Fig 2 - available from: European Journal of Applied Physiology
This content is subject to copyright. Terms and conditions apply.
Electrodes (recording and stimulating) positioning. White pods represent the neuromuscular stimulator active wireless electrodes placed in a bipolar configuration on the soleus, gastrocnemius lateralis and gastrocnemius medialis muscles. sEMG surface electromyography of the soleus muscle
Source publication
PurposeNeuromuscular electrical stimulation (NMES) superimposed on voluntary muscle contraction has been recently shown as an innovative training modality within sport and rehabilitation, but its effects on the neuromuscular system are still unclear. The aim of this study was to investigate acute responses in spinal excitability, as measured by the...
Contexts in source publication
Context 1
... electromyography (sEMG) was recorded by means of a wireless system (Delsys Trigno, Boston, MA, USA) at a sample rate of 2000 Hz. Surface electrodes were placed on the soleus (SOL) muscle 2-3 cm below the gastrocnemii musculotendinous junction with Achille's tendon (Fig. 2), and on the tibialis anterior (TA) muscle above the muscle belly parallel to the TA muscle fibres. TA muscle was chosen to control any possible pre-activation of the antagonist muscles during H-reflex assessments, which is known to significantly affect H-reflex responses of the soleus (Hoffmann 1952). Before applying the surface ...
Context 2
... or superimposed on voluntary effort. The stimulator produced a rectangular, balanced biphasic pulse and was always safely handled and controlled by the investigator. Self-adhesive electrodes (Compex DuraStick plus) with positive polarity were placed over the motor points of gastrocnemius lateralis, gastrocnemius medialis, and soleus muscles (Fig. 2). Motor points were identified at the beginning of the experimental session with a handheld cathode ball electrode in accordance with the electrical stimulator user's guide. In addition, three self-adhesive electrodes with negative polarity were placed on each muscle about 3 cm above the positive electrodes located on the motor points. ...
Similar publications
The aim of the current study was to investigate the effect of a single session of prolonged tendon vibration combined with low submaximal isometric contraction on maximal motor performance. Thirty-two young sedentary adults were assigned into two groups that differed based on the knee angle tested: 90° or 150° (180° = full knee extension). Particip...
Citations
... Several research works revealed that NMES training can influence spinal reflex excitability in young healthy subjects. On one hand, an acute depression of H-reflex amplitude was reported after NMES passively applied over muscles (Wegrzyk et al. 2015;Gueugneau et al. 2017;Grosprêtre et al. 2018;Borzuola et al. 2020). On the other hand, Lagerquist et al. (2012) and Borzuola et al. (2020) demonstrated a potentiation of soleus H-reflex responses following a single session of NMES superimposed on voluntary isometric contractions. ...
... On one hand, an acute depression of H-reflex amplitude was reported after NMES passively applied over muscles (Wegrzyk et al. 2015;Gueugneau et al. 2017;Grosprêtre et al. 2018;Borzuola et al. 2020). On the other hand, Lagerquist et al. (2012) and Borzuola et al. (2020) demonstrated a potentiation of soleus H-reflex responses following a single session of NMES superimposed on voluntary isometric contractions. However, the spinal mechanisms underlying NMES training have not been investigated in older adults yet. ...
... Therefore, this study aims at comparing acute responses in spinal excitability, as measured by H-reflex, between older and young people, following a single session of NMES superimposed onto voluntary isometric contractions of the ankle plantar-flexor muscles (NMES+), with respect to passive NMES (pNMES) and voluntary isometric contractions only (ISO). Based on the previous findings by Lagerquist et al. (2012) and Borzuola et al. (2020), which were carried out in young individuals, it was hypothesised that: ...
Purpose
This study aims at comparing acute responses in spinal excitability, as measured by H-reflex, between older and young individuals, following a single session of NMES superimposed onto voluntary isometric contractions of the ankle plantar-flexor muscles (NMES+), with respect to passive NMES (pNMES) and voluntary isometric contractions only (ISO).
Methods
Thirty-two volunteers, 16 older (OLDER) and 16 young (YOUNG), were asked to sustain a constant force at 20% of maximal voluntary isometric contraction (MVIC) of the ankle plantar-flexor muscles in the dominant limb during each of the 3 conditions (NMES+ , pNMES and ISO). Fifteen repetitions of 6 s were performed, with a resting interval of 6 s between repetitions. Before and after each condition, soleus H-reflexes were elicited by percutaneous electrical stimulation of the posterior tibial nerve and H-reflex amplitudes recorded by surface EMG.
