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Cody B. Bremner, William R. Holcomb, Christopher D. Brown and Melanie E. Perreault

Clinical Scenario:

Orthopedic knee conditions are regularly treated in sports-medicine clinics. Rehabilitation protocols for these conditions are often designed to address the associated quadriceps strength deficits. Despite these efforts, patients with orthopedic knee conditions often fail to completely regain their quadriceps strength. Disinhibitory modalities have recently been suggested as a clinical tool that can be used to counteract the negative effects of arthrogenic muscle inhibition, which is believed to limit the effectiveness of therapeutic exercise. Neuromuscular electrical stimulation (NMES) is commonly accepted as a strengthening modality, but its ability to simultaneously serve as a disinhibitory treatment is not as well established.

Clinical Question:

Does NMES effectively enhance quadriceps voluntary activation in patients with orthopedic knee conditions?

Summary of Key Findings:

Four randomized controlled trials (RCTs) met the inclusion criteria and were included. Of those, 1 reported statistically significant improvements in quadriceps voluntary activation in the intervention group relative to a comparison group, but the statistical significance was not true for another study consisting of the same sample of participants with a different follow-up period. One study reported a trend in the NMES group, but the between-groups differences were not statistically significant in 3 of the 4 RCTs.

Clinical Bottom Line:

Current evidence does not support the use of NMES for the purpose of enhancing quadriceps voluntary activation in patients with orthopedic knee conditions.

Strength of Recommendation:

There is level B evidence that the use of NMES alone or in conjunction with therapeutic exercise does not enhance quadriceps voluntary activation in patients with orthopedic knee conditions (eg, anterior cruciate ligament injuries, osteoarthritis, total knee arthroplasty).

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Justin L. Rush, Lindsey K. Lepley, Steven Davi and Adam S. Lepley

in participants with a history of ACLR. Methods Design A randomized crossover design was used to assess quadriceps muscle activity (electromyographic [EMG] activity, isometric strength, and voluntary activation) and self-reported levels of pain and function (Knee Injury and Osteoarthritis Outcome

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Thomas Cattagni, Clément Billet, Christophe Cornu and Marc Jubeau

Context: Prolonged tendon vibration may induce muscle fatigue, as assessed by a decrease in maximal force production. It remains unknown, however, whether the decrease in muscle strength after prolonged Achilles tendon vibration is related to the vibration frequency. Objective: To assess the maximal capacity of plantar-flexor (PF) neuromuscular function before and after prolonged Achilles tendon vibration at low and high frequencies generated using a portable device. Design: Pre- and posttest intervention with control.Setting: University laboratory. Participants: 10 healthy men age 22.6 ± 4.0 y. Intervention: Each subject participated in 3 experimental sessions that were randomly distributed and separated by 1 wk. During each experimental session, 1 of the following vibration protocols was applied for 30 min: 40-Hz vibration, 100-Hz vibration, or no vibration (control protocol). Main Outcome Measures: Maximal-voluntary-contraction torque, voluntary activation level, twitch torque, maximal electromyographic activity, and maximal M-wave of PF muscles (measured before and after each vibration or control protocol).Results: Statistical analysis exhibited no significant effect of vibration protocol on the measured variables. Conclusions: The current study demonstrates that 30 min of Achilles tendon vibration at a low or high frequency using a portable stimulator did not affect the neuromuscular performance of the PF muscles. These results emphasize the limits of tendon vibration, whatever the frequency applied, for inducing neuromuscular fatigue.

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Adriana M. Holmes and David M. Andrews

