Christopher D. Ingersoll

Quadriceps activation following knee injuries: a systematic review.

CONTEXT Arthrogenic muscle inhibition is an important underlying factor in persistent quadriceps muscle weakness after knee injury or surgery. OBJECTIVE To determine the magnitude and prevalence of volitional quadriceps activation deficits after knee injury. DATA SOURCES Web of Science database. STUDY SELECTION Eligible studies involved human participants and measured quadriceps activation using either twitch interpolation or burst superimposition on patients with knee injuries or surgeries such as anterior cruciate ligament deficiency (ACLd), anterior cruciate ligament reconstruction (ACLr), and anterior knee pain (AKP). DATA EXTRACTION Means, measures of variability, and prevalence of quadriceps activation (QA) failure (<95%) were recorded for experiments involving ACLd (10), ACLr (5), and AKP (3). DATA SYNTHESIS A total of 21 data sets from 18 studies were initially identified. Data from 3 studies (1 paper reporting data for both ACLd and ACLr, 1 on AKP, and the postarthroscopy paper) were excluded from the primary analyses because only graphical data were reported. Of the remaining 17 data sets (from 15 studies), weighted mean QA in 352 ACLd patients was 87.3% on the involved side, 89.1% on the uninvolved side, and 91% in control participants. The QA failure prevalence ranged from 0% to 100%. Weighted mean QA in 99 total ACLr patients was 89.2% on the involved side, 84% on the uninvolved side, and 98.5% for the control group, with prevalence ranging from 0% to 71%. Thirty-eight patients with AKP averaged 78.6% on the involved side and 77.7% on the contralateral side. Bilateral QA failure was commonly reported in patients. CONCLUSIONS Quadriceps activation failure is common in patients with ACLd, ACLr, and AKP and is often observed bilaterally.

Balance Training Improves Function and Postural Control in Those with Chronic Ankle Instability

PURPOSE The purpose of this randomized controlled trial was to determine the effect of a 4-wk balance training program on static and dynamic postural control and self-reported functional outcomes in those with chronic ankle instability (CAI). METHODS Thirty-one young adults with self-reported CAI were randomly assigned to an intervention group (six males and 10 females) or a control group (six males and nine females). The intervention consisted of a 4-wk supervised balance training program that emphasized dynamic stabilization in single-limb stance. Main outcome measures included the following: self-reported disability on the Foot and Ankle Disability Index (FADI) and the FADI Sport scales; summary center of pressure (COP) excursion measures including area of a 95% confidence ellipse, velocity, range, and SD; time-to-boundary (TTB) measures of postural control in single-limb stance including the absolute minimum TTB, mean of TTB minima, and SD of TTB minima in the anteroposterior and mediolateral directions with eyes open and closed; and reach distance in the anterior, posteromedial, and posterolateral directions of the Star Excursion Balance Test (SEBT). RESULTS The balance training group had significant improvements in the FADI and the FADI Sport scores, in the magnitude and the variability of TTB measures with eyes closed, and in reach distances with the posteromedial and the posterolateral directions of the SEBT. Only one of the summary COP-based measures significantly changed after balance training. CONCLUSIONS Four weeks of balance training significantly improved self-reported function, static postural control as detected by TTB measures, and dynamic postural control as assessed with the SEBT. TTB measures were more sensitive at detecting improvements in static postural control compared with summary COP-based measures.

Effect of knee joint effusion on quadriceps and soleus motoneuron pool excitability.

