-week post-surgery, the muscle fiber cross-sectional area (CSA) in the rectus femoris (RF) and semitendinosus (ST) was measured to assess muscle atrophy. In addition, we examined joint swelling and serum C‑reactive protein (CRP) levels to assess local and systemic inflammation, respectively. RESULTS Each additional procedure (i.e., arthrotomy, ACL transection, and ACL reconstruction) gradually decreased the muscle fiber CSAs in the RF and ST on both operated and contralateral sides. The degree of muscle fiber atrophy on the operated side was larger than that detected on the contralateral side. Moreover, ACL reconstruction induced joint swelling on the operated side and tended to increase serum CRP levels. CBX lessened the RF atrophy on both sides and was associated with less joint swelling and a smaller increase CRP level; however, it did not affect ST atrophy on either side. CONCLUSIONS Anti-inflammatory treatments after ACL reconstruction may be effective in lessening muscle atrophy in the quadriceps, but not in the hamstrings.
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Labanca L, Rocchi JE, Giannini S, Faloni ER, Montanari G, Mariani PP, Macaluso A. Early Superimposed NMES Training is Effective to Improve Strength and Function Following ACL Reconstruction with Hamstring Graft regardless of Tendon Regeneration. J Sports Sci Med 2022; 21:91-103. [PMID: 35250338 DOI: 10.52082/jssm.2022.91] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/28/2021] [Indexed: 12/25/2022]
Abstract
The study aimed at investigating the effects of neuromuscular electrical stimulation superimposed on functional exercises (NMES+) early after anterior cruciate ligament reconstruction (ACLr) with hamstring graft, on muscle strength, knee function, and morphology of thigh muscles and harvested tendons. Thirty-four participants were randomly allocated to either NMES+ group, who received standard rehabilitation with additional NMES of knee flexor and extensor muscles, superimposed on functional movements, or to a control group, who received no additional training (NAT) to traditional rehabilitation. Participants were assessed 15 (T1), 30 (T2), 60 (T3), 90 (T4) and at a mean of 380 days (T5) after ACLr. Knee strength of flexors and extensors was measured at T3, T4 and T5. Lower limb loading asymmetry was measured during a sit-to-stand-to-sit movement at T1, T2, T3, T4 and T5, and a countermovement-jump at T4 and T5. An MRI was performed at T5 to assess morphology of thigh muscles and regeneration of the harvested tendons. NMES+ showed higher muscle strength for the hamstrings (T4, T5) and the quadriceps (T3, T4, T5), higher loading symmetry during stand-to-sit (T2, T3, T4, T5), sit-to-stand (T3, T4) and countermovement-jump (T5) than NAT. No differences were found between-groups for morphology of muscles and tendons, nor in regeneration of harvested tendons. NMES+ early after ACLr with hamstring graft improves muscle strength and knee function in the short- and long-term after surgery, regardless of tendon regeneration.
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Affiliation(s)
- Luciana Labanca
- Department of Movement, Human and Health Sciences, University of Rome Foro Italico, Rome, Italy
| | - Jacopo E Rocchi
- Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
| | - Silvana Giannini
- Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
| | - Emanuele R Faloni
- Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
| | - Giulio Montanari
- Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
| | - Pier Paolo Mariani
- Department of Movement, Human and Health Sciences, University of Rome Foro Italico, Rome, Italy.,Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
| | - Andrea Macaluso
- Department of Movement, Human and Health Sciences, University of Rome Foro Italico, Rome, Italy.,Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
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Individuals with impaired lumbopelvic control demonstrate lumbar multifidus muscle activation deficit using ultrasound imaging in conjunction with electrical stimulation: A cross-sectional study. Arch Phys Med Rehabil 2022; 103:1951-1957. [DOI: 10.1016/j.apmr.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 12/21/2021] [Accepted: 02/12/2022] [Indexed: 11/30/2022]
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Effect of High-Protein Diets on Integrated Myofibrillar Protein Synthesis before Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Pilot Study. Nutrients 2022; 14:nu14030563. [PMID: 35276922 PMCID: PMC8840691 DOI: 10.3390/nu14030563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Increasing dietary protein intake during periods of muscle disuse may mitigate the resulting decline in muscle protein synthesis (MPS). The purpose of this randomized pilot study was to determine the effect of increased protein intake during periods of disuse before anterior cruciate ligament (ACL) reconstruction on myofibrillar protein synthesis (MyoPS), and proteolytic and myogenic gene expression. Six healthy, young males (30 ± 9 y) were randomized to consume a high-quality, optimal protein diet (OP; 1.9 g·kg−1·d−1) or adequate protein diet (AP; 1.2 g·kg−1·d−1) for two weeks before ACL reconstruction. Muscle biopsies collected during surgery were used to measure integrated MyoPS during the intervention (via daily deuterium oxide ingestion) and gene expression at the time of surgery. MyoPS tended to be higher, with a large effect size in OP compared to AP (0.71 ± 0.1 and 0.54 ± 0.1%·d−1; p = 0.076; g = 1.56). Markers of proteolysis and myogenesis were not different between groups (p > 0.05); however, participants with greater MyoPS exhibited lower levels of MuRF1 gene expression compared to those with lower MyoPS (r = −0.82, p = 0.047). The data from this pilot study reveal a potential stimulatory effect of increased daily protein intake on MyoPS during injury-mediated disuse conditions that warrants further investigation.
