The Effectiveness and Recommendation of Motor Imagery Techniques for Rehabilitation after Anterior Cruciate Ligament Reconstruction: A Systematic Review

Neuromotor Treatment of Arthrogenic Muscle Inhibition After Knee Injury or Surgery

BACKGROUND

Persistent weakness of the quadriceps muscles and extension deficit after knee injuries are due to specific alterations in neural excitability - a process known as arthrogenic muscle inhibition (AMI). The effects of a novel neuromotor reprogramming (NR) treatment based on the use of proprioceptive sensations associated with motor imagery and low frequency sounds have not been studied in AMI after knee injuries.

HYPOTHESIS

This study aimed to assess quadriceps electromyographic (EMG) activity and the effects on extension deficits in persons with AMI who completed 1 session of NR treatment. We hypothesized that the NR session would activate the quadriceps and improve extension deficits.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Between May 1, 2021 and February 28, 2022, patients who underwent knee ligament surgery or sustained a knee sprain with a deficit of >30% of the vastus medialis oblique (VMO) on EMG testing in comparison with the contralateral limb after their initial rehabilitation were included in the study. The maximal voluntary isometric contraction of the VMO measured on EMG, the knee extension deficit (distance between the heel and the table during contraction), and the simple knee value (SKV) were assessed before and immediately after completion of 1 session of NR treatment.

RESULTS

A total of 30 patients with a mean age of 34.6 ± 10.1 years (range, 14-50 years) were included in the study. After the NR session, VMO activation increased significantly, with a mean increase of 45% (P < 0.01). Similarly, the knee extension deficit significantly improved from 4.03 ± 0.69 cm before the treatment to 1.93 ± 0.68 after the treatment (P < 0.01). The SKV was 50 ± 5.43% before the treatment, and this increased to 67.5 ± 4.09% after the treatment (P < 0.01).

CONCLUSION

Our study indicates that this innovative NR method can improve VMO activation and extension deficits in patients with AMI. Therefore, this method could be considered a safe and reliable treatment modality in patients with AMI after knee injury or surgery.

CLINICAL RELEVANCE

This multidisciplinary treatment modality for AMI can enhance outcomes through the restoration of quadriceps neuromuscular function and subsequent reduction of extension deficits after knee trauma.

Incidence of and Risk Factors for Arthrogenic Muscle Inhibition in Acute Anterior Cruciate Ligament Injuries: A Cross-Sectional Study and Analysis of Associated Factors From the SANTI Study Group

BACKGROUND

Arthrogenic muscle inhibition (AMI) is a process in which neural inhibition after injury or surgery to the knee results in quadriceps activation failure and knee extension deficit.

PURPOSE

To determine the incidence and spectrum of the severity of AMI after acute anterior cruciate ligament (ACL) injury using the Sonnery-Cottet classification, to determine the interobserver reliability of the classification system, and to investigate potential important factors associated with AMI after ACL injury.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Consecutive patients who had an acute ACL injury between October 2021 and February 2022 were considered for study inclusion. Eligible patients underwent a standardized physical examination at their first outpatient appointment. This included an assessment of quadriceps inhibition, identification of any extension deficits, and grading of AMI and its reversibility according to the Sonnery-Cottet classification.

RESULTS

A total of 300 consecutive patients with acute ACL ruptures were prospectively enrolled in the study. Of them, 170 patients (56.7%) had AMI. Patients evaluated with AMI showed a significantly inferior Lysholm score, International Knee Documentation Committee score, Simple Knee Value, and Knee injury and Osteoarthritis Outcome Score than patients without AMI (P < .0001). Multivariate analysis revealed that the presence of effusion, concomitant injuries, and high pain scores were associated with a significantly greater risk of AMI. Additional associations with the presence of AMI included a short duration between injury and evaluation, the use of crutches, and using a pillow as a support at night. In contrast, a previous ACL injury was associated with significantly lower odds of developing AMI (OR, 0.025; 95% CI, 0-0.2; P = .014). Among the 170 patients with AMI, 135 patients (79%) showed a resolution of their inhibition at the end of the consultation after application of simple exercises; the remaining 35 patients required specific rehabilitation. Interobserver reliability of the classification system was almost perfect (95% CI, 0.86-0.99).

CONCLUSION

AMI occurs in over half of patients with acute ACL injuries. When it occurs, it is easily reversible in the majority of patients with simple exercises targeted at abolishing AMI. The presence of "red flags" should increase the index of suspicion for the presence of AMI, and these include the presence of an effusion, high pain scores, a short time between injury and evaluation, multiligament injuries, the use of crutches, and using a pillow as a support at night. Patients with a history of ipsilateral or contralateral ACL injury are at a significantly lower risk of AMI than those with a first-time ACL injury.

Does graded motor imagery benefit individuals with knee pain: A systematic review and meta-analysis

OBJECTIVE

Evaluate how Graded Motor Imagery (GMI) may be used in those with knee pain, if individuals with knee pain present with a central nervous system (CNS) processing deficit, and if GMI is associated with improved outcomes.

METHODS

An electronic database search was conducted of PubMed, SPORTDiscus, CINHAL, MEDLINE, Google Scholar, and Sports Medicine Education Index using keywords related to GMI and knee pain. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Out of the 13,224 studies reviewed, 14 studies were included that used GMI for knee pain. Effect sizes were reported with standardized mean differences (SMD).

RESULTS

Individuals with knee osteoarthritis demonstrated poor performance with correctly identifying images of left or right knees, and GMI improved performance. In contrast, individuals with an anterior cruciate ligament injury demonstrated no evidence of CNS processing deficit and mixed outcomes with GMI. Meta-analysis was limited to individuals post total knee arthroplasty showing low certainty that GMI can improve quadriceps force production [SMD 0.64 (0.07,1.22)], but evidence of no effect to reduce pain or improve Timed up and Go performance and self-reported function.