PURPOSE To examine changes in quadriceps and soleus MN pool activity resulting from knee joint effusion over a 4-h period and assess the relationship between the muscles. METHODS A repeated measures before-after trial design was used for this study. Eight, neurologically sound volunteers (age 23.3+/-2.1 yr, height 171.8+/-15.9 cm, mass 65.5+/-17.7 kg) participated in this study. An area superomedial to the patella was cleaned and anesthetized, and 30 mL of sterile saline was injected into the knee joint capsule to mimic mechanical joint effusion. The Hoffman reflex (H-reflex) was elicited by applying a percutaneous stimulus to the appropriate nerve and recording the response through surface electromyography. Soleus and vastus medialis H-reflex measures were collected from each volunteer before, at 30 min, 90 min, 150 min, and 210 min intervals over a 4-h period after knee effusion. RESULTS All soleus H-reflex measures after effusion (30 min 5.89+/-0.92 V; 90 min 6.16+/-0.48 V; 150 min 6.59+/-0.50 V; 210 min 6.70+/-0.56 V) were increased in relation to the preeffusion measure (5.01+/-0.79 V). All vastus medialis H-reflex measures after effusion (30 min 4.23+/-0.94 V; 90 min 4.15 +/-1.11 V; 150 min 4.16+/-0.57 V; and 210 min 4.99+/-1.23) were decreased in relation to the preeffusion measure (5.88+/-1.44 V; P < or = 0.05). CONCLUSIONS Afferent activity from the knee joint capsule resulted in an inhibitory effect on the vastus medialis and a facilitatory effect on the soleus. Facilitation of the soleus in cooperation with other lower extremity musculature could be a mechanism for compensation of the inhibited quadriceps to maintain lower kinetic chain function.

Neuromuscular consequences of anterior cruciate ligament injury.

The neuromuscular consequences of anterior cruciate ligament (ACL) injury are important considerations because these deficits play a crucial role in a patients recovery following ACL injury or reconstruction. The purpose of this article is to review and synthesize the known neuromuscular consequences of ACL injury and reconstruction. Specifically, changes in somatosensation, muscle activation, muscle strength, atrophy, balance, biomechanics, and patient-oriented outcomes are discussed. Understanding neuromuscular consequences aids in the construction of optimized rehabilitation strategies.

Arthrogenic Muscle Inhibition in the Leg Muscles of Subjects Exhibiting Functional Ankle Instability

Background: Functional ankle instability or a subjective report of “giving way” at the ankle may be present in up to 40% of patients after a lateral ankle sprain. Damage to mechanoreceptors within the lateral ankle ligaments after injury is hypothesized to interrupt neurologic feedback mechanisms resulting in functional ankle instability. The altered input can lead to weakness of muscles surrounding a joint, or arthrogenic muscle inhibition. Arthrogenic muscle inhibition may be the underlying cause of functional ankle instability. Establishing the involvement of arthrogenic muscle inhibition in functional ankle instability is critical to understanding the underlying mechanisms or chronic ankle instability. The purpose of this investigation was to determine if arthrogenic muscle inhibition is present in the ankle joint musculature of patients exhibiting unilateral functional ankle instability. Methods: Twenty-nine subjects, 15 with unilateral functional ankle instability and 14 healthy control subjects, consented to participate. Bilateral soleus, peroneal, and tibialis anterior H-reflex and M-wave recruitment curves were obtained. Maximal H-reflex and maximal M-wave values were identified and the H:M ratios were calculated for data analysis. Separate 1 × 2 ANOVA were done for both the functional ankle instability and control groups to evaluate differences between limbs on the H:M ratios. Bonferroni multiple comparison procedures were used for post hoc comparisons (p ≤ 0.05). Results: The soleus and peroneal H:M ratios for subjects with functional ankle instability were smaller in the injured limb when compared with the uninjured limb (p < 0.05). No limb difference was detected for the tibialis anterior H:M ratio in the functional ankle instability group (p = 0.904). No side-to-side differences were detected for the H:M ratios in patients reporting no history of ankle injury (p > 0.05). Conclusions: Depressed H:M ratios in the injured limb suggest that arthrogenic muscle inhibition is present in the ankle musculature of patients exhibiting functional ankle instability. Establishing and using therapeutic techniques to reverse arthrogenic muscle inhibition may reduce the incidence of functional ankle instability.

