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Cobian DG, Oppenheim ZR, Roehl TJ, Joachim MR, Heiderscheit BC. Knee Extensor Torque Steadiness and Quadriceps Activation Variability in Collegiate Athletes 4, 6, and 12 Months After ACL Reconstruction. Orthop J Sports Med 2024; 12:23259671241253843. [PMID: 38867919 PMCID: PMC11168251 DOI: 10.1177/23259671241253843] [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: 10/25/2023] [Accepted: 11/16/2023] [Indexed: 06/14/2024] Open
Abstract
Background Quadriceps performance after anterior cruciate ligament reconstruction (ACLR) is typically characterized by peak force/torque, but the ability to generate consistent knee extensor torque may be clinically meaningful. Purpose/Hypothesis The purpose of this study was to evaluate knee extensor torque steadiness and quadriceps activation variability in collegiate athletes 4 to 12 months after ACLR. It was hypothesized that between-limb asymmetries in torque steadiness and activation variability would be observed and that steadiness would be associated with activation variability and peak knee extensor torque symmetry. Study Design Case-control study; Level of evidence, 3. Methods A total of 30 National Collegiate Athletic Association Division I athletes completed maximal voluntary isometric contractions 4, 6, and 12 months after ACLR. Torque and surface electromyography of the superficial quadriceps were recorded. Torque steadiness was calculated as the mean difference between initial and low-pass filtered torque signals and was expressed as a percentage of peak torque. Quadriceps activation variability was calculated similarly and was expressed as a percentage of peak electromyography. Linear mixed models were used to assess change in torque steadiness and activation variability over time. Associations between torque steadiness of the operated limb, activation variability, and quadriceps strength symmetry were evaluated using the Spearman correlation coefficient. Results Limb-by-time interactions were detected for torque steadiness and activation variability (P < .001), with reductions (improvements) in limb steadiness and activation variability observed with increasing time since surgery. Between-limb differences in torque steadiness and activation variability were observed at 4 and 6 months postoperatively (P < .05). Significant associations between operated limb torque steadiness and quadriceps activation variability were observed at 4 months (P < .001) and 6 months (P < .01). Torque steadiness of the operated limb was associated with peak knee extensor torque symmetry at 4 months (r S = -0.49; P < .01) and 6 months (r S = -0.49; P < .01). Conclusion In collegiate athletes, impaired knee extensor torque steadiness of the operated limb and associated abnormal quadriceps activation patterns were observed 4 to 12 months after ACLR, and the consistency of knee extensor torque production was associated with greater quadriceps strength asymmetries, particularly 4 to 6 months after surgery. Operated limb torque steadiness and activation variability improved from 4 to 12 months after ACLR. Clinical assessment of knee extensor torque steadiness after ACLR may improve prognosis and specificity of rehabilitation efforts.
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Affiliation(s)
- Daniel G. Cobian
- Orthopedics and Rehabilitation, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Badger Athletic Performance Program, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Doctor of Physical Therapy Program, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Zachary R. Oppenheim
- Badger Athletic Performance Program, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Department of Biomedical Engineering, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Tyler J. Roehl
- Badger Athletic Performance Program, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Doctor of Physical Therapy Program, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Mikel R. Joachim
- Orthopedics and Rehabilitation, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Badger Athletic Performance Program, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Bryan C. Heiderscheit
- Orthopedics and Rehabilitation, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Badger Athletic Performance Program, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Department of Biomedical Engineering, University of Wisconsin–Madison, Madison, Wisconsin, USA
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Riehm CD, Bonnette S, Rush JL, Diekfuss JA, Koohestani M, Myer GD, Norte GE, Sherman DA. Corticomuscular cross-recurrence analysis reveals between-limb differences in motor control among individuals with ACL reconstruction. Exp Brain Res 2024; 242:355-365. [PMID: 38092900 PMCID: PMC10872341 DOI: 10.1007/s00221-023-06751-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/16/2023] [Indexed: 01/04/2024]
Abstract
Surgical reconstruction of the anterior cruciate ligament (ACL) and subsequent physical therapy can help athletes return to competition; however, re-injury rates remain disproportionately high due, in part, to lingering biomechanical and neurological factors that are not fully addressed during rehabilitation. Prior reports indicate that individuals exhibit altered electrical activity in both brain and muscle after ACL reconstruction (ACLR). In this investigation, we aimed to extend existing approaches by introducing a novel non-linear analysis of corticomuscular dynamics, which does not assume oscillatory coupling between brain and muscle: Corticomuscular cross-recurrence analysis (CM-cRQA). Our findings indicate that corticomuscular dynamics vary significantly between involved (injured) and uninvolved legs of participants with ACLR during voluntary isometric contractions between the brain and both the vastus medialis and lateralis. This finding points to a potential lingering neural deficit underlying re-injury for athletes after surgical reconstruction, namely the dynamical structure of neuromuscular (brain to quad muscle) coordination, which is significantly asymmetric, between limbs, in those who have ACLR.