Results
In OLDER, H-reflex amplitude did not change following any experimental condition (ISO: p = 0.203; pNMES: p = 0.542; NMES+: p = 0.431) compared to baseline. On the contrary, in YOUNG, H-reflex amplitudes significantly increased (p < 0.000) and decreased (p = 0.001) following NMES+ and pNMES, respectively, while there was no significant change in reflex responses following ISO (p = 0.772).
Conclusion
The lack of change in H-reflex responses following either NMES+ or pNMES might reflect a reduced ability of older people in modulating spinal excitability after the conditions. Specifically, an age-related alteration in controlling mechanisms at presynaptic level was suggested.
... Since the early studies, major attention has been given to the alterations occurring in the spinal circuitry following acute and chronic exercise (Aagaard et al., 2002;Scaglioni et al., 2002). Two neurophysiological studies indicated that the effectiveness of NMES + intervention could be related to an increase in spinal excitability resulting from plastic changes in Ia reflex pathways (Lagerquist et al., 2012;Borzuola et al., 2020). Specifically, an acute potentiation of the Hoffmann (H) reflex responses in the soleus muscle was reported following voluntary isometric ankle plantar flexions paired with superimposed NMES applied on the posterior tibial nerve (Lagerquist et al., 2012), and on triceps surae motor points (Borzuola et al., 2020). ...
... Two neurophysiological studies indicated that the effectiveness of NMES + intervention could be related to an increase in spinal excitability resulting from plastic changes in Ia reflex pathways (Lagerquist et al., 2012;Borzuola et al., 2020). Specifically, an acute potentiation of the Hoffmann (H) reflex responses in the soleus muscle was reported following voluntary isometric ankle plantar flexions paired with superimposed NMES applied on the posterior tibial nerve (Lagerquist et al., 2012), and on triceps surae motor points (Borzuola et al., 2020). ...
... We also hypothesized that increases in motor unit discharge rates would be accompanied by a decrease in MU recruitment threshold. Finally, based on the increase in spinal motoneuron excitability reported in previous studies following superimposed electrical stimulation (Lagerquist et al., 2012;Borzuola et al., 2020), we expected that the input-output relationship of the spinal motoneuron would be increased following the NMES + ISO condition. Altogether, these findings would provide a portrait of the adjustments occurring at the motor unit level following different type of acute exercise. ...
Introduction: The application of neuromuscular electrical stimulation superimposed on voluntary muscle contractions (NMES+) has demonstrated a considerable potential to enhance or restore muscle function in both healthy and individuals with neurological or orthopedic disorders. Improvements in muscle strength and power have been commonly associated with specific neural adaptations. In this study, we investigated changes in the discharge characteristics of the tibialis anterior motor units, following three acute exercises consisting of NMES+, passive NMES and voluntary isometric contractions alone.
Methods: Seventeen young participants participated in the study. High-density surface electromyography was used to record myoelectric activity in the tibialis anterior muscle during trapezoidal force trajectories involving isometric contractions of ankle dorsi flexors with target forces set at 35, 50 and 70% of maximal voluntary isometric contraction (MVIC). From decomposition of the electromyographic signal, motor unit discharge rate, recruitment and derecruitment thresholds were extracted and the input-output gain of the motor neuron pool was estimated.
Results: Global discharge rate increased following the isometric condition compared to baseline at 35% MVIC while it increased after all experimental conditions at 50% MVIC target force. Interestingly, at 70% MVIC target force, only NMES+ led to greater discharge rate compared to baseline. Recruitment threshold decreased after the isometric condition, although only at 50% MVIC. Input-output gain of the motor neurons of the tibialis anterior muscle was unaltered after the experimental conditions.
Discussion: These results indicated that acute exercise involving NMES+ induces an increase in motor unit discharge rate, particularly when higher forces are required. This reflects an enhanced neural drive to the muscle and might be strongly related to the distinctive motor fiber recruitment characterizing NMES+.
