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Conrad M. Gabler, Adam S. Lepley, Tim L. Uhl, and Carl G. Mattacola

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?

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Justin L. Rush, David A. Sherman, David M. Bazett-Jones, Christopher D. Ingersoll, and Grant E. Norte

reported that focal joint cooling, neuromuscular electrical stimulation (NMES), and transcutaneous electrical nerve stimulation (TENS) are effective treatment strategies to limit the effects of AMI. 11 These interventions have also shown promise to aid in the preservation and restoration of muscle

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Brandon Warner, Kyung-Min Kim, Joseph M. Hart, and Susan Saliba


Quadriceps function improves after application of focal joint cooling or transcutaneous electrical nerve stimulation to the knee in patients with arthrogenic muscle inhibition (AMI), yet it is not known whether superficial heat is able to produce a similar effect.


To determine quadriceps function after superficial heat to the knee joint in individuals with AMI.


Single blinded randomized crossover.




12 subjects (4 female, 8 males; 25.6 ± 7.7 y, 177.2 ± 12.7 cm, 78.4 ± 18.2 kg) with a history of knee-joint pathology and AMI, determined with a quadriceps central activation ratio (CAR) of <90%.


3 treatment conditions for 15 min on separate days: superficial heat using a cervical moist-heat pack (77°C), sham using a cervical moist pack (room temperature at about 24°C), and control (no treatment). All subjects received all treatment conditions in a randomized order.

Main Outcome Measures:

Central activation ratio and knee-extension torque during maximal voluntary isometric contraction with the knee flexed to 60° were collected at pre, immediately post, 30 min post, and 45 min posttreatment. Skin temperature of the quadriceps and knee and room temperature were also recorded at the same time points.


Three (treatment conditions) by 4 (time) repeated ANOVAs found that there were no significant interactions or main effects in either CAR or knee-extension torque (all P > .05). Skin-temperature 1-way ANOVAs revealed that the skin temperature in the knee during superficial heat was significantly higher than other treatment conditions at all time points (P < .05).


Superficial heat to the knee joint using a cervical moist-heat pack did not influence quadriceps function in individuals with AMI in the quadriceps.

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J. Ty Hopkins and Christopher D. Ingersoll


To define the concept of arthrogenic muscle inhibition (AMI), to discuss its implications in the rehabilitation of joint injury, to discuss the neurophysiologic events that lead to AMI, to evaluate the methods available to measure AM1 and the models that might be implemented to examine AMI, and to review therapeutic interventions that might reduce AMI.

Data Sources:

The databases MEDLINE, SPORTDiscus, and CIHNAL were searched with the terms reflex inhibition, joint mechanoreceptor, Ib interneuron, Hoffmann reflex, effusion, and joint injury. The remaining citations were collected from references of similar papers.


AMI is a limiting factor in the rehabilitation of joint injury. It results in atrophy and deficiencies in strength and increases the susceptibility to further injury. A therapeutic intervention that results in decreased inhibition, allowing for active exercise, would lead to faster and more complete recovery.

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Laura A. Verbruggen, Melissa M. Thompson, and Chris J. Durall

, clinicians should utilize a multifaceted approach when treating patients with plantar fasciitis. Specifically, clinicians should consider the use of LDT in conjunction with other conservative measures, such as transcutaneous electrical nerve stimulation and infra-red treatment, 1 calf stretching, 2 , 3

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Grant Norte, Justin Rush, and David Sherman

. NMES indicates neuromuscular electrical stimulation; TENS, transcutaneous electrical nerve stimulation. Acute Recovery During this stage of healing and rehabilitation, it is important to (1) minimize pain, effusion, and inflammation of the injured joint; (2) improve muscle activation; and (3) minimize

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Matthew K. Seeley, Hyunwook Lee, S. Jun Son, Mattie Timmerman, Mariah Lindsay, and J. Ty Hopkins

In the first study, 7 activation patterns immediately returned to normal upon pain abatement. In the second study, 10 altered activation patterns remained even while investigators attempted to restore prepain activation patterns via cryotherapy and transcutaneous electrical nerve stimulation (TENS

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Jennifer Ostrowski, C. Collin Herb, James Scifers, Teraka Gonzalez, Amada Jennings, and Danvirg Breton

feature in this study could potentially have influenced heat transfer. Transcutaneous electrical nerve stimulation has been shown to increase skin temperature, 17 but no studies were located that indicated electrical stimulation increased muscle temperature. Isometric muscle contractions are known to

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Brian Pietrosimone, Adam S. Lepley, Christopher Kuenze, Matthew S. Harkey, Joseph M. Hart, J. Troy Blackburn, and Grant Norte

in a subsequent increase in quadriceps strength, 131 , 132 suggesting that utilizing interventions to decrease AMI in addition to traditional therapeutic exercise may allow more beneficial rehabilitation regimens. Transcutaneous Electrical Nerve Stimulation and Cryotherapy Transcutaneous electrical

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Scott W. Cheatham and Morey J. Kolber

. Karasuno H , Ogihara H , Morishita K , et al . The combined effects of transcutaneous electrical nerve stimulation (TENS) and stretching on muscle hardness and pressure pain threshold . J Phys Ther Sci . 2016 ; 28 ( 4 ): 1124 – 1130 . PubMed doi:10.1589/jpts.28.1124 10.1589/jpts.28