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Affiliation(s)
- Christopher D Riehm
- Emory Sports Performance And Research Center (SPARC), Flowery Branch, GA, USA.
- Emory Sports Medicine Center, Atlanta, GA, USA.
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA.
| | - Scott Bonnette
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Justin L Rush
- Division of Physical Therapy, School of Rehabilitation Sciences, Ohio University, Athens, OH, USA
| | - Jed A Diekfuss
- Emory Sports Performance And Research Center (SPARC), Flowery Branch, GA, USA
- Emory Sports Medicine Center, Atlanta, GA, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Moein Koohestani
- Neuroplasticity, & Sarcopenia (CNS) Lab, Institute of Exercise Physiology and Rehabilitation Science, University of Central Florida, Orlando, FL, USA
| | - Gregory D Myer
- Emory Sports Performance And Research Center (SPARC), Flowery Branch, GA, USA
- Emory Sports Medicine Center, Atlanta, GA, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
- Youth Physical Development Centre, Cardiff Metropolitan University, Wales, UK
| | - Grant E Norte
- Neuroplasticity, & Sarcopenia (CNS) Lab, Institute of Exercise Physiology and Rehabilitation Science, University of Central Florida, Orlando, FL, USA
| | - David A Sherman
- Live4 Physical Therapy and Wellness, Acton, MA, USA
- Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
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Riehm CD, Zuleger T, Diekfuss JA, Arellano E, Myer GD. The Evolution of Neuroimaging Technologies to Evaluate Neural Activity Related to Knee Pain and Injury Risk. Curr Rev Musculoskelet Med 2024; 17:14-22. [PMID: 38109007 PMCID: PMC10766917 DOI: 10.1007/s12178-023-09877-5] [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] [Accepted: 11/26/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW In this review, we present recent findings and advancements in the use of neuroimaging to evaluate neural activity relative to ACL injury risk and patellofemoral pain. In particular, we describe prior work using fMRI and EEG that demonstrate the value of these techniques as well as the necessity of continued development in this area. Our goal is to support future work by providing guidance for the successful application of neuroimaging techniques that most effectively expose pain and injury mechanisms. RECENT FINDINGS Recent studies that utilized both fMRI and EEG indicate that athletes who are at risk for future ACL injury exhibit divergent brain activity both during active lower extremity movement and at rest. Such activity patterns are likely due to alterations to cognitive, visual, and attentional processes that manifest as coordination deficits during naturalistic movement that may result in higher risk of injury. Similarly, in individuals with PFP altered brain activity in a number of key regions is related to subjective pain judgements as well as measures of fear of movement. Although these findings may begin to allow objective pain assessment and identification, continued refinement is needed. One key limitation across both ACL and PFP related work is the restriction of movement during fMRI and EEG data collection, which drastically limits ecological validity. Given the lack of sufficient research using EEG and fMRI within a naturalistic setting, our recommendation is that researchers target the use of mobile, source localized EEG as a primary methodology for exposing neural mechanisms of ACL injury risk and PFP. Our contention is that this method provides an optimal balance of spatial and temporal resolution with ecological validity via naturalistic movement.
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Affiliation(s)
- Christopher D Riehm
- Emory Sports Performance And Research Center (SPARC), 4450 Falcon Pkwy, Flowery Branch, GA, 30542, USA.
- Emory Sports Medicine Center, Atlanta, GA, USA.