... With respect to peripheral neural pathways, some authors have used the Hoffman reflex (H-reflex) to investigate the acute effects of NMES or voluntary contractions on spinal excitability. A recent work showed that NMES applied over the motor points of the triceps surae superimposed on voluntary isometric contractions of the ankle plantar-flexors produces an acute potentiation of the soleus H-reflex compared with passive NMES and voluntary contractions alone (16). Similarly, Lagerquist et al. (17) reported greater spinal reflex responses of the soleus following NMES þ , although in this study the superimposed electrical stimulation was applied directly on the posterior tibial nerve. ...
... Similarly, Lagerquist et al. (17) reported greater spinal reflex responses of the soleus following NMES þ , although in this study the superimposed electrical stimulation was applied directly on the posterior tibial nerve. A considerable H-reflex attenuation was observed immediately after passive NMES (16)(17)(18)(19)(20), whereas no change in H-reflex amplitude after voluntary exercise was observed in most of the recent work (16,17,20). Various researchers suggested that during NMES þ the combination of increased spinal excitability in conjunction with enhanced descending drive could have a positive effect on contractile properties and motor unit recruitment, partially explaining the enhancements in motor function induced by the NMES þ methodology (16,17). ...
... Similarly, Lagerquist et al. (17) reported greater spinal reflex responses of the soleus following NMES þ , although in this study the superimposed electrical stimulation was applied directly on the posterior tibial nerve. A considerable H-reflex attenuation was observed immediately after passive NMES (16)(17)(18)(19)(20), whereas no change in H-reflex amplitude after voluntary exercise was observed in most of the recent work (16,17,20). Various researchers suggested that during NMES þ the combination of increased spinal excitability in conjunction with enhanced descending drive could have a positive effect on contractile properties and motor unit recruitment, partially explaining the enhancements in motor function induced by the NMES þ methodology (16,17). ...
Superimposing neuromuscular electrical stimulation (NMES) on voluntary muscle contractions has shown the potential to improve motor performance even more than voluntary exercise alone. Nevertheless, the neurophysiological and neurocognitive mechanisms underlying this technique are still unclear. The aim of this study was to investigate the acute responses in spinal excitability, and brain activity following three conditions: NMES superimposed on isometric contractions (NMES+ISO), passive NMES, and voluntary isometric contractions (ISO). Each condition involved fifteen intermittent ankle plantar-flexions at submaximal level. Before and after each condition, tibial nerve stimulation was used to elicit H-reflexes, which represent a measure of spinal excitability, and somatosensory evoked potentials (SEPs), which index the activity of subcortical and cortical somatosensory areas. H-reflex amplitudes increased following NMES+ISO and decreased following passive NMES compared to baseline values. Subcortical lemniscal activity remained unaltered after the conditions. Activity in both primary and secondary somatosensory cortices (S1 and S2) increased after the NMES+ISO and decreased after the ISO condition. At later stages of S2 processing, cortical activity increased also after NMES, however the NMES+ISO effect was greater than that produced by NMES alone. These findings indicate that the beneficial effects of the NMES may be mediated by potentiation of the reflex pathways at the spinal level. At the brain level, peripheral input representation in the brainstem was not influenced by the experimental conditions which, conversely, altered cortical activity by affecting the synaptic efficiency through the somatosensory pathway. While the ISO effect was suppressive, the NMES was excitatory, especially if combined with voluntary contractions.
... during strength training based on NMES+ it is possible to gradually increase loading by means of very small increases in the current intensity, without using external loads. Further, there is evidence on the effectiveness of superimposed NMES in improving neural function at both central and peripheral level [15][16][17] . In addition, a reduction in pain has been reported following training interventions based on NMES+ in individuals with low back pain [11][12][13][14] and in individuals with anterior knee pain due to surgical damage to the patellar tendon 18 . ...
Objective: This study aimed at investigating the effectiveness of an 8-week training protocol, based on neuromuscular electrical stimulation of the quadriceps, which was superimposed onto voluntary exercise (NMES+), in comparison to a traditional heavy slow resistance training (HSRT), in individuals with patellar tendinopathy.
Methods: Thirty-two physically active participants, aged: 33.6±10.2 years, were divided into two groups: NMES+ or HSRT. Maximal voluntary isometric contraction (MVIC) of knee extensor and flexor muscles, power during a countermovement jump (CMJ), and VISA-p
questionnaire scores were recorded at the start(T0), 2-weeks(T1), 4-weeks(T2), 6-weeks(T3), 8-weeks(T4) and 4-months post-training (T5). Knee pain and rate of perceived exertion (RPE) were recorded at each training session with a 0-10 scale.
