Correlative Study of Static Quadriceps Setting Exercise Measured by Sphygmomanometer and E

CORRELATIVE STUDY OF STATIC QUADRICEPS SETTING EXERCISE MEASURED BY SPHYGMOMANOMETER AND E.M.G. BIOFEEDBACK IN POST OPERATIVE ANTERIOR CRUCIATE LIGAMENT SUBJECTS

A

Protocol submitted to

HOSMAT HOSPITAL & EDUCATIONAL INSTITUTE

Bangalore

DISSERTATION RESEARCH PROJECT

By

ARJUN B

M.P.T. (Musculoskeletal and Sports)

Guide: Mrs Sherin George

Co Guide: Mr R. Dev Anand

RESEARCH APPROVAL

Correlative Study Of Static Quadriceps Setting Exercise Measured By Sphygmomanometer And E.M.G. In Post Operative Anterior Cruciate Ligament Subjects

Research proposal approved by Institutional ethics Committee on 08/12/2009.

INSTITUTIONAL ETHICS COMMITTEE

HHEI

BANGALORE-25.

CONTENTS

Page No.

1 INTRODUCTION 04

1.1 Background of the study 04

1.2 Statement of the problem 05

1.3 Objective of the study 05

1.4 Hypothesis 05

1.5 Null Hypothesis 05

1.6 Operational Definition 05

1.7 Clinical Significance 05

2 REVIEW OF LITERATURE 06

3 METHODOLOGY 08

3.1 Study Design 08

3.2 Study Setting 08

3.3 Sample 08

3.4 Inclusion Criteria 08

3.5 Exclusion Criteria 08

3.6 Materials 09

3.7 Procedure 10

3.8 Outcome Measures 11

3.9 Data Analysis 11

4 REFERENCES 12

5 APPENDIX-1 15

6 APPENDIX -2 16

7 APPENDIX-3 17

INTRODUCTION

1.1  Background of the study

The knee joint is the largest joint in body. It is a synovial joint hinge type[21]. The anterior cruciate ligament plays a crucial role in stabilising the knee joint by preventing anterior glide of tibia on femur [1]. The recent trend in surgical management is the use of bone patella tendon bone grafts as it has a better functional outcome[16] Traditional rehabilitation programs aim to return subject to sporting activity by nine to twelve months post operatively. However in past decade the rehabilitation programs have been accelerated with patients returning to normal functional activity by four to six months.[1]

Quadriceps femoris muscles suffers the greatest functional loss after ACL reconstruction and are the focus of rehabilitation protocols [17] This is due to failure of voluntary muscle activation either by arthrogenous or reflex inhibition [4,12] Functional rehabilitation of knee requires the activation of quadriceps femoris muscle.

Activation of quadriceps is mostly focused in the initial phases of ACL rehabilitation. Activation of quadriceps is performed by both sensory & motor approaches using various techniques. Methods of activating include reducing joint effusion, cryotherapy, TENS, anaesthetics, neuromuscular electrical stimulation, biofeedback [clinics in sports med, 18]

In routine physiotherapy rehabilitation protocol, quadriceps setting exercise (QSE) is often prescribed in first two post operative weeks [10] QSE is one of modes of activation of quadriceps muscle.[17] It is simple, economical and takes minimal time to practice.[13] However, practical difficulty exists in executing an effective quadriceps setting exercise following knee surgery, and subjects compensate by contracting hip musculature neglecting active contraction of knee extensors. [draper] Also, arthrogenic muscle inhibition prevents complete voluntary activation, and hence active exercise may be ineffective in patients’ recovery. [18]. Studies have shown that active exercises have been shown to be more beneficial than passive modes of activation. This necessitates the need to achieve active control of quadriceps in post operative subjects.

Activation of quadriceps, specifically VMO, has been well studied in literature with surface EMG. [17] .Surface EMG has been used in assessing activation of quadriceps muscle[19, 20] and sphygmomanometer can be used to assess QSE [5,7]

QSE are routinely performed as a primary mode of activating quadriceps (VMO) in clinical practice. This study wants to highlight whether there is activation of quadriceps (VMO) during a QSE using a surface EMG and quantifying the QSE with a sphygmomanometer

1.2  Statement of the problem

Ø  QSE may not actually activate quadriceps(VMO); instead the movement may be compensated by hip musculature.

1.3  Aim of the study

Ø  To check & correlate whether quadriceps muscle setting exercise facilitates VMO activation in post operative anterior cruciate ligament reconstruction.

1.4  Objective of study

Ø  To correlate and check reliability of sphygmomanometer with surface EMG in normal subjects

Ø  To correlate the pressure exerted during quadriceps setting and VMO muscle activation during subacute phase [10, 13] of post operative ACL rehabilitation

Ø  To find the trend of VMO muscle activation with quadriceps setting exercise in subacute phase [10,13]of post operative ACL rehabilitation

1.5  Hypothesis

Ø  There is no correlation between the pressure exerted during quadriceps setting and VMO muscle activation.

