Early quadriceps strength loss after total knee arthroplasty - The contributions of muscle atrophy and failure of voluntary muscle activation

Department of Physical Therapy, 301 McKinly Laboratory, University of Delaware, Newark, Deleware 19716, USA.
The Journal of Bone and Joint Surgery (Impact Factor: 4.31). 05/2005; 87(5):1047-53. DOI: 10.2106/JBJS.D.01992
Source: PubMed

ABSTRACT While total knee arthroplasty reduces pain and provides a functional range of motion of the knee, quadriceps weakness and reduced functional capacity typically are still present one year after surgery. The purpose of the present investigation was to determine the role of failure of voluntary muscle activation and muscle atrophy in the early loss of quadriceps strength after surgery.
Twenty patients with unilateral knee osteoarthritis were tested an average of ten days before and twenty-seven days after primary total knee arthroplasty. Quadriceps strength and voluntary muscle activation were measured with use of a burst-superimposition technique in which a supramaximal burst of electrical stimulation is superimposed on a maximum voluntary isometric contraction. Maximal quadriceps cross-sectional area was assessed with use of magnetic resonance imaging.
Postoperatively, quadriceps strength was decreased by 62%, voluntary activation was decreased by 17%, and maximal cross-sectional area was decreased by 10% in comparison with the preoperative values; these differences were significant (p < 0.01). Collectively, failure of voluntary muscle activation and atrophy explained 85% of the loss of quadriceps strength (p < 0.001). Multiple linear regression analysis revealed that failure of voluntary activation contributed nearly twice as much as atrophy did to the loss of quadriceps strength. The severity of knee pain with muscle contraction did not change significantly compared with the preoperative level (p = 0.31). Changes in knee pain during strength-testing did not account for a significant amount of the change in voluntary activation (p = 0.14).
Patients who are managed with total knee arthroplasty have profound impairment of quadriceps strength one month after surgery. This impairment is predominantly due to failure of voluntary muscle activation, and it is also influenced, to a lesser degree, by muscle atrophy. Knee pain with muscle contraction played a surprisingly small role in the reduction of muscle activation.

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Available from: Lynn Snyder-Mackler, Dec 17, 2014
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    • "Based on this, we thought that tourniquet use would add to the effect of the surgical trauma on changing afferent signalling to the CNS, whereby efferent activation of the quadriceps muscle would be further reduced. Reduced efferent activation of the quadriceps muscle — known as central activation deficits or arthrogenic muscle inhibition — [15] [23] is well known shortly following TKA [13] [24]. The neural mechanisms are not fully understood, but it has been attributed, at least in part, to alter afferent feedback from the operated knee joint due to swelling, inflammation, pain, and damage to joint afferent [15] [23]. "
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    ABSTRACT: Thigh tourniquet is commonly used in total knee arthroplasty (TKA) but may contribute to pain and muscle damage. Consequently, the reduction in knee-extension strength after TKA may be caused by quadriceps muscle ischaemia underneath the cuff.
    The Knee 12/2014; 22(2). DOI:10.1016/j.knee.2014.12.010 · 1.70 Impact Factor
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    • "The failure to activate voluntarily the quadriceps muscle has been indicated as a cause of persistent weakness in these muscles, commonly observed after acute [5], chronic [6], or even experimental knee joint injuries [1]. The appearance of this condition has been linked to several factors such as patellar injury [5], anterior knee pain [2], edema [1], ligament injuries or ligament surgical reconstruction [7] [8], osteoarthritis [9– 11], and total knee replacement (TKR) [12] [13]. These factors lead to muscle inhibition which can persist a long time after the injury [4]. "
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    ABSTRACT: BACKGROUND AND PURPOSE: Neuromuscular electrical stimulation (NMES) is an important tool in clinical practice to improve the recruitment of motor units. Optimal forms of NMES, as well as the optimal frequency to achieve the highest torque with the least possible discomfort are not well established. This study was designed to compare maximum electrically-induced torque (MEIT) in the quadriceps, the maximum intensity tolerated by the subject, and the level of discomfort generated by three types of stimulation. METHODS: Thirty subjects (mean age of 25.0 ± 3.0 years) participated in the study. Each subject was submitted to three cur-rents: medium frequency (2500 Hz) modulated in low frequency (Russian Current), and two currents of low frequency (50 Hz), i.e. without an intrapulse interval (FES), and another with an intrapulse interval of 100 µs (VMS). The maximum voluntary iso-metric torque (MVIT) of the quadriceps was measured. The MEIT, the level of discomfort, and the maximum intensity reached were also measured while applying the three types of NMES. The order of the tests was randomized and the torque was normal-ized in relation to MVIT. RESULTS: The results showed no significant difference between the three types of NMES in relation to the generated torque. However, the subjects were able to tolerate a significantly higher intensity with the medium frequency current, and suffered less discomfort when compared to subjects exposed to low frequency currents. CONCLUSION: Russian Current, FES, and VMS can be used clinically in order to increase the torque of the quadriceps muscle. However, we suggest using the Russian Current in the early stages of a rehabilitation protocol because it showed better tolerance by the participants with less discomfort.
    Isokinetics and exercise science 01/2013; 21:167-173. DOI:10.3233/IES-130495 · 0.35 Impact Factor
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    • "Quadriceps weakness of the operated limb was explained by deficits of voluntary activation (i.e. muscle inhibition) in the acute phase (e.g. 1 month) after TKA [9]. Yet, quadriceps muscle strength becomes more highly associated to the muscle cross-sectional area by the 1 year mark after TKA as the deficits in voluntary activation are substantially reduced by this stage of recovery [11] [12]. "
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    ABSTRACT: INTRODUCTION: Quadriceps weakness is one of the primary post-operative impairments that persist long term for patients after total knee arthroplasty (TKA). We hypothesized that early gait muscle recruitment patterns of the quadriceps and hamstrings with diminished knee performance at 3months after surgery would be related to long-term quadriceps strength at 1year after TKA. METHODS: Twenty-one subjects who underwent primary unilateral TKA and 14 age-matched healthy controls were analyzed. At 3months after TKA, the maximum voluntary isometric contraction of the quadriceps and a comprehensive gait analysis were performed. Quadriceps strength was assessed again at 1year after surgery. RESULTS: Quadriceps muscle recruitment of the operated limb was greater than the non-operated limb during the loading response of gait (p=0.03), but there were no significant differences in hamstring recruitment or co-contraction between limbs (p>0.05). There were significant differences in quadriceps muscle recruitment during gait between the non-operated limbs of the TKA group and the healthy control group (p<0.05). The TKA group showed a significant inverse relationship between one year quadriceps strength and co-contraction (r=-0.543) and hamstring muscle recruitment (r=-0.480) during loading response at 3months after TKA. CONCLUSIONS: The results revealed a reverse relationship where stronger patients tended to demonstrate lower quadriceps recruitment at 3months post-surgery that was not observed in the healthy peer group. The altered neuromuscular patterns of the quadriceps and hamstrings during gait may influence chronic quadriceps strength in individuals after TKA. LEVEL OF EVIDENCE: III.
    The Knee 01/2013; 20(6). DOI:10.1016/j.knee.2012.12.008 · 1.70 Impact Factor
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