The Use of Neuromuscular Electrical Stimulation to Improve Activation Deficits in a Patient With Chronic Quadriceps Strength Impairments Following Total Knee Arthroplasty

Abstract

Study Design: Case report. Background: Long-term deficits in quadriceps femoris muscle strength and impaired muscle activation are common among individuals with total knee arthroplasty (TKA). Failure to address strength-related impairments results in poor surgical and functional outcomes, which may accelerate the progression of osteoarthritis in other lower extremity joints. The purpose of the current case report was to implement a neuromuscular electrical stimulation (NMES) treatment protocol in conjunction with an intense weight-training program, with the aim of reversing persistent quadriceps muscle impairments after TKA. Case Description: The patient was a 62-year-old male cyclist 12 months following simultaneous, bilateral TKA with impairments in left quadriceps strength and volitional muscle activation. His left quadriceps strength was 26% weaker than his right and central activation ratio (CAR) of his left quadriceps was 13% lower than his right quadriceps CAR. NMES to the left quadriceps was implemented for 6 weeks, in addition to an intense volitional weight-training program with emphasis on unilateral lower extremity exercises. Outcomes: The patient demonstrated a 25% improvement in left quadriceps femoris maximal volitional force output following 16 treatments of combined NMES and volitional strength training over a 6-week period. The patient's volitional muscle activation improved from a CAR of 0.83 before treatment to 0.97 after treatment. At discharge from physical therapy and at his 18-month postoperative follow-up, the patient's left quadriceps strength was only 4% lower than his right quadriceps strength. At the 24-month follow-up, the patient's left quadriceps strength was 6% stronger than his right quadriceps strength. Discussion: The patient was able to achieve symmetrical quadriceps strength and complete muscle activation following 6 weeks of NMES and volitional strength training. An intense strengthening program may have the potential to reverse persistent strength-related impairments following TKA.

Quadriceps Activation Following Knee Injuries: A Systematic Review

“…This indicates the clinical importance of prescribing therapies aimed at removing AMI before rehabilitation exercises begin. Modalities such as manual therapy, 14,51,52 focal knee joint cooling, [53][54][55][56] transcutaneous electric nerve stimulation, [55][56][57][58] and neuromuscular electric stimulation 59,60 have been shown to improve quadriceps function and may be useful in patients experiencing posttraumatic AMI.…”

Physiological and methodological considerations for the use of neuromuscular electrical stimulation

“…Such peculiarity of NMES recruitment inevitably entails some disadvantages (e.g., onset and extent of muscle fatigue, see below) but also several advantages, particularly for impaired muscles. For example, elderly individuals and patients presenting a selective atrophy of type II muscle fibers (e.g., chronic obstructive pulmonary disease, chronic steroid myopathy) (Gosker et al 2002;Kanda et al 2001), or orthopedic patients who cannot perform high-intensity voluntary contractions because of injury, recent surgery or impaired activation (Petterson and Snyder-Mackler 2006;Stevens et al 2004), and also athletes requiring high levels of muscle strength and power (Babault et al 2007;Delitto et al 1989;Malatesta et al 2003), would benefit from the use of NMES exercise-even at low intensity-to (re)train at least some of the fast fibers that otherwise can only be activated using high-force voluntary efforts.…”

Disinhibitory Interventions and Voluntary Quadriceps Activation: A Systematic Review

“…One additional investigation 26 was included after cross-referencing. Four studies [22][23][24][25] were excluded because means and standard deviations of voluntary quadriceps activation data were not reported, and 2 studies 27,28 were excluded because they were case reports. Ten studies matched our inclusion criteria and contained the appropriate statistics.…”