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87
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Effectiveness of Ultrasound-Guided Canal Adductor Blockade for Chronic Pain and Functioning in Knee Osteoarthritis: A Prospective Longitudinal Observational Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5270662. [PMID: 35103237 PMCID: PMC8800601 DOI: 10.1155/2022/5270662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/18/2021] [Accepted: 12/01/2021] [Indexed: 11/17/2022]
Abstract
Methods Seventy-seven patients with chronic knee osteoarthritis pain received ultrasound-guided ACB with 14 ml 0.25% levobupivacaine and 100 mcg clonidine. At baseline and 1 month after the blockade, we assessed maximal and minimal pain intensity in the knee using a numeric rating scale (NRS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS). The range of motion in extension and flexion (ROMext and ROMflex) and quadriceps muscle strength of both knees (QS), Timed Up and Go Test (TUG), and 30-Second Chair Stand Test (30CST) results were determined at baseline, 1 hour, 1 week, and 1 month after the blockade. Results ACB with levobupivacaine and clonidine appeared to decrease pain severity (NRSmax 8.13 to 4.2, p < 0.001 and NRSmin 3.32 to 1.40, p < 0.001). Similarly, knee ROMext decreased from 3.90 preintervention to 2.89 postintervention at 1 month, p < 0.001; ROMflex decreased from 5.70 to 3.29, p < 0.001; TUG time decreased from 3.22 to 2.93, <0.001; QS increased from 18.43 to 22.77, p < 0.001; CST increased from 8.23 to 10.74, p < 0.001. The KOOS for pain (36.40 to 58.34), symptoms (52.55 to 64.32), activities of daily living functions (ADLs, 36.36 to 60.77), and quality of life (QoL, 17.87 to 30.97) also increased, all p < 0.001. Conclusion ACB appeared to decrease pain and increase ambulation. If our preliminary results are reproducible in a planned randomized controlled trial, ACB could be a useful adjunctive pain therapy in patients with disabling pain due to knee OA.
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Preoperative muscle thickness influences muscle activation after arthroscopic knee surgery. Knee Surg Sports Traumatol Arthrosc 2022; 30:1880-1887. [PMID: 34921320 PMCID: PMC9165278 DOI: 10.1007/s00167-021-06820-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/25/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE The aim of this study was to compare the correlation between preoperative quadriceps femoris muscle thickness and postoperative neuromuscular activation and quadriceps femoris strength in patients with and without patellofemoral pain after arthroscopic partial meniscectomy. METHODS A series of 120 patients were prospectively analysed in a longitudinal cohort study of patients scheduled for arthroscopic partial meniscectomy. The patellofemoral pain group included patients who developed anterior knee pain after surgery while the control group included those who had not done so. Patients with preoperative patellofemoral pain, previous knee surgeries as well as those on whom additional surgical procedures had been performed were excluded. Of the 120 initially included in the study, 90 patients were analysed after the exclusions. RESULTS There is a direct correlation between preoperative quadriceps femoris muscle thickness and the neuromuscular activity values and the strength of the muscle at 6 weeks after surgery. These results were seen exclusively in the group of patients who do not develop patellofemoral pain (0.543, p = 0.008). The group of patients who developed anterior knee pain in the postoperative period did not show this correlation (n.s.). CONCLUSION In patients without patellofemoral pain after meniscectomy, the greater the preoperative thickness of the quadriceps femoris, the more postoperative neuromuscular activation and strength they had. This correlation did not occur in those patients who develop patellofemoral pain after meniscal surgery. LEVEL OF EVIDENCE II.