1.6  Null Hypothesis

Ø  There is high correlation between the pressure exerted during quadriceps setting and VMO muscle activation.

1.7  Operational definition

Ø  Isometric exercise – it is a form of exercise in which muscle contracts without visible joint movement.[9]

1.8  Clinical Significance

If study proves no correlation between pressure exerted and VMO activation during QS exercises, Therapist has to focus on

1.  Using alternative methods of VMO activation-sensory and motor(18)

2.  Can identify substitution strategies and prevent them

Review of Literature

ACL Rehabilitation

[Gauti Laxdal et al 2007, 16] The recent trend of surgical management bone-patellar-tendon-bone graft is preferred to hamstring tendon grafts]

[Minetta Mendonza 2007 , 1]Rehabilitation programs have been acclerated,with patients returning to normal functional activity within four to six months.

Quadriceps setting exercise

[Hosea etal 1990] Isometric exercises are most important in early phase of anterior cruciate ligament

[Shaw et al 2005, 13]Quadriceps setting exercise is a simple economical intervention taking minimal time to perform.

[Masaaki Nakajima 2003,2]QS can be used in early knee rehabilitation.

Vaness Draper PhD(1990) quadricepsfemoris suffer the greatest functional loss after ACL reconstruction and are focus of rehabilitation protocols. QS are commonly used by therapist in rehabilitation. But several clinicians have noted patients having difficulty in executing QS exercise contraction , contracting primarily hip musculature and neglecting to contract knee extensors.

[Gary L Soderberg ,1987,23]compared EMG data between QS and Straight leg raising.checked the intensity of contrction required in knee and hip musculature during common therapeutic exercises

E.M.G. in Anterior cruciate ligament rehabilitation

[Vaness Draper 1990] Regular use of E.M.G. Biofeedback during muscle strengthening exercise significantly improves rate of functional recovery of quadriceps femoris muscle.

[Hugo Maxwell et al,22]used EMG to study the electrical activity of muscles that stabilize the knee joint.

[MJ Callagham ,2009 , 20] measured surface emg data from superficial quadriceps during submaximal isometric fatiguing.

[Kelly Rafael Ribeiro Coqueiro, 2005, 24 ] used EMG to check the effect of hip abduction on activity of VMO and VLL muscles during semisquat exercises.

Sphygmomanometer with quadriceps setting exercise

[Sherrinton, SR Lord, 2003 7] Sphygmomanometer can be used to measure isometric strength of muscle. It is readily available and inexpensive mode for evaluating muscle strength. The apparatus cuff inflated to 20 mm of Hg before being placed under the limb.

[Claudionor Delgado et al, 2004, 5]evaluated knee joint flexor and extensor muscle strength in militaries using sphygmomanometer.

METHODOLOGY

3.1 Study Design

Ø  Observation design [single blinded]

Ø  Correlative study.

3.2 Study Setting

Ø  Department of physiotherapy, HOSMAT Hospital, Bangalore.

3.3  Sample

Sampling – Purposive sampling

Sample size - 60

The population would be all the subjects referred for physiotherapy following ACL reconstruction surgery.

The subjects will be scrutinized for inclusion exclusion criteria and interested subjects will participate in the study sample.

.

3.4 Inclusion Criteria

ü  Both gender

ü  NRS < 6 / 10

ü  Oriented patients

ü  Anterior cruciate ligament reconstruction with bone patellar tendon bone grafting – Unilaterally affected

3.5 Exclusion Criteria

v  Bilateral ACL injury

v  Fractures of lower limb bones

v  Multiple ligamentous injury of knee or lower limb

v  Pathological diseases of lower limb joints

v  Degenerative joint disease of knee joint

v  Deformities of lower limb

v  Pronated foot

v  Uncooperative subjects

v  Neurological deficit

3.6 Materials

v  2 Sphygmomanometer

v  Surface EMG Relax II device with accessories, gel

v  2 Crepe bandages

v  Re-education board

v  Spirit, cotton

v  Self adhesive plaster

3.7 Procedure

Phase I – Reliability of sphygmomanometer with surface EMG in normal subjects

Population – Students of HOSMAT Hospital Educational Institute

Sample – Simple random sampling

Sample size – 100 subjects

The register of all the students of HOSMAT Hospital Educational Institute shall be scrutinized and made into a list assigning each student a corresponding number based on alphabetical order of every year student, in all the courses of the institute. A computer generated random number list shall be generated and the corresponding students shall be requested to participate in the study. Subjects who have knee pains, lower limb deformities, have underwent any lower limb surgeries, limb length deficits, foot pains, flat foot, pronated feet shall be excluded from participation. Interested and suitable candidates shall sign a written consent and be included in sample.

The normal subjects shall undergo the same procedure as described below to correlate the pressure generated during quadriceps setting and surface EMG intensity. The procedure shall be performed 3 times and the average of the three trials shall be taken for data analysis. The subjects shall be requested to attend 2 sessions on 2 consecutive days and the test repeated.

