Disinhibitory Interventions and Voluntary Quadriceps Activation: A Systematic Review

Harkey, Matthew S.; Gribble, Phillip A.; Pietrosimone, Brian

doi:10.4085/1062-6050-49.1.04

Cited by 65 publications

(51 citation statements)

References 46 publications

(118 reference statements)

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“…Researchers investigating the immediate and short-term effects of disinhibitory modalities alone or coupled with strengthening exercises have reported similar phenomena of improved knee-extension strength 18 and facilitation of voluntary activation, 18,19 indicating that this approach to treatment may improve muscle function through reduced inhibitory signaling 41 rather than the peripheral muscle hypertrophy associated with longer-duration strength-training interventions. Further investigation into the effects of a prolonged strengthening intervention, including disinhibitory modalities on quadriceps function or broader measures of lower extremity function, is an essential next step to improve the clinical applicability of our findings.…”

Section: Discussionmentioning

confidence: 97%

“…Addressing the underlying source of inhibition using a disinhibitory modality may provide a short treatment window (30À90 minutes 21À24 ) during a rehabilitation session throughout which the effect of rehabilitation-based strengthening exercises on quadriceps function may be maximized. 18,25 This strategy has been shown to induce clinically meaningful improvements in knee-extension strength, 19,26 quadriceps activation, 19,26 and lower extremity biomechanics 17 over 2-to 4-week interventions; however, the effect of this intervention style on limb symmetry in quadriceps function among individuals with a history of ACLR has not been established. Researchers have clearly shown a positive contralateral effect, known as a crossover effect, of involved or uninvolved limb strength or functional status among healthy individuals, 16 as well as those with a history of knee-joint injury.…”

Section: ])mentioning

confidence: 99%

“…Whereas these strategies are diverse, investigators have provided strong support for using disinhibitory modalities, 18 such as cryotherapy, 19 transcutaneous electrical nerve stimulation, 20 and neuromuscular electrical stimulation, 17 in conjunction with quadriceps-strengthening exercises to optimize rehabilitation outcomes. Theoretically, using disinhibitory modalities enables the clinician to treat the underlying source of muscle dysfunction at the level of the central nervous system.…”

Section: ])mentioning

confidence: 99%

See 2 more Smart Citations

Unilateral Quadriceps Strengthening With Disinhibitory Cryotherapy and Quadriceps Symmetry After Anterior Cruciate Ligament Reconstruction

Kuenze

Kelly

Jun

et al. 2017

Journal of Athletic Training

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Context: The effect of unilateral cryotherapy-facilitated rehabilitation exercise on involved-limb quadriceps function and limb symmetry in individuals with quadriceps dysfunction after anterior cruciate ligament reconstruction (ACLR) remains unclear.Objective: To measure the effect of a 2-week unilateral cryotherapy-facilitated quadriceps-strengthening program on knee-extension strength and quadriceps central activation ratio (CAR) in participants with ACLR.Design: Controlled laboratory study. Setting: Laboratory. Patients or Other Participants: A total of 10 volunteers with unilateral ACLR (1 man, 9 women; age ¼ 21.0 6 2.8 years, height ¼ 164.6 6 5.0 cm, mass ¼ 64.0 6 6.1 kg, body mass index ¼ 23.7 6 2.7 kg/m 2 ) and 10 healthy volunteers serving as control participants (1 man, 9 women; age ¼ 20.8 6 2.5 years, height ¼ 169.1 6 6.2 cm, mass ¼ 61.1 6 6.4 kg, body mass index ¼ 21.4 6 2.3 kg/m 2 ) participated. Intervention(s): Participants with ACLR completed a 2-week unilateral cryotherapy-facilitated quadriceps-strengthening intervention.Main Outcome Measure(s): Bilateral normalized kneeextension maximal voluntary isometric contraction (MVIC) torque (Nm/kg) and quadriceps CAR (%) were assessed preintervention and postintervention. Limb symmetry index (LSI) was calculated at preintervention and postintervention testing. Preintervention between-groups differences in unilateral quadriceps function and LSI were evaluated using independentsamples t tests. Preintervention-to-postintervention differences in quadriceps function were evaluated using paired-samples t tests. Conclusions: Two weeks of cryotherapy-facilitated exercise may improve involved-limb quadriceps function while preserving between-limbs symmetry in patients with a history of ACLR.Key Words: disinhibitory modalities, quadriceps strength, quadriceps central activation ratio, limb symmetry index, crosseducation Key PointsA 2-week cryotherapy-facilitated strengthening program may improve involved-limb quadriceps function and preserve between-limbs symmetry in patients with a history of anterior cruciate ligament reconstruction. Clinicians should consider using this approach when treating patients with persistent quadriceps weakness during recovery from anterior cruciate ligament reconstruction.

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Section: Discussionmentioning

confidence: 97%

Section: ])mentioning

confidence: 99%

Section: ])mentioning

confidence: 99%

See 1 more Smart Citation

Unilateral Quadriceps Strengthening With Disinhibitory Cryotherapy and Quadriceps Symmetry After Anterior Cruciate Ligament Reconstruction

Kuenze

Kelly

Jun

et al. 2017

Journal of Athletic Training

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“…1,2 Disinhibitory modalities have recently been suggested as a clinical tool for clinicians to use to counteract the negative effects of AMI and enhance the effectiveness of therapeutic exercise. [2][3][4] Some of these modalities were originally intended for other purposes but are now hypothesized to provide disinhibitory effects, as well. For example, neuromuscular electrical stimulation (NMES) is a well-known strengthening modality that has recently been identified as having the potential to serve as a disinhibitory modality.…”

Section: Clinical Scenariomentioning

confidence: 99%

The Effectiveness of Neuromuscular Electrical Stimulation in Improving Voluntary Activation of the Quadriceps: A Critically Appraised Topic