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89
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Waiteman MC, Botta AFB, Perez VO, de Oliveira Silva D, Pazzinatto MF, Magalhães FH, de Azevedo FM, Briani RV. Relationship between vastus medialis Hoffmann reflex excitability and knee extension biomechanics during different tasks in women with patellofemoral pain. Clin Biomech (Bristol, Avon) 2022; 91:105544. [PMID: 34896835 DOI: 10.1016/j.clinbiomech.2021.105544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 10/22/2021] [Accepted: 11/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Impaired knee extension biomechanics and spinal excitability have been reported in women with patellofemoral pain, but their relationship has not been explored. A significant relationship between them could indicate the need for investigating the potential benefits of disinhibitory interventions for women with patellofemoral pain. Thus, this study aimed to investigate the relationship between vastus medialis Hoffmann reflex and (1) maximal isometric, concentric and eccentric knee extensor strength and rate of torque development; (2) knee extensor torque steadiness; and (3) knee extensor moment during functional tasks; in women with patellofemoral pain. METHODS Spinal excitability of twenty-four participants was assessed by the amplitude of maximal vastus medialis Hoffmann reflex. Knee extensor strength, rate of torque development and torque steadiness were assessed using an isokinetic dynamometer. Knee extensor moment during step-down and stair descent tasks were obtained using a three-dimensional motion analysis system. FINDINGS A moderate negative relationship was found between vastus medialis Hoffmann reflex and knee extensor torque steadiness (r = -0.35; p = 0.05); whereas a moderate positive relationship was found with maximal isometric knee extensor strength (r = 0.37; p = 0.044). No significant relationships were found between vastus medialis Hoffmann reflex and the other variables. INTERPRETATION Our findings provide insight on the relationship between spinal excitability and neuromuscular control of maximal and submaximal isometric torque production in women with patellofemoral pain. Conversely, spinal excitability does not seem to be related with dynamic torques and moments of the knee extensors in women with patellofemoral pain.
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Affiliation(s)
- Marina Cabral Waiteman
- Laboratory of Biomechanics and Motor Control (LABCOM), School of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, Sao Paulo, Brazil.
| | - Ana Flavia Balotari Botta
- Laboratory of Biomechanics and Motor Control (LABCOM), School of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, Sao Paulo, Brazil
| | - Vitória Ozores Perez
- Laboratory of Biomechanics and Motor Control (LABCOM), School of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, Sao Paulo, Brazil
| | - Danilo de Oliveira Silva
- La Trobe Sport and Exercise Medicine Research Centre (LASEM), School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Marcella Ferraz Pazzinatto
- La Trobe Sport and Exercise Medicine Research Centre (LASEM), School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Fernando Henrique Magalhães
- Laboratory of Biomechanics and Motor Control (LABCOM), School of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, Sao Paulo, Brazil; School of Arts, Sciences, and Humanities, University of Sao Paulo, Sao Paulo, Brazil
| | - Fábio Mícolis de Azevedo
- Laboratory of Biomechanics and Motor Control (LABCOM), School of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, Sao Paulo, Brazil
| | - Ronaldo Valdir Briani
- Laboratory of Biomechanics and Motor Control (LABCOM), School of Science and Technology, Sao Paulo State University (UNESP), Presidente Prudente, Sao Paulo, Brazil
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Arthrogenic Muscle Inhibition: Best Evidence, Mechanisms, and Theory for Treating the Unseen in Clinical Rehabilitation. J Sport Rehabil 2021; 31:717-735. [PMID: 34883466 DOI: 10.1123/jsr.2021-0139] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/06/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT Arthrogenic muscle inhibition (AMI) impedes the recovery of muscle function following joint injury, and in a broader sense, acts as a limiting factor in rehabilitation if left untreated. Despite a call to treat the underlying pathophysiology of muscle dysfunction more than three decades ago, the continued widespread observations of post-traumatic muscular impairments are concerning, and suggest that interventions for AMI are not being successfully integrated into clinical practice. OBJECTIVES To highlight the clinical relevance of AMI, provide updated evidence for the use of clinically accessible therapeutic adjuncts to treat AMI, and discuss the known or theoretical mechanisms for these interventions. EVIDENCE ACQUISITION PubMed and Web of Science electronic databases were searched for articles that investigated the effectiveness or efficacy of interventions to treat outcomes relevant to AMI. EVIDENCE SYNTHESIS 122 articles that investigated an intervention used to treat AMI among individuals with pathology or simulated pathology were retrieved from 1986 to 2021. Additional articles among uninjured individuals were considered when discussing mechanisms of effect. CONCLUSION AMI contributes to the characteristic muscular impairments observed in patients recovering from joint injuries. If left unresolved, AMI impedes short-term recovery and threatens patients' long-term joint health and well-being. Growing evidence supports the use of neuromodulatory strategies to facilitate muscle recovery over the course of rehabilitation. Interventions should be individualized to meet the needs of the patient through shared clinician-patient decision-making. At a minimum, we propose to keep the treatment approach simple by attempting to resolve inflammation, pain, and effusion early following injury.
