The Immediate Effects of Focal Knee Joint Cooling & TENS on - PowerPoint PPT Presentation

The Immediate Effects of Focal Knee Joint Cooling & TENS on Quadriceps Activation in Participants with Tibiofemoral Osteoarthritis Brian G. Pietrosimone, M.Ed, ATC EATA Meeting and Clinical Symposia January 10, 2009 bpietrosimone@virginia.edu

Quadriceps Inhibition The inability to activate the quadriceps following knee joint injury is common in a variety of knee injuries. – Anterior Knee Pain Suter et al. Clinical Biomechanics.1998. – ACL Injury Urbach et al. Unfallchirug. 2000. Urbach et al. Med Sci Sport Ex. 1999. Snyder- Mackler et al. J Bone and Joint Surg Am. 1994. – Total Knee Arthroplasty Mizner et al. Phys Ther. 2003 Mizner et al. J Bone and Joint Surg Am. 2005 – Meniscus Injury or Meniscectomy Shakespeare et al. Clin Physiol. 1985. – Osteoarthritis Pap et al. Journal of Ortho Research. 2004 Lewek et al. Journal of Ortho Research. 2004 Petterson et al. Med Sci Sport Ex. 2008.

Arthrogenic Muscle Inhibition • Decreased motor neuron pool excitability in an uninjured muscle surrounding an injured joint, modulated by both pre and postsynaptic inhibitory mechanisms. Palmieri et al. J Electromyogr Kinesiol. 2004. Palmieri et al. Knee Surg Sports Traumatol Arthrosc. 2005. • Recent evidence that supraspinal mechanisms may contribute. Heroux et al. Knee Surg Sports Traumatol Arthrosc. 2006. Urbach et al. Muscle Nerve. 2005. • Contributes to activation deficits & muscle weakness Pap et al. Journal of Ortho Research. 2004 Lewek et al. Journal of Ortho Research. 2004 Petterson et al. Med Sci Sport Ex. 2008. Mizner et al. Phys Ther. 2003 Mizner et al. J Bone and Joint Surg Am. 2005

The Underlying Clinical Impairment • Activation deficits last for years following resolution of injury Urbach et al. Med Sci Sport Exerc.1999. Lewek et al. Clinical Biomechanics.2002. Suter et al. Clinical biomechanics.1998. Chmielewski et al. Journal of Ortho Research.2004. • Quadriceps inhibition contributes to altered gait and landing kinematics useful in distributing forces Torry et al. Clinical Biomech. 2000. Palmieri- Smith et al. Am J Sports Med. 2007. • Possible precursor to osteoarthritis Hurley et al. Rheumatic Disease Clinics of North America. 1999. Hurley et al. Rheum & Arthri. 2003. Becker et al. Journal of Ortho Research.2004.

Disinhibitory Modalities • Patients with inhibition may need more specialized therapy Suter et al. Clinical Biomechanics.1998. Petterson et al. Med Sci Sport Ex. 2008. • A modality that could increase motor neuron pool excitability would allow for more optimal rehabilitation by allowing for more normalized motor neuron firing patterns Hopkins & Ingersoll. J Sport Rehabilitation. 2000. Hopkins et al. J Athl Train. 2002.

Focal Knee Joint Cooling and TENS 8.5 Facilitation 8 7.5 (Cryotherapy) H-Reflex (mV) 7 6.5 6 Disinhibition 5.5 5 (Transcutaneous 4.5 Electrical Nerve 4 Stimulation) 3.5 Inhibition (Caused t 5 0 5 0 t s s by Artificial Knee 1 3 4 6 e e t t e t s r Joint Effusion) o P P Time Hopkins JT, Ingersoll CD, Krause BA, Edwards JE, Cordova ML. Cryotherapy and TENS decrease arthrogenic muscle inhibition of the Vastus Medialis following knee joint effusion. J Athl Train . 2001; 37:25-31.

Increased Muscle Activation in Healthy Subjects Central Activation Ratio 1 Joint Cooling Joint Re- Warming 0.9 * ┼ * 0.79 0.79 0.77 0.8 0.73 0.7 0.74 0.73 0.69 0.69 0.6 0.5 0 10 20 30 40 50 Time (Minutes) Knee Cooling Control Pietrosimone BG & Ingersoll CD. Society for Neuroscience. November 2007.

The Tibiofemoral Osteoarthritis Model • Effects millions of people each year Jordan et al. The Journal of Rheumatology. 2007. Dillon et al. The Journal of Rheumatology, 2006. • Has been established as having AMI Stevens et al. Journal of Ortho Research.2003. O’Reilly et al. Ann Rheum Dis. 1998. Petterson et al. Med Sci Sport Ex. 2008. • Also been established as having disability that has been linked to quadriceps dysfunction Deluzio et al. Gait & Posture. 2007. Astephen et al. J Biomechanics. 2007. Lewek et al. Gait & Posture. 2006. Al- Zahrani et al. Dis and Rehabil. 2002.

Purpose • To determine the immediate effects of focal knee joint cooling and TENS on quadriceps activation and torque production in participants with tibiofemoral knee osteoarthritis.