CONCLUSIONS

Graded motor imagery may be an effective intervention for individuals with knee osteoarthritis. However, there was limited evidence that GMI was effective for an anterior cruciate ligament injury.

Effects of the Practice of Movement Representation Techniques in People Undergoing Knee and Hip Arthroplasty: A Systematic Review

OBJECTIVE

To analyze the effects of movement representation techniques (MRT) combined with conventional physical therapy (CFT) in people undergoing knee and hip arthroplasty compared to conventional physical therapy alone in terms of results in physical and functionality variables, cognitive function, and quality of life.

METHODOLOGY

the review was carried out according to the criteria of the PRISMA statement, considering studies in the electronic databases PubMed/Medline, Pubmed Central/Medline, Web of Science, EBSCO, and ScienceDirect.

RESULTS

MRT plus CFT generated therapeutic effects in some aspects of the physical variables: 100% pain (7 of 7 studies); 100% strength (5 out of 5 studies); range of motion 87.5% (7 out of 8 studies); 100% speed (1 of 1 study), functional variables: 100% gait (7 of 7 studies); functional capacity 87.5% (7 out of 8 studies); cognitive variables: 100% motor visualization ability (2 out of 2 studies); cognitive performance 100% (2 of 2 studies); and quality of life 66.6% (2 of 3 studies). When comparing its effects with conventional physical therapy, the variables that reported the greatest statistically significant changes were motor visualization ability, speed, pain, strength and gait. The most used MRT was motor imagery (MI), and the average time extension of therapies was 3.5 weeks.

CONCLUSIONS

movement representation techniques combined with conventional physical therapy are an innocuous and low-cost therapeutic intervention with therapeutic effects in patients with knee arthroplasty (KA) and hip arthroplasty (HA), and this combination generates greater therapeutic effects in physical, functional, and cognitive variables than conventional physical therapy alone.

The effect of kinesiophobia on functional outcomes following anterior cruciate ligament reconstruction surgery: an integrated literature review

PURPOSE

Evaluate the effect of kinesiophobia on functional outcomes following anterior cruciate ligament reconstruction (ACLR).

MATERIALS AND METHODS

A three-phase, integrated mixed-methods review of observational and qualitative studies was undertaken. (1) Systematic search of studies with participants over 12 years old, following ACLR and focusing on kinesiophobia, using the Tampa Scale of Kinesiophobia (TSK) for observational studies. Exclusion criteria included ipsilateral knee surgery and the involvement of elite athletes. (2) Critical appraisal for both design types was undertaken. (3) Synthesis occurred in five stages. Results were reported as a relationship between the TSK and other functional outcome measures. Finally, qualitative results were integrated to explain the results.

RESULTS

Twenty-four studies (1174 participants) were included with no exclusion based on the quality appraisal. Six themes were identified: (1) return to sport (RTS); (2) activities of daily living; (3) knee-related quality of life; (4) gait; (5) reinjury; and (6) knee disability and physical function. The highest strength of evidence was the negative association between increased TSK scores and both decreased activity levels and RTS.

CONCLUSIONS

Kinesiophobia affects a range of functional outcomes. Further research is required to identify screening tools and interventions for patients with kinesiophobia.IMPLICATIONS FOR REHABILITATIONKinesiophobia affects the effectiveness of rehabilitation following anterior cruciate ligament reconstruction, therefore addressing kinesiophobia both pre- and post-ACLR is important to optimise rehabilitation.Validated screening tools are required to identify kinesiophobia in individuals early to allow appropriate rehabilitation.Physiotherapists need to use a range of physiotherapeutic techniques, such as motor imagery and prehabilitation to assist individuals to overcome their kinesiophobia and improve their functional outcomes post-ACLR.

Effectiveness of motor imagery for improving functional performance after total knee arthroplasty: a systematic review with meta-analysis

Background

The aim of this study was to appraise the effects of motor imagery on the functional performance improvement among total knee arthroplasty patients systematically. We hypothesized a relatively greater recovery in the motor imagery group.

Methods

Medline (Ovid), Embase and Cochrane Controlled Register of Trials (CENTRAL) were searched from inception to October 1st, 2021. We included randomized controlled trials evaluating the effects of motor imagery on the functional recovery among total knee arthroplasty patients. Measurements included range of motion, strength intensity, Visual Analogue Scale, Time Up and Go Test, Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, all of which were evaluated before and after intervention. Mean differences (MD) or standard mean differences (SMD) and 95% confidence intervals (CI) were calculated. The Cochrane risk of bias tool was used to assess the risk of bias.

Results

Six studies with 168 patients were included for the meta-analysis. The SMD of strength intensity was increased (SMD = 0.90, 95% CI = [0.47]–[1.32], P < 0.001). The SMD of Visual Analogue Scale was reduced (SMD =  − 0.91; 95% CI = [− 1.29]–[− 0.52], P < 0.001). The SMD of Time Up and Go Test was reduced (SMD =  − 0.56, 95% CI = [− 0.94]–[− 0.19], P = 0.003). The MD of Oxford Knee Score was slightly increased (MD = 0.79-point, 95% CI = [− 0.31]–[1.88], P = 0.159). The outcomes of range of motion, Western Ontario and McMaster Universities Osteoarthritis Index were described according to the original data.

Conclusion

Compared with control therapy, motor imagery in the intervention group achieved an effective treatment for strength enhancement, pain reduction and physical activities improvement. More large-scale, prospective researches are needed in the future.

Trial registration: The PROSPERO trial registration number is CRD42021250996.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-02946-4.