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91
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Weaver A, Ness BM, Roman DP, Giampetruzzi N, Cleland JA, Pace JL, Crepeau AE. Short-term isokinetic and isometric strength outcomes after anterior cruciate ligament reconstruction in adolescents. Phys Ther Sport 2021; 53:75-83. [PMID: 34875528 DOI: 10.1016/j.ptsp.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To examine differences in knee strength outcomes after ACL reconstruction according to quadriceps tendon (QT) or hamstring tendon (HT) autograft in adolescents. DESIGN Retrospective cohort. METHODS Surgical and clinical outcome data were collected. Analyses were conducted separately for female and male cohorts and grouped by graft type (HT or QT). A Mann-Whitney U test of independent samples was used to examine group differences according to graft type. RESULTS 107 females (age = 15.6 ± 1.5 years) and 94 males (age = 15.7 ± 1.5 years) were included. Mean time since surgery ranged from 7.2 to 7.9 months. Those with a QT autograft had decreased normalized isokinetic quadriceps peak torque on the involved limb compared to the HT group (p < 0.01, ES = 0.71-0.89). Normalized isometric hamstring peak torque was decreased for those with HT autograft in the female cohort (p = 0.02, ES = 0.57). CONCLUSION Normalized isokinetic quadriceps peak torque was reduced by 18-20% on the involved limb in those with a QT autograft. Normalized isometric hamstring peak torque was decreased by 13% for those with HT autograft in the female cohort. Method of strength testing may be an important consideration to fully appreciate strength deficits after ACL reconstruction according to graft type.
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Affiliation(s)
- Adam Weaver
- Connecticut Children's, Sports Physical Therapy, Farmington, CT, USA
| | - Brandon M Ness
- Doctor of Physical Therapy Program, Tufts University School of Medicine, Boston, MA, USA
| | - Dylan P Roman
- Connecticut Children's, Sports Physical Therapy, Farmington, CT, USA.
| | | | - Joshua A Cleland
- Doctor of Physical Therapy Program, Tufts University School of Medicine, Boston, MA, USA
| | - J Lee Pace
- Elite Sports Medicine at Connecticut Children's, Hartford, CT, USA; UConn Health, Division of Sports Medicine, Department of Orthopedics, Farmington, CT, USA
| | - Allison E Crepeau
- Elite Sports Medicine at Connecticut Children's, Hartford, CT, USA; UConn Health, Division of Sports Medicine, Department of Orthopedics, Farmington, CT, USA
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Smeets A, Willems M, Gilson L, Verschueren S, Staes F, Vandenneucker H, Claes S, Vanrenterghem J. Neuromuscular and biomechanical landing alterations persist in athletes returning to sport after anterior cruciate ligament reconstruction. Knee 2021; 33:305-317. [PMID: 34741830 DOI: 10.1016/j.knee.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/18/2021] [Accepted: 10/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstructed (ACLR) athletes show increased hamstrings activation and decreased knee flexion moments (KFMs) during single leg landing tasks at time of return-to-sport (RTS). Although these landing alterations seem protective in the short term, they might become undesirable if they persist after RTS. Therefore, the main aim of this study was to investigate whether those landing alterations persist in the months following RTS. METHODS Sixteen athletes who had an ACLR performed five unilateral landing tasks at three different time points (at RTS, and at 3 and 6 months after RTS) while KFMs and hamstrings activation were recorded. The following clinical parameters were registered: isokinetic strength of quadriceps and hamstrings, ACL return-to-sport after injury scale (ACL-RSI), Tampa scale of kinesiophobia, self-reported instability and single leg hop distance. A one-way repeated measures analysis of variance (ANOVA) was used to assess whether landing deficits changed over time. Additionally, an explorative analysis was performed to assess whether those athletes whose deficits persisted the most could be identified based on baseline clinical parameters. RESULTS The ANOVA showed no differences in landing deficits between sessions, indicating persisting reduced KFMs and increased hamstrings activation in the injured leg compared with the contralateral leg. A significant improvement of the quadriceps concentric strength (at 120°/s), ACL-RSI score and jump distance of the single leg hop was found over time. CONCLUSIONS Landing alterations were not resolved 6 months after RTS. Additional interventions may be needed to normalize landing alterations prior to return to sport.