Results: Knee pain was significantly lower in NMES+ compared to HSRT during all training sessions. No significant between-group differences were found for VISA-p scores and forces recorded during MVICs at T0,T1,T2,T3,T4 and T5. A significant increase of VISA-p and peak forces during MVIC was recorded across-time in both groups. No significant
between-group or across-time differences were found for RPE and CMJ parameters. Conclusions: NMES+ and HSRT were equally effective in decreasing tendinopathy symptoms and increasing strength, with NMES+ having the advantage to be a pain-free resistance training modality.
... Many have argued that contractions produced by combination of two stimuli of different nature, as in NMES superimposed on voluntary contraction, could constitute a potential complementary training modality, which could carry additional neurological and physiological effects (Paillard, 2018;Paillard et al., 2005b;Vanderthommen & Duchateau, 2007;Wahl et al., 2014). A recent study showed that superimposing NMES to voluntary isometric contractions of the ankle plantar-flexors produces an acute potentiation of the spinal excitability of the soleus muscle compared to passive NMES and voluntary contractions only (Borzuola, Labanca, Macaluso, & Laudani, 2020). The authors suggested that during superimposed NMES the combination of increased spinal excitability in conjunction with enhanced descending drive during superimposed NMES could reflect a positive effect on contractile capabilities and motor unit recruitment. ...
... Such evidence reiterates the assumption that submaximal tasks promote a more comprehensive muscle fibres recruitment with NMES+ rather than voluntary training alone. Two recent studies, which investigated the neuromechanical characteristics of superimposed NMES, showed that stimulation applied on isometric submaximal contractions of the ankle plantar-flexor muscles, produce a potentiation of the spinal reflex response, which could reflect an increase excitability of the motor neuronal pool and potentially an improved force generating capacity (Borzuola et al., 2020;Lagerquist et al., 2006). Several researchers had already observed that the superimposition of electrical stimulation onto sub-maximal voluntary contraction could induce a neurogenic facilitatory effect by promoting recruitment of supplementary motor units (Paillard et al., 2005a;Valli, Boldrini, Milano, & Miserocchi, 2002). ...
Training and rehabilitation programmes involving neuromuscular electrical stimulation superimposed onto voluntary contractions (NMES+) have gained popularity in the last decades. Yet, there is no clear consensus on the effectiveness of such intervention. The aim of this review was to evaluate the effect of chronic exposure to NMES+ on muscle strength and mass compared to conventional volitional training or passive electrical stimulation alone. Two authors conducted an electronic search to identify randomized controlled trials that investigated the effect of NMES+ training, involved healthy participants or orthopaedic patients, detailed a well-defined NMES training protocol, and provided outcomes related to muscle strength and/or mass. The authors extracted data on participants, intervention characteristics, muscle-related outcomes, and assessed the methodological quality of the studies. A total of twenty-four studies were included in the review. The majority of these reported an increase in muscle strength following NMES+ training compared to an equivalent voluntary or passive NMES training. The highest improvements were found when NMES was superimposed on sub-maximal exercises involving both concentric and eccentric contractions. Two studies reported an increase in muscle mass after NMES+, while two other studies exhibited no differences. This review indicated that chronic exposure to NMES+ determines muscle strength improvements greater or equal compared to volitional training alone. However, differences in the methodological characteristics of the stimulation and the type of exercise associated with NMES+ revealed significant discrepancies in the results. A deeper understanding of the neurophysiological adaptations to NMES+ is crucial to fully explain the muscle-related enhancement resulting from such intervention.
• Highlights
• NMES+ consists of simultaneously applying neuromuscular electrical stimulation while voluntarily contracting the stimulated muscle.
• Although a growing number of studies have suggested that intervention based on NMES+ have a strong potential in enhancing as well as preserving muscle function, there is still no clear consensus on the effectiveness of such technique.
• This review revealed that training based on NMES+ can induce a significant improvement of muscle strength in both healthy and orthopaedic individuals.