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA.
| | - Taylor Zuleger
- Emory Sports Performance And Research Center (SPARC), 4450 Falcon Pkwy, Flowery Branch, GA, 30542, USA
- Emory Sports Medicine Center, Atlanta, GA, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
- Neuroscience Graduate Program, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Jed A Diekfuss
- Emory Sports Performance And Research Center (SPARC), 4450 Falcon Pkwy, Flowery Branch, GA, 30542, USA
- Emory Sports Medicine Center, Atlanta, GA, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Emilio Arellano
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Gregory D Myer
- Emory Sports Performance And Research Center (SPARC), 4450 Falcon Pkwy, Flowery Branch, GA, 30542, USA
- Emory Sports Medicine Center, Atlanta, GA, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
- Youth Physical Development Centre, Cardiff Metropolitan University, Wales, UK
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
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Harput G, Demirci S, Nyland J, Soylu AR, Tunay VB. Sports activity level after ACL reconstruction is predicted by vastus medialis or vastus medialis obliquus thickness, single leg triple hop distance or 6-m timed hop, and quality of life score. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3483-3493. [PMID: 37198499 DOI: 10.1007/s00590-023-03571-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/05/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE Recovery after anterior cruciate ligament reconstruction (ACLR) may take > 2 years, and younger athletes have higher re-injury risk. The purpose of this prospective longitudinal study was to determine how the early to mid-term Tegner Activity Level Scale (TALS) scores of athletically active males ≥ 2 years post-ACLR follow-up was predicted by bilateral isokinetic knee extensor and flexor torque, quadriceps femoris thickness, single leg hop test performance, and self-reported knee function (Knee Injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee (IKDC) Subjective Assessment score). METHODS After ACLR with a hamstring tendon autograft and safely returning to sports at least twice weekly, 23 men (18.4 ± 3.5 years of age) were evaluated at final follow-up (mean = 4.5, range = 2-7 years). Exploratory forward stepwise multiple regression was used to determine the relationship between independent surgical and non-surgical lower limb variables peak concentric isokinetic knee extensor-flexor torque at 60°/sec and 180°/sec, quadriceps femoris muscle thickness, single leg hop test profile results, KOOS subscale scores, IKDC Subjective Assessment scores, and time post-ACLR on TALS scores at final follow-up. RESULTS Subject TALS scores were predicted by KOOS quality of life subscale score, surgical limb vastus medialis obliquus (VMO) thickness, and surgical limb single leg triple hop for distance (SLTHD) performance. Subject TALS scores were also predicted by KOOS quality of life subscale score, non-surgical limb vastus medialis (VM) thickness, and non-surgical limb 6 m single leg timed hop (6MSLTH) performance. CONCLUSION TALS scores were influenced differently by surgical and non-surgical lower extremity factors. At ≥ 2 years post-ACLR, ultrasound VM and VMO thickness measurements, single leg hop tests that challenge knee extensor function, and self-reported quality of life measurements predicted sports activity levels. The SLTHD test may be better than the 6MSLTH for predicting long-term surgical limb function.
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Affiliation(s)
- Gulcan Harput
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Serdar Demirci
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Balıkesir University, Balıkesir, Turkey
| | - John Nyland
- Kosair Charities College of Health and Natural Sciences, Athletic Training Program, Norton Orthopedic Institute, Spalding University, 901 South 4Th Street, Louisville, KY, USA.