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Affiliation(s)
- Annemie Smeets
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Miel Willems
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Human Movement Biomechanics Research Group, Department of Movement Science, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Laurens Gilson
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sabine Verschueren
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Staes
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hilde Vandenneucker
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - Steven Claes
- Department of Orthopedic Surgery, AZ Herentals Hospital, Herentals, Belgium
| | - Jos Vanrenterghem
- Musculoskeletal Rehabilitation Research Group, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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93
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Coulondre C, Souron R, Rambaud A, Dalmais É, Espeit L, Neri T, Pinaroli A, Estour G, Millet GY, Rupp T, Feasson L, Edouard P, Lapole T. Local vibration training improves the recovery of quadriceps strength in early rehabilitation after anterior cruciate ligament reconstruction: A feasibility randomised controlled trial. Ann Phys Rehabil Med 2021; 65:101441. [PMID: 33059096 DOI: 10.1016/j.rehab.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND After anterior cruciate ligament reconstruction (ACLR), quadriceps strength must be maximised as early as possible. OBJECTIVES We tested whether local vibration training (LVT) during the early post-ACLR period (i.e., ∼10 weeks) could improve strength recovery. METHODS This was a multicentric, open, parallel-group, randomised controlled trial. Thirty individuals attending ACLR were randomised by use of a dedicated Web application to 2 groups: vibration (standardised rehabilitation plus LVT, n=16) or control (standardised rehabilitation alone, n=14). Experimenters, physiotherapists and participants were not blinded. Both groups received 24 sessions of standardised rehabilitation over ∼10 weeks. In addition, the vibration group received 1 hour of vibration applied to the relaxed quadriceps of the injured leg at the end of each rehabilitation session. The primary outcome - maximal isometric strength of both injured and non-injured legs (i.e., allowing for limb asymmetry measurement) - was evaluated before ACLR (PRE) and after the 10-week rehabilitation (POST). RESULTS Seven participants were lost to follow-up, so data for 23 participants were used in the complete-case analysis. For the injured leg, the mean (SD) decrease in maximal strength from PRE to POST was significantly lower for the vibration than control group (n=11, -16% [10] vs. n=12, -30% [11]; P=0.0045, Cohen's d effect size=1.33). Mean PRE-POST change in limb symmetry was lower for the vibration than control group (-19% [11] vs. -29% [13]) but not significantly (P=0.051, Cohen's d effect size=0.85). CONCLUSION LVT improved strength recovery after ACLR. This feasibility study suggests that LVT applied to relaxed muscles is a promising modality of vibration therapy that could be implemented early in ACLR. TRIAL REGISTRATION ClinicalTrials.gov: NCT02929004.
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Affiliation(s)
- Claire Coulondre
- Inter-university laboratory of human movement biology (LIBM), University of Savoie-Mont Blanc, EA 7424, 73000 Chambéry, France; Centre d'évaluation et de prévention articulaire (CEPART), 73490 Challes-les-Eaux, France; Centre d'orthopédie et de traumatologie du sport, 73000 Bassens, France
| | - Robin Souron
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France; Laboratory of impact of physical activity on health (IAPS), UR n(o)201723207F, University of Toulon, Toulon, France
| | - Alexandre Rambaud
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France
| | - Étienne Dalmais
- Inter-university laboratory of human movement biology (LIBM), University of Savoie-Mont Blanc, EA 7424, 73000 Chambéry, France; Centre d'évaluation et de prévention articulaire (CEPART), 73490 Challes-les-Eaux, France; Centre d'orthopédie et de traumatologie du sport, 73000 Bassens, France
| | - Loïc Espeit
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France
| | - Thomas Neri
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France; Department of orthopaedic surgery, university hospital of Saint Étienne, Faculty of medicine, Saint-Étienne, France
| | | | | | - Guillaume Y Millet
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France; Institut universitaire de France (IUF), France
| | - Thomas Rupp
- Inter-university laboratory of human movement biology (LIBM), University of Savoie-Mont Blanc, EA 7424, 73000 Chambéry, France
| | - Léonard Feasson
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France; Department of clinical and exercise physiology, sports medicine and myology units, regional institute of medicine and sports engineering (IRMIS), University hospital of Saint-Étienne, Faculty of medicine, Saint-Étienne, France
| | - Pascal Edouard
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France; Department of clinical and exercise physiology, sports medicine and myology units, regional institute of medicine and sports engineering (IRMIS), University hospital of Saint-Étienne, Faculty of medicine, Saint-Étienne, France
| | - Thomas Lapole
- Université de Lyon, UJM-Saint-Étienne, Inter-university laboratory of human movement biology, EA 7424, 42023 Saint-Étienne, France.