... In fact, with NMES, it is possible to overcome patients' inability to voluntarily activate muscles by means of externally elicited muscle contractions, which can be increased by increasing the intensity of stimulation [6]. Therefore, to maximize the effects on the neuromuscular system, NMES can be superimposed to isometric contractions [7] or easy functional movements that can be performed also by orthopaedic patients early after surgery [8,9]. Finally, the development of battery-powered electrical stimulators allows NMES-based rehabilitation to be carried out anywhere: in rehabilitation centres as well as at patients' homes. ...
... However, a number of studies suggest that some benefits may exist by superimposing NMES to voluntary contractions or movements. Facilitation of spinal excitability has been recorded following a session of NMES superimposed on voluntary isometric contraction in comparison with NMES alone [7], thus suggesting that this training modality should be particularly recommended for patients with spinal inhibition, as in the case of TKA patients. In addition, it seems that the superimposition of NMES during the execution of functional movements in the early phase following knee surgery leads not only to a higher increase in muscle strength but also to an improvement in the biomechanics of movements [8]. ...
Patients undergoing total knee arthroplasty (TKA) show postsurgical quadriceps weakness. Neuromuscular electrical stimulation (NMES) has been shown to be an effective treatment for muscle strength recovery in a number of orthopaedic conditions. The aim of this review is to investigate whether adding NMES to TKA rehabilitation leads to a better quadriceps strength recovery in comparison with standardized rehabilitation. A second aim is to investigate which are the most commonly used NMES pulse settings and their effectiveness. A systematic review of literature was conducted on PubMed, Cochrane, Scopus and Web-of-Science. Intervention studies evaluating the effects of a rehabilitation intervention based on quadriceps NMES in patients undergoing TKA were retrieved. Methodological quality was assessed using the risk of bias-2 Cochrane tool. Features of NMES rehabilitation and technical data on NMES settings were extracted from the studies. Four studies met the inclusion criteria. Due to the limited number and the heterogeneity of the selected studies, it was not appropriate to carry out a meta-analysis. All the studies reported higher quadriceps strength in patients undergoing quadriceps NMES, particularly early after TKA. The addition of NMES or traditional strength training shows similar long-term effects. Short duration and low-intensity NMES have limited effects on quadriceps strength. Heterogeneity was found on NMES methodologies and pulse settings. NMES is effective for quadriceps strength recovery following TKA. NMES intensity and duration are essential for good NMES outcomes on quadriceps strength. Further studies on NMES methodologies, pulse features and settings are required to address the gaps in knowledge on NMES following TKA.
... Furthermore, it may enhance activation of target muscles resulting in immediate adaptation of the neural system and enhanced neuromuscular control [41]. In addition, earlier studies have shown that FES may facilitate spinal [42] and cortical motor excitability [43,44], especially when combined with voluntary repeated movements. These mechanisms may explain immediate or long-lasting gait modifications following FES observed in patients with neurological conditions [45][46][47]. ...
Chronic ankle instability (CAI) is a common condition that may develop after an ankle sprain. Compared with healthy individuals, those with CAI demonstrate excessive ankle inversion and increased peroneal electromyography (EMG) activity throughout the stance phase of gait, which may put them at greater risk for re-injury. Functional electrical stimulation (FES) of targeted muscles may provide benefits as a treatment modality to stimulate immediate adaptation of the neuromuscular system. The present study investigated the effect of a single, 10 min peroneal FES session on ankle kinematics and peroneal EMG activity in individuals with (n = 24) or without (n = 24) CAI. There were no significant differences in ankle kinematics between the groups before the intervention. However, after the intervention, healthy controls demonstrated significantly less ankle inversion between 0–9% (p = 0.009) and 82–87% (p = 0.011) of the stance phase. Furthermore, a significant within-group difference was observed only in the control group, demonstrating increased ankle eversion between 0–7% (p = 0.011) and 67–81% (p = 0.006) of the stance phase after the intervention. Peroneal EMG activity did not differ between groups or measurements. These findings, which demonstrate that peroneal FES can induce ankle kinematics adaptations during gait, can help to develop future interventions for people with CAI.
... Two frequencies of stimulation were used, 35 and 50 Hz, which were alternately applied at each session in accordance with a previous study (Labanca et al. 2018). The intensity of stimulation was increased by the trainer during each exercise repetition throughout the session, in accordance with patient tolerance, to maximise motor unit recruitment (Maffiuletti, 2010;Borzuola et al. 2020). In addition, the intensity was selectively increased for each muscle to guarantee a homogeneous distribution of the exercise load. ...