Methods: Experimental Design Blinded, Randomized Controlled Trial Independent variables: – Group (Focal knee joint cooling, TENS, Control) – Time (Pretest, Posttests 20,30 &45 minutes post initial intervention) Main Outcome Measure: – Quadriceps Central Activation Ratio Secondary Outcome Measure: – Quadriceps Torque Production – Visual Analog Scores During MVIC

Methods: Participants Inclusion Criteria Exclusion Criteria • Ages 18- 80 • History of Rheumatoid Arthritis •Previous evidence of tibiofemoral •Cold Allergy/ Raynaud’s osteoarthritis (Radiographic, MRI, •History of orthopaedic surgery or Arthroscopy) injury in the past 6 months •Knee replacement in the knee being tested IRB Approved (HSR#13215) Informed consent form signed by all •Other nerve or muscle subjects abnormalities

39 Participants Qualified based on History 3 Participants Excluded No Activation Deficit 36 Participants Randomly Allocated to Group TENS Knee Cooling Control 2 Participants Removed 1 Participant Removed 12 Participants -Unable to perform MVIC -Unable to perform MVIC - Premature removal of TENS Focal Knee TENS Joint Cooling 10 Participants 11 Participants

Subject Demographics Age (years) Height (cm) Mass (kg) Male/Female Control 54 ± 9.91 166.37 ± 92.14 ± 25.37 5 M/ 7 F 13.07 n = 12 Focal Joint 58 ± 8.44 176.41 ± 8.29 83.18 ± 17.98 6 M/ 5 F Cooling n =11 TENS 57 ± 12.5 174.18 ± 92.77 ± 21.30 6 M/ 4 F 10.78 n = 10

Injury History & Self Reported Function Hx of WOMAC WOMAC WOMAC injury/ Pain Function Total Surgery (%) Control 83 % 3.42 ± 2.15 39 ± 10.77 59.25 ± 17.63 n = 12 Focal Joint 81% 3.36 ± .67 35.82 ± 57.45 ± Cooling 11.47 14.71 n =11 TENS 70% 2.6 ± .84 32.7 ± 52 ± 16.67 12.71 n = 10 * None of the groups were significantly different in WOMAC scores or subscales

Positioning on Dynamometer • Back 85 ° of flexion • Axis of rotation – lateral femoral condyle • Knee was positioned at 70 ° of knee flexion • Subject crossed arms over chest during MVIC Pietrosimone BG et al. Am J Physical Med & Rehab. 2008. Pietrosimone BG & Ingersoll CD. Society for Neuroscience. November 2007.

Electrode Placement • The anode is placed over the proximal Vastus lateralis • The cathode is placed over the distal Vastus medialis oblique • Both carbon backed electrodes were strapped down Snyder-Mackler et al.. Med Sci Sports Exerc. 1993;25(7):783- 789. Mizner et al.. J Bone Joint Surg Am. May 2005;87(5):1047-1053. Hart et al . Journal of Athletic Training. 2006. 41(11): 79-86.

Applications of Interventions • Applied by experienced certified athletic trainers. • All ATCs applying the treatments were given verbal and written instructions on exactly how to apply the treatment.

Focal Joint Cooling Intervention Length = 20 - minutes Two 1.5 liter bags of crushed ice were applied to the anterior and posterior knee and secured with a elastic wrap Hopkins et al. Journal of Athletic Training. 2001;37(1):25-31 Hopkins JT. Journal of Athletic Training.2006;41(2): 177- 184. Pietrosimone BG & Ingersoll CD. Society for Neuroscience. 2007. Pietrosimone et al. National Athletic Trainers’ Association Annual Symposium . 2008

Transcutaneous Electrical Nerve Stimulation • TENS 210(T) (Mettler Electronics Corp., Anaheim, CA) • Continuous biphasic pulsatile current • Pulse Rate = 150 Hz • Pulse duration = 150 μ sec • Amplitude = Submotor

Transcutaneous Electrical Nerve Stimulation • Skin Preparation • Four, 2x2 self adhesive electrodes • Currents were crossed • Accommodation addressed • Applied for 45-minutes

TENS Application Duration • TENS therapy continued for 45 minutes • Previous research has reported MNPE to be increased only when TENS is applied Hopkins et al. Journal of Athletic Training. 2001;37(1):25-31 • Cryotherapy has a re-warming period suggesting that therapeutic effect lasts longer than the cooling intervention

Maintaining the Blind • Blind Random Allocation • Investigator Blinded to Intervention – Investigator left room – Curtain was used • Experienced Independent researcher analyzed the data

Measuring the Amount of Quadriceps Voluntary Activation •Two to three measurements were conducted at each time in the time series (~ 60 seconds apart) •Posttests 20, 30 & 45 minutes post initial intervention •Subjects performed a maximal voluntary isometric contraction augmented by a supramaximal stimulus

Burst Superimposition Force Tracing

Calculating Central Activation Ratio (CAR) MVIC + SIB MVIC ~10 ms Motor Neurons Activated CAR = Total Motor Neurons Available

Assessment of Pain • MVIC without a 10 cm Visual Analog Scale stimulus conducted at each time interval Absolutely Worst pain imaginable • “How did your knee no pain feel during the MVIC”