| | - Abdullah Ruhi Soylu
- Department of Biophysics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Volga Bayrakci Tunay
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
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Sherman DA, Rush J, Stock MS, D. Ingersoll C, E. Norte G. Neural drive and motor unit characteristics after anterior cruciate ligament reconstruction: implications for quadriceps weakness. PeerJ 2023; 11:e16261. [PMID: 37818333 PMCID: PMC10561646 DOI: 10.7717/peerj.16261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/18/2023] [Indexed: 10/12/2023] Open
Abstract
Purpose The purpose of this investigation was to compare the quality of neural drive and recruited quadriceps motor units' (MU) action potential amplitude (MUAPAMP) and discharge rate (mean firing rate (MFR)) relative to recruitment threshold (RT) between individuals with anterior cruciate ligament reconstruction (ACLR) and controls. Methods Fourteen individuals with ACLR and 13 matched controls performed trapezoidal knee extensor contractions at 30%, 50%, 70%, and 100% of their maximal voluntary isometric contraction (MVIC). Decomposition electromyography (dEMG) and torque were recorded concurrently. The Hoffmann reflex (H-reflex) and central activation ratio (CAR) were acquired bilaterally to detail the proportion of MU pool available and volitionally activated. We examined MUAPAMP-RT and MFR-RT relationships with linear regression and extracted the regression line slope, y-intercept, and RT range for each contraction. Linear mixed effect modelling used to analyze the effect of group and limb on regression line slope and RT range. Results Individuals with ACLR demonstrated lower MVIC torque in the involved limb compared to uninvolved limb. There were no differences in H-reflex or CAR between groups or limbs. The ACLR involved limb demonstrated smaller mass-normalized RT range and slower MU firing rates at high contraction intensities (70% and 100% MVIC) compared to uninvolved and control limbs. The ACLR involved limb also demonstrated larger MU action potentials in the VM compared to the contralateral limb. These differences were largely attenuated with relative RT normalization. Conclusions These results suggest that persistent strength deficits following ACLR may be attributable to a diminished quadriceps motor neuron pool and inability to upregulate the firing rate of recruited MUs.
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Affiliation(s)
- David A. Sherman
- Live4 Physical Therapy and Wellness, Acton, Massachusetts, United States of America
- Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts, United States of America
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, United States of America
| | - Justin Rush
- Division of Physical Therapy, School of Rehabilitation and Communication Sciences, College of Health Sciences and Professions, Ohio University, Athens, Ohio, United States of America
| | - Matt S. Stock
- Cognition, Neuroplasticity, & Sarcopenia (CNS) Lab, Institute of Exercise Physiology and Rehabilitation Science, University of Central Florida, Orlando, FL, United States of America
| | - Christopher D. Ingersoll
- College of Health Professions and Sciences, School of Kinesiology and Rehabilitation Sciences, University of Central Florida, Orlando, Florida, United States of America
| | - Grant E. Norte
- Cognition, Neuroplasticity, & Sarcopenia (CNS) Lab, Institute of Exercise Physiology and Rehabilitation Science, University of Central Florida, Orlando, FL, United States of America
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Johnson AK, Rodriguez KM, Lepley AS, Palmieri-Smith RM. Quadriceps torque complexity before and after anterior cruciate ligament reconstruction. J Sci Med Sport 2023; 26:533-538. [PMID: 37775409 DOI: 10.1016/j.jsams.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES The purpose of this project was to longitudinally examine quadriceps torque complexity in a group of individuals who tore their ACL and underwent ACL reconstruction. DESIGN Cohort analysis. METHODS Thirty-four individuals completed maximal effort bilateral isometric strength testing after ACL injury but pre-surgery, five months' post-surgery (mid-point of rehabilitation), and when cleared to return to activity. Sample entropy, a nonlinear analysis of quadriceps torque control (complexity), was calculated from maximal isometric contractions. Two 3 × 2 repeated measures analysis of variance were used to examine changes over time and between limbs for quadriceps torque complexity and peak torque. RESULTS Quadriceps peak torque was lower in the involved limb when compared to the uninvolved limb at every time point (p < 0.001). Peak torque of the involved limb was decreased at mid-point of rehabilitation compared to before surgery (p = 0.023) and at mid-point compared to return to activity (p = 0.041). Quadriceps sample entropy was higher in the involved limb compared to the uninvolved limb at the mid-point of rehabilitation (p < 0.001) and return to activity (p < 0.001), indicating greater complexity. The involved limb also demonstrated increased torque sample entropy from pre-surgery to mid-point of rehabilitation (p = 0.023), but not from pre-surgery to return to activity (p = 0.169) or from mid-point to return to activity (p = 0.541). CONCLUSIONS Not only does quadriceps strength decline with ACL reconstruction, but quality of the quadriceps muscle contraction is also compromised. Increased torque complexity experienced in the ACL limb after reconstruction may contribute to impaired physical function in individuals following ACL reconstruction.
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Affiliation(s)
| | | | | | - Riann M Palmieri-Smith
- School of Kinesiology, University of Michigan, USA; Department of Orthopedic Surgery, University of Michigan, USA
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