... In addition, a trend to an increase in knee joint pain was observed in patients performing only the additional exercises in comparison with those performing the additional exercises with the superimposition of the NMES. In addition, in a more recent study (Borzuola et al. 2020), it was found that only superimposing NMES to voluntary muscle contractions leads to an increase of motoneuron excitability with respect to NMES only, without voluntary muscle contractions, or voluntary muscle contractions only, without NMES. Thus, it seems that in patients showing neural alteration and muscle inhibition, like in ALC reconstructed patients, the most effective way for an early recovery of muscle strength is functional exercise with superimposed NMES. ...
The study aimed at investigating the effects of neuromuscular electrical stimulation superimposed on functional exercises (NMES+) early after anterior cruciate ligament reconstruction (ACLr) with hamstring graft, on muscle strength, knee function, and morphology of thigh muscles and harvested tendons. Thirty-four participants were randomly allocated to either NMES+ group, who received standard rehabilitation with additional NMES of knee flexor and extensor muscles, superimposed on functional movements, or to a control group, who received no additional training (NAT) to traditional rehabilitation. Participants were assessed 15 (T1), 30 (T2), 60 (T3), 90 (T4) and at a mean of 380 days (T5) after ACLr. Knee strength of flexors and extensors was measured at T3, T4 and T5. Lower limb loading asymmetry was measured during a sit-to-stand-to-sit movement at T1, T2, T3, T4 and T5, and a countermovement-jump at T4 and T5. An MRI was performed at T5 to assess morphology of thigh muscles and regeneration of the harvested tendons. NMES+ showed higher muscle strength for the hamstrings (T4, T5) and the quad-riceps (T3, T4, T5), higher loading symmetry during stand-to-sit (T2, T3, T4, T5), sit-to-stand (T3, T4) and countermovement-jump (T5) than NAT. No differences were found between-groups for morphology of muscles and tendons, nor in regeneration of harvested tendons. NMES+ early after ACLr with hamstring graft improves muscle strength and knee function in the short-and long-term after surgery, regardless of tendon regeneration.
... More recently, in an uninjured population, NMES has been used in conjunction with isometric contractions to improve motor neuron pool excitability of the soleus. 95 These findings suggest that the combination of NMES and exercise restores muscle strength in pathological groups by enhancing voluntary recruitment of motor neurons and may facilitate the motor neuron pool of the treated muscles. However, later in rehabilitation, voluntary strength training is likely more effective for improving strength, suggesting that NMES may be a better tool early after injury or surgery. ...
... [96][97][98][99] Although the broader effects of NMES on the central nervous system are unknown, some evidence suggests that corticospinal and spinal-reflexive excitability increases after an NMES intervention among uninjured populations. 95,100,101 Until future research can determine whether NMES alters neural excitability following joint injury, its use is indicated early for strength benefits. ...
Context:
Arthrogenic muscle inhibition (AMI) impedes the recovery of muscle function following joint injury, and in a broader sense, acts as a limiting factor in rehabilitation if left untreated. Despite a call to treat the underlying pathophysiology of muscle dysfunction more than three decades ago, the continued widespread observations of post-traumatic muscular impairments are concerning, and suggest that interventions for AMI are not being successfully integrated into clinical practice.
Objectives:
To highlight the clinical relevance of AMI, provide updated evidence for the use of clinically accessible therapeutic adjuncts to treat AMI, and discuss the known or theoretical mechanisms for these interventions.
Evidence acquisition:
PubMed and Web of Science electronic databases were searched for articles that investigated the effectiveness or efficacy of interventions to treat outcomes relevant to AMI.
Evidence synthesis:
122 articles that investigated an intervention used to treat AMI among individuals with pathology or simulated pathology were retrieved from 1986 to 2021. Additional articles among uninjured individuals were considered when discussing mechanisms of effect.
Conclusion:
AMI contributes to the characteristic muscular impairments observed in patients recovering from joint injuries. If left unresolved, AMI impedes short-term recovery and threatens patients' long-term joint health and well-being. Growing evidence supports the use of neuromodulatory strategies to facilitate muscle recovery over the course of rehabilitation. Interventions should be individualized to meet the needs of the patient through shared clinician-patient decision-making. At a minimum, we propose to keep the treatment approach simple by attempting to resolve inflammation, pain, and effusion early following injury.