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94
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Ucero-Lozano R, Pérez-Llanes R, López-Pina JA, Cuesta-Barriuso R. One Session Effects of Knee Motion Visualization Using Immersive Virtual Reality in Patients with Hemophilic Arthropathy. J Clin Med 2021; 10:jcm10204725. [PMID: 34682847 PMCID: PMC8538542 DOI: 10.3390/jcm10204725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/25/2022] Open
Abstract
(1) Background: Hemophilic knee arthropathy is characterized by a loss of muscle mass and decreased strength of the quadriceps muscle. The visualization of movement aims to favor the recruitment of the motor system in the same premotor and parietal areas, as would happen with the active execution of the observed action. The aim was to evaluate changes in quadriceps activation in patients with hemophilic knee arthropathy following immersive VR visualization of knee extension movements. (2) Methods: We recruited 13 patients with severe hemophilia A and knee arthropathy. Patients underwent a 15 min session of immersive VR visualization of knee extension movements. The quadriceps muscle activation was evaluated by surface electromyography. (3) Results: After the intervention, there were no changes in the muscle activation of vastus medialis, vastus lateralis, or rectus femoris muscles. There was a large effect size of changes in rectus femoris muscle activation. Age and knee joint damage did not correlate with changes in quadriceps activation. Dominance, inhibitor development, and type of treatment were not related with post-intervention muscle activation. (4) Conclusions: A session of immersive VR visualization of knee extension movement does not modify quadriceps muscle activation. A specific protocol for patients with hemophilic knee arthropathy may be effective in improving the activation of the rectus femoris muscle.
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Affiliation(s)
- Roberto Ucero-Lozano
- Department of Physiotherapy, European University of Madrid, 28670 Villaviciosa de Odón, Spain;
| | - Raúl Pérez-Llanes
- Department of Physiotherapy, Catholic University San Antonio-UCAM, 30107 Murcia, Spain;
| | | | - Rubén Cuesta-Barriuso
- Department of Physiotherapy, University of Murcia, 30100 Murcia, Spain
- Royal Victoria Eugenia Foundation, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-868-887286
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95
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Nuccio S, Del Vecchio A, Casolo A, Labanca L, Rocchi JE, Felici F, Macaluso A, Mariani PP, Falla D, Farina D, Sbriccoli P. Deficit in knee extension strength following anterior cruciate ligament reconstruction is explained by a reduced neural drive to the vasti muscles. J Physiol 2021; 599:5103-5120. [PMID: 34605556 DOI: 10.1113/jp282014] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/30/2021] [Indexed: 11/08/2022] Open
Abstract
The persistence of quadriceps weakness represents a major concern following anterior cruciate ligament reconstruction (ACLR). The underlying adaptations occurring in the activity of spinal motoneurons are still unexplored. This study examined the discharge patterns of large populations of motor units (MUs) in the vastus lateralis (VL) and vastus medialis muscles following ACLR. Nine ACLR individuals and 10 controls performed unilateral trapezoidal contractions of the knee extensor muscles at 35%, 50% and 70% of the maximal voluntary isometric force (MVIF). High-density surface electromyography (HDsEMG) was used to record the myoelectrical activity of the vasti muscles in both limbs. HDsEMG signals were decomposed with a convolutive blind source separation method and MU properties were extracted and compared between sides and groups. The ACLR group showed a lower MVIF on the reconstructed side compared to the contralateral side (28.1%; P < 0.001). This force deficit was accompanied by reduced MU discharge rates (∼21%; P < 0.05), lower absolute MU recruitment and derecruitment thresholds (∼22% and ∼22.5%, respectively; P < 0.05) and lower input-output gain of motoneurons (27.3%; P = 0.009). Deficits in MU discharge rates of the VL and in absolute recruitment and derecruitment thresholds of both vasti MUs were associated with deficits in MVIF (P < 0.05). A strong between-side correlation was found for MU discharge rates of the VL of ACLR individuals (P < 0.01). There were no significant between-group differences (P > 0.05). These results indicate that mid- to long-term strength deficits following ACLR may be attributable to a reduced neural drive to vasti muscles, with potential changes in excitatory and inhibitory synaptic inputs. KEY POINTS: Impaired expression and control of knee extension forces is common after anterior cruciate ligament reconstruction and is related to high risk of a second injury. To provide novel insights into the neural basis of this impairment, the discharge patterns of motor units in the vastus lateralis and vastus medialis were investigated during voluntary force contractions. There was lower knee extensor strength on the reconstructed side with respect to the contralateral side, which was explained by deficits in motor unit discharge rate and an altered motoneuronal input-output gain. Insufficient excitatory inputs to motoneurons and increased inhibitory afferent signals potentially contributed to these alterations. These results further our understanding of the neural underpinnings of quadriceps weakness following anterior cruciate ligament reconstruction and can help to develop effective rehabilitation protocols to regain muscle strength and reduce the risk of a second injury.
