The early addition of NMES effectively attenuated loss of quadriceps muscle strength and improved functional performance following TKA. The effects were most pronounced and clinically meaningful within the first month after surgery, but persisted through 1 year after surgery.

Background/rationale Although TKA reliably reduces pain from knee osteoarthritis, full recovery of muscle strength and physical function to normal levels is rare. We presumed that a better understanding of acute changes in hamstrings and quadriceps muscle performance would allow us to enhance early rehabilitation after TKA and improve long-term function. Questions/purposes The purposes of this study were to (1) evaluate postoperative quadriceps and hamstrings muscle strength loss after TKA and subsequent recovery using the nonoperative legs and healthy control legs for comparison, and (2) measure hamstrings coactivation before and after TKA during a maximal isometric quadriceps muscle contraction and compare with nonoperative and healthy control legs. Methods We prospectively followed 30 patients undergoing TKA at 2 weeks preoperatively and 1, 3, and 6 months postoperatively and compared patient outcomes with a cross-sectional cohort of 15 healthy older adults. Bilateral, isometric strength of the quadriceps and hamstrings was assessed along with EMG measures of hamstrings coactivation during a maximal isometric quadriceps contraction. Results There were no differences in strength loss or recovery between the quadriceps and hamstrings muscles of the operative leg throughout the followup, although differences existed when compared with nonoperative and healthy control legs. Hamstrings muscle coactivation in the operative leg during a maximal quadriceps effort was elevated at 1 month (144.5%) compared to the nonoperative leg. Conclusions Although quadriceps dysfunction after TKA typically is recognized and addressed in postoperative therapy protocols, hamstrings dysfunction also is present and should be addressed. Clinical Relevance Quadriceps and hamstrings muscle strengthening should be the focus of future rehabilitation programs to optimize muscle function and long-term outcomes.

It has been proposed that different forms of rhythmic human limb movement have a common central neural control ('common core hypothesis'), just as in other animals. We compared the modulation patterns of background EMG and cutaneous reflexes during walking, arm and leg cycling, and arm-assisted recumbent stepping. We hypothesized that patterns of EMG and reflex modulation during cycling and stepping (deduced from mathematical principal components analysis) would be comparable to those during walking because they rely on similar neural substrates. Differences between the tasks were assessed by evoking cutaneous reflexes via stimulation of nerves in the foot and hand in separate trials. The EMG was recorded from flexor and extensor muscles of the arms and legs. Angular positions of the hip, knee and elbow joints were also recorded. Factor analysis revealed that across the three tasks, four principal components explained more than 93% of the variance in the background EMG and middle-latency reflex amplitude. Phase modulation of reflex amplitude was observed in most muscles across all tasks, suggesting activity in similar control networks. Significant correlations between EMG level and reflex amplitude were frequently observed only during static voluntary muscle activation and not during rhythmic movement. Results from a control experiment showed that strong correlation between EMG and reflex amplitudes was observed during discrete, voluntary leg extension but not during walking. There were task-dependent differences in reflex modulation between the three tasks which probably arise owing to specific constraints during each task. Overall, the results show strong correlation across tasks and support common neural patterning as the regulator of arm and leg movement during various rhythmic human movements. The innate capacity for generation of rhythmic movement patterns is found across the animal kingdom (Orlovsky et al. 1999). Humans produce a variety of rhythmic motor patterns during all forms of terrestrial and aquatic locomotion by way of walking, running, cycling, crawling, creeping and swimming. Considerable overlap with shared neurons and reorganization of synaptic activity to produce different rhythmic motor patterns with similar neuronal ensembles is well documented in invertebrate preparations such as the crayfish (Hooper & DiCaprio, 2004). A contribution to rhythmic motor outputs by spinal central pattern-generating elements (CPGs) has been suggested in many species, including humans (see for review Rossignol, 1996;Dietz, 2003;Zehr & Duysens, 2004;Yang et al. 2004;Rossignol et al. 2006). Using the research model of the infant walking paradigm, Yang and colleagues have shown that multiple locomotor tasks, including forward and backward walking and side-stepping, are probably controlled by the same reconfigured CPGs (Lamb & Yang, 2000).We previously suggested that an estimate of the probable contributions of CPG activity can be evaluated by the phase-dependent modulation of reflex amplitudes evoked during rhyth...

Neuronal coupling between the arms and legs allowing coordinated rhythmic movement during locomotion is poorly understood. We used the modulation of cutaneous reflexes to probe this neuronal coupling between the arms and legs using a cycling paradigm. Participants performed rhythmic cycling with arms, legs, or arms and legs together. We hypothesized that any contributions from the arms would be functionally linked to locomotion and would thus be phase-dependent. Reflexes were evoked by electrical stimulation of the superficial peroneal nerve at the ankle, and electromyography (EMG) was recorded from muscles in the arms and legs. The main finding was that the relative contribution from the arms and legs was linked to the functional state of the legs. For example, in tibialis anterior, the largest contribution from arm movement [57% variance accounted for (VAF), P < 0.05] was during the leg power phase, whereas the largest from leg movement (71% VAF, P < 0.05) was during leg cycling recovery. Thus the contribution from the arms was functionally gated throughout the locomotor cycle in a manner that appears to support the action of the legs. Additionally, the effect of arm cycling on reflexes in leg muscles when the legs were not moving was relatively minor; full expression of the effect of rhythmic arm movement was only observed when both the arms and legs were moving. Our findings provide experimental support for the interaction of rhythmic arm and leg movement during human locomotion.

Higher NMES training intensities were associated with greater quadriceps muscle strength and activation after TKA.