Bremner¹,

Holcomb²,

Brown³

et al. 2017

Journal of Sport Rehabilitation

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Clinical Scenario: Orthopedic knee conditions are regularly treated in sports-medicine clinics. Rehabilitation protocols for these conditions are often designed to address the associated quadriceps strength deficits. Despite these efforts, patients with orthopedic knee conditions often fail to completely regain their quadriceps strength. Disinhibitory modalities have recently been suggested as a clinical tool that can be used to counteract the negative effects of arthrogenic muscle inhibition, which is believed to limit the effectiveness of therapeutic exercise. Neuromuscular electrical stimulation (NMES) is commonly accepted as a strengthening modality, but its ability to simultaneously serve as a disinhibitory treatment is not as well established. Clinical Question: Does NMES effectively enhance quadriceps voluntary activation in patients with orthopedic knee conditions? Summary of Key Findings: Four randomized controlled trials (RCTs) met the inclusion criteria and were included. Of those, 1 reported statistically significant improvements in quadriceps voluntary activation in the intervention group relative to a comparison group, but the statistical significance was not true for another study consisting of the same sample of participants with a different follow-up period. One study reported a trend in the NMES group, but the between-groups differences were not statistically significant in 3 of the 4 RCTs. Clinical Bottom Line: Current evidence does not support the use of NMES for the purpose of enhancing quadriceps voluntary activation in patients with orthopedic knee conditions. Strength of Recommendation: There is level B evidence that the use of NMES alone or in conjunction with therapeutic exercise does not enhance quadriceps voluntary activation in patients with orthopedic knee conditions (eg, anterior cruciate ligament injuries, osteoarthritis, total knee arthroplasty).

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“…Therefore, disinhibitory interventions need to be selected based on the status of the patient and origin of quadriceps activation failure. A newly published systematic review by Harkey et al 15 assessed all of the disinhibitory interventions that have been reported in the literature for improving quadriceps activation. More research efforts such as these are needed to determine the best methods for treating both the spinal and supraspinal origins of quadriceps activation failure.…”

Section: Clinical Recommendationmentioning

confidence: 99%

Comparison of Transcutaneous Electrical Nerve Stimulation and Cryotherapy for Increasing Quadriceps Activation in Patients With Knee Pathologies

Gäbler¹,

Lepley²,

Uhl³

et al. 2016

Journal of Sport Rehabilitation

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Clinical Scenario: Proper neuromuscular activation of the quadriceps muscle is essential for maintaining quadriceps (quad) strength and lower-extremity function. Quad activation (QA) failure is a common characteristic observed in patients with knee pathologies, defined as an inability to voluntarily activate the entire alpha-motor-neuron pool innervating the quad. One of the more popular techniques used to assess QA is the superimposed burst (SIB) technique, a force-based technique that uses a supramaximal, percutaneous electrical stimulation to activate all of the motor units in the quad during a maximal, voluntary isometric contraction. Central activation ratio (CAR) is the formula used to calculate QA level (CAR = voluntary force/SIB force) with the SIB technique. People who can voluntarily activate 95% or more (CAR = 0.95-1.0) of their motor units are defined as being fully activated. Therapeutic exercises aimed at improving quad strength in patients with knee pathologies are limited in their effectiveness due to a failure to fully activate the muscle. Within the past decade, several disinhibitory interventions have been introduced to treat QA failure in patients with knee pathologies. Transcutaneous electrical nerve stimulation (TENS) and cryotherapy are sensory-targeted modalities traditionally used to treat pain, but they have been shown to be 2 of the most successful treatments for increasing QA levels in patients with QA failure. Both modalities are hypothesized to positively affect voluntary QA by disinhibiting the motor-neuron pool of the quad. In essence, these modalities provide excitatory afferent stimuli to the spinal cord, which thereby overrides the inhibitory afferent signaling that arises from the involved joint. However, it remains unknown whether 1 is more effective than the other for restoring QA levels in patients with knee pathologies. By knowing the capabilities of each disinhibitory modality, clinicians can tailor treatments based on the rehabilitation goals of their patients. Focused Clinical Question: Is TENS or cryotherapy the more effective disinhibitory modality for treating QA failure (quantified via CAR) in patients with knee pathologies?Keywords: rehabilitation, neuromuscular system, muscle function Clinical ScenarioProper neuromuscular activation of the quadriceps muscle is essential for maintaining quadriceps strength and lower-extremity function. Quadriceps activation failure is a common characteristic observed in patients with knee pathologies, and it is defined as an inability to voluntarily activate the entire alpha-motor-neuron pool innervating the quadriceps. 1 One of the more popular techniques used to assess quadriceps activation is the superimposed burst (SIB) technique. 2 The SIB technique is a force-based technique that uses a supramaximal, percutaneous electrical stimulation to activate all of the motor units in the quadriceps during a maximal, voluntary isometric contraction of the quadriceps. Central activation ratio (CAR) is the formula used to calculate quadric...

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Disinhibitory Interventions and Voluntary Quadriceps Activation: A Systematic Review

Cited by 65 publications

References 46 publications

Unilateral Quadriceps Strengthening With Disinhibitory Cryotherapy and Quadriceps Symmetry After Anterior Cruciate Ligament Reconstruction

Unilateral Quadriceps Strengthening With Disinhibitory Cryotherapy and Quadriceps Symmetry After Anterior Cruciate Ligament Reconstruction

The Effectiveness of Neuromuscular Electrical Stimulation in Improving Voluntary Activation of the Quadriceps: A Critically Appraised Topic

Comparison of Transcutaneous Electrical Nerve Stimulation and Cryotherapy for Increasing Quadriceps Activation in Patients With Knee Pathologies

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