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Affiliation(s)
- Stefano Nuccio
- Department of Movement, Human and Health Sciences, University of Rome 'Foro Italico', Rome, Italy
| | - Alessandro Del Vecchio
- Department Artificial Intelligence in Biomedical Engineering, Friedrich-Alexander University, Erlangen, Germany
| | - Andrea Casolo
- Department of Biomedical Sciences, University of Padova, Padua, Italy
| | - Luciana Labanca
- Department of Movement, Human and Health Sciences, University of Rome 'Foro Italico', Rome, Italy
| | | | - Francesco Felici
- Department of Movement, Human and Health Sciences, University of Rome 'Foro Italico', Rome, Italy
| | - Andrea Macaluso
- Department of Movement, Human and Health Sciences, University of Rome 'Foro Italico', Rome, Italy.,Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
| | - Pier Paolo Mariani
- Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Rome, Italy
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London, UK
| | - Paola Sbriccoli
- Department of Movement, Human and Health Sciences, University of Rome 'Foro Italico', Rome, Italy
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96
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Bielitzki R, Behrendt T, Behrens M, Schega L. Time to Save Time: Beneficial Effects of Blood Flow Restriction Training and the Need to Quantify the Time Potentially Saved by Its Application During Musculoskeletal Rehabilitation. Phys Ther 2021; 101:6315163. [PMID: 34228788 DOI: 10.1093/ptj/pzab172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/14/2021] [Accepted: 06/06/2021] [Indexed: 11/14/2022]
Abstract
The main goal of musculoskeletal rehabilitation is to achieve the pre-injury and/or pre-surgery physical function level with a low risk of re-injury. Blood flow restriction (BFR) training is a promising alternative to conventional therapy approaches during musculoskeletal rehabilitation because various studies support its beneficial effects on muscle mass, strength, aerobic capacity, and pain perception. In this perspective article, we used an evidence-based progressive model of a rehabilitative program that integrated BFR in 4 rehabilitation phases: (1) passive BFR, (2) BFR combined with aerobic training, (3) BFR combined with low-load resistance training, and (4) BFR combined with low-load resistance training and traditional high-load resistance training. Considering the current research, we propose that a BFR-assisted rehabilitation has the potential to shorten the time course of therapy to reach the stage where the patient is able to tolerate resistance training with high loads. The information and arguments presented are intended to stimulate future research, which compares the time to achieve rehabilitative milestones and their physiological bases in each stage of the musculoskeletal rehabilitation process. This requires the quantification of BFR training-induced adaptations (eg, muscle mass, strength, capillary-to-muscle-area ratio, hypoalgesia, molecular changes) and the associated changes in performance with a high measurement frequency (≤1 week) to test our hypothesis. This information will help to quantify the time saved by BFR-assisted musculoskeletal rehabilitation. This is of particular importance for patients, because the potentially accelerated recovery of physical functioning would allow them to return to their work and/or social life earlier. Furthermore, other stakeholders in the health care system (eg, physicians, nurses, physical therapists, insurance companies) might benefit from that with regard to work and financial burden.
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Affiliation(s)
- Robert Bielitzki
- Department of Sport Science, Institute III, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Tom Behrendt
- Department of Sport Science, Institute III, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Martin Behrens
- Department of Sport Science, Institute III, Otto von Guericke University Magdeburg, Magdeburg, Germany.,Department of Orthopedics, University Medicine Rostock, Rostock, Germany
| | - Lutz Schega
- Department of Sport Science, Institute III, Otto von Guericke University Magdeburg, Magdeburg, Germany
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97
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Lloyd D. The future of in-field sports biomechanics: wearables plus modelling compute real-time in vivo tissue loading to prevent and repair musculoskeletal injuries. Sports Biomech 2021:1-29. [PMID: 34496728 DOI: 10.1080/14763141.2021.1959947] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/20/2021] [Indexed: 01/13/2023]
Abstract
This paper explores the use of biomechanics in identifying the mechanistic causes of musculoskeletal tissue injury and degeneration. It appraises how biomechanics has been used to develop training programmes aiming to maintain or recover tissue health. Tissue health depends on the functional mechanical environment experienced by tissues during daily and rehabilitation activities. These environments are the result of the interactions between tissue motion, loading, biology, and morphology. Maintaining health of and/or repairing musculoskeletal tissues requires targeting the "ideal" in vivo tissue mechanics (i.e., loading and deformation), which may be enabled by appropriate real-time biofeedback. Recent research shows that biofeedback technologies may increase their quality and effectiveness by integrating a personalised neuromusculoskeletal modelling driven by real-time motion capture and medical imaging. Model personalisation is crucial in obtaining physically and physiologically valid predictions of tissue biomechanics. Model real-time execution is crucial and achieved by code optimisation and artificial intelligence methods. Furthermore, recent work has also shown that laboratory-based motion capture biomechanical measurements and modelling can be performed outside the laboratory with wearable sensors and artificial intelligence. The next stage is to combine these technologies into well-designed easy to use products to guide training to maintain or recover tissue health in the real-world.