The data collected in normal subjects shall be utilized to assess the intra rater reliability of the procedure.

Phase two

Subjects who are interested in participating shall be informed about the aims, procedure of the study. Interested participants shall sign the written consent to be considered a study subject. A general physiotherapy assessment shall be taken and the data collection shall be on the day of reporting to department during 2nd post operative week.

Procedure for checking quadriceps muscle activation by quadriceps setting:

Subject shall be positioned in supine lying with a pillow under the head. Both the lower limbs will be placed on re-education board with 15 degree of knee flexion (as measured with goniometer(11). The suprapatellar area over the lower thigh shall be cleaned with spirit and E.M.G. leads shall be fixed (using a self adhesive plaster) anteromedial to medial pole of patella towards adductor tubercle on VMO of both the knee joints(15) .The electrodes are spaced at 2 cm distance between them. EMG electrodes shall be fixed on both the lower limbs. A ground electrode is commonly placed over the leg. (14 ) Both the knees are wrapped by crepe bandage to blind the affected side from the observer. The cuffs of sphygmomanometers shall be placed under both the knees & inflated to 20 mm of Hg. (7)

The first investigator will provide instructions to familiarize the procedure using unaffected knee. The subject will perform sets of the same procedure to become familiarized. The data shall be obtained from both the knees by a second investigator. The affected and unaffected knees are blinded from the second investigator by the use of crepe bandage. The first investigator determines the order of knee examination by a coin toss method, where heads refers to left side and tails refers to right side. The order of examination is then provided to the second investigator.

Once the subject is prepared by first investigator, the second investigator shall be called in and provides standard command to the subject to initiate quadriceps contraction. The command given shall be “press knee down and tighten front of thigh muscle”. No verbal encouragement is provided by the researcher. The researcher observes & records the pressure (in mmHg) and the corresponding EMG activity (mV) displayed in the EMG-BFB device. Three trials are repeated with rest interval of 1 minute on one knee. The same procedure is repeated on the opposite knee after a rest interval of 5 minutes. All the data collected shall be handed over by second investigator to the first investigator after the data have been collected.

The subject shall undergo routine physiotherapy rehabilitation program during the study period. The same procedure is carried over at 1 week and 3 weeks after first session.

3.8 Outcome Measures

·  Pressure (mmHg) as measured in sphygmomanometer

·  Muscle activity (mV) recorded in EMG-BFB device

3.9 Data Analysis

Phase one

·  Intraclass correlation coefficient (ICC) for reliability of sphygmomanometer & EMG in normal subjects

Phase two

·  Pearson’s correlation test

EMG & Pressure values at first session, second session & third session

·  ANOVA for trend changes

REFERENCES

1. Minetta Mendonza . Hiral Patel . Sandra Bassett PhD.

Influences of psychological factors and rehabilitation adherence on the outcome post ACL reconstruction.

Newzealand journal of physiotherapy . July 2007 . vol 35. 62-71

2.Masaaki Nakajima. Kenji Kawamura .Iso Takeda Electromyographic analysis of a modified manuver for quadriceps femoris muscle setting with co-contraction of the hamstrings. Journal of orthopaedics research. Vol. 21. 2003.559-564

3.Jennifer M Scarvell.Paul N Smith. Kathryn M.Howard R Galloway. Kevin R Woods. Association between abnormal kinematics and degenerative change in knees of people with chronic ACL deficiency:A MRI study Australian journal of physiotherapy, vol 51, 2005.223-240

4. Riannm et al. Pre-synaptic modulation of quadriceps arthrogenic muscle inhibition. July 2005. vol 13. 5. 370-376 .

5.Claudionor Delgado. Jose Fernandes Filho. Fernando Policarpo.Hildeamo Bonifacio Oliveira. Use of sphygmomanometer in the evaluation of the knee joint flexor and extensor muscle strength in militaries. Rev Bras Med Esporte. 2004. 5. vol 10.

6.Anthony Delitto. Steven J Rose .Joseph m Mckowe. Richard C Lehman. James A Thomas Robert A Shively. Electrical stimulation versus voluntary exercise in strengthening thigh musculature after ACL surgery. Physical therapy May 1988. vol 68. 660-663

7. Sherrinton. Stephen R lord. Reliability of simple portable

Tests of physical performance in older people after hip

Fracture. 2003 December . 19. 496-504

8. Lars L Andersen . S Peter Magnusson, Michael Nielsen , John Haleem. Kenn Poulsen. Per Aagaard. Nueromuscular activation in conventional therapeutic exercise and heavy resistance exercises: Implications for rehabilitation. Physical therapy May 2006. vol 86. 683-697.

9. Carolyn Kisner . Lynn Allen Colby. Therapeutic exercise foundations and Techniques. Fourth ed. Jaypee . p-80

10. S Brent Brotzman Clinical orthopaedic rehabilitation.

P-195. .

11. Cynthia Norkin and Joyce White Measurement of Joint Motion , A Guide To Goniometry . Second ed . p143