The purpose of this research was to examine the effects of voluntarily manipulating muscle activation and localized muscle fatigue on tibial response parameters, including peak tibial acceleration, time to peak tibial acceleration, and the acceleration slope, measured at the knee during unshod heel impacts. A human pendulum delivered consistent impacts to 15 female and 15 male subjects. The tibialis anterior and lateral gastrocnemius were examined using electromyography, thus allowing voluntary contraction to various activation states (baseline, 15%, 30%, 45%, and 60% of the maximum activation state) and assessing localized muscle fatigue. A skin-mounted uniaxial accelerometer, preloaded medial to the tibial tuberosity, allowed tibial response parameter determination. There were significant decreases in peak acceleration during tibialis anterior fatigue, compared to baseline and all other activation states. In females, increased time to peak acceleration and decreased acceleration slope occurred during fatigue compared to 30% and 45%, and compared to 15% through 60% of the maximum activation state, respectively. Slight peak acceleration and acceleration slope increases, and decreased time to peak acceleration as activation state increased during tibialis anterior testing, were noted. When examining the lateral gastrocnemius, the time to peak acceleration was significantly higher across gender in the middle activation states than at the baseline and fatigue states. The acceleration slope decreased at all activation states above baseline in females, and decreased at 60% of the maximum activation state in males compared to the baseline and fatigue states. Findings agree with localized muscle fatigue literature, suggesting that with fatigue there is decreased impact transmission, which may protect the leg. The relative effects of leg stiffness and ankle angle on tibial response need to be verified.

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Sungwan Kim, Daeho Kim and Jihong Park

.946) showed less quadriceps strength ( χ 2  = 16.08, df = 3, P  < .02; ES for AKP = 1.11, ES for ACLR = 0.99; Table  4 ) and voluntary activation ( χ 2  = 27.07, df = 3, P  < .003; ES for AKP = 1.20, ES for ACLR = 0.89; Table  4 ). However, we did not observe differences in quadriceps strength ( χ 2  = 16

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Daria Neyroud, Jimmy Samararatne, Bengt Kayser and Nicolas Place

of this ratio points toward excitation-contraction coupling failure. 23 As a measure of central activation, voluntary activation level (VAL) was calculated as 24 : VAL = ( 1 − ( superimposed   PS 100 × ( force level at stimulation / MVC   force ) / potentiated   PS 100 ) ) × 100 Electromyography

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Marco J. Konings, Jordan Parkinson, Inge Zijdewind and Florentina J. Hettinga

perform a self-paced 4-km cycling TT as fast as possible. Before and after the TTs, maximal voluntary contraction (MVC), doublet twitches at rest, and voluntary activation of the quadriceps muscle (VA) were determined. The first 4-km TT was always a familiarization TT (FAM). In the final 2 visits

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Karin Tammik, Mariann Matlep, Jaan Ereline, Helena Gapeyeva and Mati Pääsuke

Isometric voluntary force production and relaxation capacity of the quadriceps femoris (QF) muscle was compared between 12 children with spastic diplegic cerebral palsy (CP) and healthy controls, age 10–11 years. Children with CP had less (p < .05) maximal voluntary-contraction force, voluntary activation, and rate of force development than controls. Visual reaction to contraction did not differ significantly in measured groups, whereas the reaction time to relaxation and halfrelaxation time were longer (p < .05) in children with CP. The authors concluded that in children with CP, the capacity for rapid voluntary force production and relaxation is reduced to a greater extent than isometric maximal force.

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Sofia I. Lampropoulou and Alexander V. Nowicky

The way psychometric and neurophysiological measurements of fatigue are connected is not well understood. Thus, the time course of perceived effort changes due to fatigue, as well as the peripheral and central neurophysiological changes accompanying fatigue, were evaluated. Twelve healthy participants (35 ± 9 years old) undertook 10 min intermittent isometric fatiguing exercise of elbow flexors at 50% of maximum voluntary contraction (MVC). Perceived effort ratings, using the 0–10 numeric rating scale (NRS), were recorded at midrange of MVC. Single pulse TMS of the left motor cortex and electrical stimulation over the biceps muscle was used for the assessment of voluntary activation and peripheral fatigue. The fatiguing exercise caused a 44% reduction in the MVC (p < .001) accompanied by an 18% nonsignificant reduction of the biceps MEP amplitude. The resting twitch force decreased (p < .001) while the superimposed twitches increased (p < .001) causing a decrease (19%) of the voluntary activation (p < .001). The perceived effort ratings increased by 1 point at 30%, by 2 points at 50% MVC respectively on the NRS (p < .001) and were accompanied by an increase in mean biceps EMG. A substantial role of the perceived effort in the voluntary motor control system was revealed.