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Affiliation(s)
- David Lloyd
- School of Health Sciences and Social Work, Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), in the Menzies Health Institute Queensland and Advanced Design and Prototyping Technologies Institute, Griffith University, Australia
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98
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Germano Maciel D, Santos Cerqueira M, Gabbett TJ, Elsangedy HM, de Brito Vieira WH. Should We Trust Perceived Effort for Loading Control and Resistance Exercise Prescription After ACL Reconstruction? Sports Health 2021; 14:764-769. [PMID: 34486455 DOI: 10.1177/19417381211041289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT The rating of perceived effort (RPE) is a common method used in clinical practice for monitoring, loading control, and resistance training prescription during rehabilitation after rupture and anterior cruciate ligament reconstruction (ACLR). It is suggested that the RPE results from the integration of the afferent feedback and corollary discharge in the motor and somatosensory cortex, and from the activation of brain areas related to emotions, affect, memory, and pain (eg, posterior cingulate cortex, precuneus, and prefrontal cortex). Recent studies have shown that rupture and ACLR induce neural adaptations in the brain commonly associated with the RPE. Therefore, we hypothesize that RPE could be affected because of neural adaptations induced by rupture and ACLR. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 5. RESULTS RPE could be directly altered by changes in the activation of motor cortex, posterior cingulate cortex, and prefrontal cortex. These neural adaptations may be induced by indirect mechanisms, such as the afferent feedback deficit, pain, and fear of movement (kinesiophobia) that patients may feel after rupture and ACLR. CONCLUSION Using only RPE for monitoring, loading control, and resistance training prescription in patients who had undergone ACLR could lead to under- or overdosing resistance exercise, and therefore, impair the rehabilitation process. STRENGTH-OF-RECOMMENDATION TAXONOMY 3C.
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Affiliation(s)
- Daniel Germano Maciel
- Department of Physical Therapy, Laboratory of Neuromuscular Performance, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Mikhail Santos Cerqueira
- Department of Physical Therapy, Laboratory of Neuromuscular Performance, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Tim J Gabbett
- Gabbett Performance Solutions, Brisbane, Queensland, Australia.,University of Southern Queensland, Institute for Resilient Regions, Ipswich, Queensland, Australia
| | - Hassan Mohamed Elsangedy
- Department of Physical Education, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Wouber Hérickson de Brito Vieira
- Department of Physical Therapy, Laboratory of Neuromuscular Performance, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
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99
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Mechanisms of Arthrogenic Muscle Inhibition. J Sport Rehabil 2021; 31:707-716. [PMID: 34470911 DOI: 10.1123/jsr.2020-0479] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 06/07/2021] [Accepted: 06/28/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT Arthrogenic muscle inhibition (AMI) continues to be a limiting factor in joint rehabilitation as the inability to volitionally activate muscle significantly dampens recovery. New evidence acquired at higher brain centers and in clinical populations continues to reshape our perspective of what AMI is and how to treat it. This review aims to stimulate discussion about the far-reaching effects of AMI by exploring the interconnected pathways by which it evolves. OBJECTIVES To discuss how reflexive inhibition can lead to adaptations in brain activity, to illustrate how changes in descending motor pathways limit our ability to contract muscle following injury, and to summarize the emerging literature on the wide-reaching effects of AMI on other interconnected systems. DATA SOURCES The databases PubMed, SPORTDiscus, and Web of Science were searched for articles pertaining to AMI. Reference lists from appropriate articles were cross-referenced. CONCLUSION AMI is a sequential and cumulative neurological process that leads to complex clinical impairments. Originating with altered afferent information arising from an injured joint, patients experience changes in afferent information, reflexive muscle inhibition, deficiencies in somatosensation, neuroplastic compensations in higher brain centers, and ultimately decreased motor output to the muscle surrounding the joint. Other aspects of clinical function, like muscle structure and psychological responses to injury, are also impaired and influenced by AMI. Removing, or reducing, AMI should continue to be a focus of rehabilitation programs to assist in the optimization of health after joint injury.
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100
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Madara KC, Aljehani M, Marmon A, Dellose S, Rubano J, Zeni J. Pre-operative predictors of early mobility and knee motion in patients undergoing a total knee arthroplasty. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2021. [DOI: 10.1080/21679169.2021.1947369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | | | - Adam Marmon
- Kinesiology and Applied Physiology, Newark, DE, USA
| | - Steven Dellose
- Department of Orthopaedics, Christiana Care Health System, Wilmington, DE, USA
| | - James Rubano
- Department of Orthopaedics, Christiana Care Health System, Wilmington, DE, USA
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