Immediate Effects of Transcutaneous Electrical Nerve Stimulation and Focal Knee Joint Cooling on Quadriceps Activation

PURPOSE To determine whether transcutaneous electrical nerve stimulation (TENS) and focal knee joint cooling will affect the quadriceps central activation ratio (CAR) in patients with tibiofemoral osteoarthritis. METHODS Thirty-three participants with diagnosed tibiofemoral osteoarthritis were randomly allocated to the 45-min TENS treatment (six males and four females, 56 +/- 10.1 yr, 174.11 +/- 10.78 cm, 89.34 +/- 21.3 kg), the 20-min focal knee joint cooling treatment (six males and five females, 58 +/- 8.4 yr, 176.41 +/- 8.29 cm, 83.18 +/- 17.97 kg), or the control group (five males and seven females, 54 +/- 9.9 yr, 166.37 +/- 13.07 cm, 92.14 +/- 25.37 kg). Volitional quadriceps activation, maximal voluntary isometric contraction, and subjective pain measurements were conducted at baseline and at 20, 30, and 45 min. The 20-min focal knee joint cooling intervention consisted of two 1.5-L ice bags to the anterior and posterior aspects of the knee. The TENS group received 45 min of a sensory, biphasic square wave stimulation (150-mus phase duration and 150 pps) from four 2 x 2-inch electrodes positioned around the patella. RESULTS : TENS resulted in a significantly higher percent change in CAR scores compared with control at 20 min (6.4 +/- 4.8 vs -3.5 +/- 8, P = 0.006), 30 min (9.7 +/- 10.16 vs -1 +/- 7.9, P = 0.025), and 45 min (11.25 +/- 6.96 vs 0.81 +/- 9.4, P = 0.029). Focal knee joint cooling resulted in significantly higher percent change scores compared with the control group at 20 min (5.75 +/- 7.25 vs -3.5 +/- 8, P = 0.009) and trended to be higher at 45 min (9.06 +/- 9.63 vs 0.81 +/- 9.4, P = 0.098). No significant differences in percent change for CAR were found between the TENS and the focal knee joint cooling group. CONCLUSIONS Both TENS and focal knee joint cooling increased the quadriceps CAR immediately after application in participants with tibiofemoral osteoarthritis.

INTERSESSION RELIABILITY FOR H-REFLEX MEASUREMENTS ARISING FROM THE SOLEUS, PERONEAL, AND TIBIALIS ANTERIOR MUSCULATURE

The Hoffmann reflex (H-reflex) has been widely used throughout neuroscience research, as it allows for the assessment of alpha motoneuron excit ability arising from a specific motoneuron pool. Recently, a protocol has been developed allowing for the simultaneous examination of the soleus, peroneal, and tibialis anterior motoneuron pools elicited from a single peripheral stimulus. In order for this protocol to be useful, the reliability of the measures must be established. The purpose of the current study was to determine the intersession reliability of the soleus, peroneal, and tibialis anterior H-reflexes and their corresponding M-waves elicited from a single stimulus to the sciatic nerve. Ten healthy neurologically sound individuals (age: 23 - 7 yrs; height: 175 - 12 cm; mass: 76 - 22 kg) volunteered to participate in this investi gation. To obtain the measurements, the sciatic nerve was stimulated just prior to its bifurcation into the tibial and common peroneal nerves in the popliteal fossa. A 1-ms square wave pulse was delivered in 0.2V increments until the maximum M wave was seen in each muscle. The maximum H-reflex and M-waves were collected from each muscle and their ratios calculated. Intersession reliability over 2 consecutive days was estimated using intraclass correlation coefficients (ICC [2,1]). Intersession reliability for the soleus Max H, Max M, and H:M ratio were 0.9953, 0.9514, and 0.9747, respectively. The peroneal reliability measurements were as follows: 0.9979 (Max H), 0.9924 (Max M), and 0.9664 (H:M ratio). Intersession reliability was 0.8591, 0.9968, and 0.7810 for the tibialis anterior Max H, Max M, and H:M ratio, respectively. These results indicate that the H-reflex measured from the soleus, peroneal, and tibialis anterior musculature elicited with a single peripheral stimulus to the sciatic nerve is reliable between sessions. This protocol allows the clinician/researcher to reliably investigate the alpha motoneuron excitability of multiple motoneuron pools about the ankle at a single point in time.

Patellar location changes following EMG biofeedback or progressive resistive exercises.

Changes in the patellofemoral congruence (PFC) angle, the patellar rotation (PR) angle, and the sulcus angle following EMG biofeedback training that emphasized vastus medialis obliquus strengthening, the Daily Adjustable Progressive Resistive Exercise (DAPRE) technique, or no exercise were studied. Subjects were 30 normal, college females. The EMG biofeedback group and the DAPRE group followed established protocols for a 3-wk training period. The control group refrained from exercise. Patellar angles were determined with x-rays both pre- and posttest with the quadriceps relaxed and contracted. Reliability of the x-rays was determined with a correlation matrix of pre- and posttest sulcus angle measurements (P less than 0.001). EMG biofeedback training resulted in significant changes in the PFC angle with the quadriceps contracted (P less than 0.05). DAPRE resulted in significant changes in the PR angle with the quadriceps contracted (P less than 0.05). The results of this study suggest that quadriceps group strength changes are not enough to fully rehabilitate patellar tracking dysfunctions. The use of EMG biofeedback training to selectively strengthen the vastus medialis obliquus appears to be essential in correcting faulty patellar tracking.

Arthrogenic muscle response to a simulated ankle joint effusion

Background: Arthrogenic muscle inhibition (AMI) is a continuing reflex reaction of the musculature surrounding a joint after distension or damage to the structures of that joint. This phenomenon has been well documented after knee joint injury and has been generalised to occur at other joints of the human body, yet minimal research has been conducted in this regard. The response of the muscles crossing the ankle/foot complex after ankle injury and effusion is not well understood. AMI may occur after an ankle sprain contributing to residual dysfunction. Objective: To determine if AMI is present in the soleus, peroneus longus, and tibialis anterior musculature after a simulated ankle joint effusion. Methods: Eight neurologically sound volunteers (mean (SD) age 23 (4) years, height 171 (6) cm, mass 73 (10) kg) participated. Maximum H-reflex and maximum M-wave measurements were collected using surface electromyography after delivery of a percutaneous stimulus to the sciatic nerve before its bifurcation into the common peroneal and posterior tibial nerves. Results: The H-reflex and M-wave measurements in all muscles increased (p⩽0.05) after the simulated ankle joint effusion. Conclusions: Simulated ankle joint effusion results in facilitation of the soleus, peroneus longus, and tibialis anterior motoneurone pools. This may occur to stabilise the foot/ankle complex in order to maintain posture and/or locomotion.

Effects of Transcutaneous Electrical Nerve Stimulation and Therapeutic Exercise on Quadriceps Activation in People With Tibiofemoral Osteoarthritis

STUDY DESIGN Blinded, randomized controlled trial. OBJECTIVES To determine if the combination of transcutaneous electrical nerve stimulation (TENS) set to a sensory level and therapeutic exercise would be more effective than the combination of placebo TENS and therapeutic exercises or therapeutic exercises only to increase quadriceps activation in individuals with tibiofemoral osteoarthritis. BACKGROUND Quadriceps activation deficits are common in those with tibiofemoral osteoarthritis, and TENS has been reported to immediately increase quadriceps activation. Yet the long-term benefits of TENS for motor neuron activation have yet to be determined. METHODS Thirty-six individuals with radiographically assessed tibiofemoral osteoarthritis were randomly assigned to the TENS and exercise, placebo and exercise, and exercise only groups. All participants completed a supervised 4-week lower extremity exercise program. TENS and placebo TENS were worn throughout the therapeutic exercise sessions, as well as during daily activities. Our primary outcome measures, quadriceps central activation ratio, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were evaluated at baseline and at 2 weeks and 4 weeks of the intervention. RESULTS Quadriceps activation was significantly higher in the TENS with exercise group compared to the exercise only group at 2 weeks (0.94 ± 0.04 versus 0.82 ± 0.12, P<.05) and the placebo and exercise group at 4 weeks (0.94 ± 0.06 versus 0.81 ± 0.15, P<.05). WOMAC scores improved in all 3 groups over time, with no significant differences among groups. CONCLUSION This study provides evidence that TENS applied in conjunction with therapeutic exercise and daily activities increases quadriceps activation in patients with tibiofemoral osteoarthritis and, while function improved for all participants, effects were greatest in the group treated with a combination of TENS and therapeutic exercises. LEVEL OF EVIDENCE Therapy, level 1b-.