Advertisement

Performance on a Clinical Quadriceps Activation Battery Is Related to a Laboratory Measure of Activation and Recovery After Total Knee Arthroplasty

Published:August 29, 2017DOI:https://doi.org/10.1016/j.apmr.2017.07.013

      Highlights

      • The quadriceps activation battery (QAB) is the first clinical battery of tests shown to be related to recovery of activation, strength, and function after total knee arthroplasty (TKA).
      • Timing of assessment of the QAB is critical because patient performance on the QAB was most informative in the initial postoperative period (4d after surgery).
      • The QAB could be used to identify individuals who may need specific interventions such as neuromuscular electrical stimulation to target activation deficits or prolonged physical therapy intervention to achieve optimal results after TKA.

      Abstract

      Objective

      To determine the relation between performance on a clinical quadriceps activation battery with (1) activation measured by doublet interpolation and (2) recovery of quadriceps strength and functional performance after total knee arthroplasty (TKA).

      Design

      Planned secondary analysis of a randomized controlled trial.

      Setting

      University research laboratory.

      Participants

      Patients (N=162; mean age, 63±7y; 89 women) undergoing TKA.

      Main Outcome Measures

      Patients were classified as high (quadriceps activation battery ≥4/6) or low (quadriceps activation battery ≤3/6) based on performance on the quadriceps activation battery measured 4 days after TKA. Differences between groups in activation and recovery at 1, 2, 3, 6, and 12 months after TKA were compared using a repeated-measures maximum likelihood model.

      Results

      The low quadriceps activation battery group demonstrated poorer quadriceps activation via doublet interpolation (P=.01), greater quadriceps strength loss (P=.01), and greater functional performance decline (all P<.001) at 1 month after TKA compared with the high quadriceps activation battery group. Differences between low and high quadriceps activation battery groups on all measures did not persist at 3 and 12 months (all P>.05).

      Conclusions

      Poor performance on the quadriceps activation battery early after TKA is related to poor quadriceps activation and poor recovery in the early postoperative period. Patients in the low quadriceps activation battery group took 3 months to recover to the same level as the high quadriceps activation battery group. The quadriceps activation battery may be useful in identifying individuals who need specific interventions to target activation deficits or different care pathways in the early postoperative period to speed recovery after TKA.

      Keywords

      List of abbreviations:

      6MWT (6-minute walk test), MVIC (maximum voluntary isometric contraction), NMES (neuromuscular electrical stimulation), OA (osteoarthritis), SCT (stair climbing test), TKA (total knee arthroplasty), TUG (Timed Up and Go)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • HCUP
        Most frequent operating room procedures performed in U.S. hospitals, 2003-2012.
        (Available at:)
        • Bade M.J.
        • Kohrt W.M.
        • Stevens-Lapsley J.E.
        Outcomes before and after total knee arthroplasty compared to healthy adults.
        J Orthop Sports Phys Ther. 2010; 40: 559-567
        • March L.M.
        • Cross M.J.
        • Lapsley H.
        • Tribe K.L.
        • Courtenay B.G.
        • Brooks P.M.
        Outcomes after hip or knee replacement surgery for osteoarthritis.
        Med J Aust. 1999; 171: 235-238
        • Walsh M.
        • Woodhouse L.J.
        • Thomas S.G.
        • Finch E.
        Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects.
        Phys Ther. 1998; 78: 248-258
        • Noble P.C.
        • Gordon M.J.
        • Weiss J.M.
        • Reddix R.N.
        • Conditt M.A.
        • Mathis K.B.
        Does total knee replacement restore normal knee function?.
        Clin Orthop. 2005; : 157-165
        • Mizner R.L.
        • Petterson S.C.
        • Stevens J.E.
        • Vandenborne K.
        • Snyder-Mackler L.
        Early quadriceps strength loss after total knee arthroplasty.
        J Bone Joint Surg. 2005; 87: 1047-1053
        • Stevens J.E.
        • Mizner R.L.
        • Snyder-Mackler L.
        Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis.
        J Orthop Res. 2003; 21: 775-779
        • Mizner R.L.
        • Petterson S.C.
        • Snyder-Mackler L.
        Quadriceps strength and the time course of functional recovery after total knee arthroplasty.
        J Orthop Sports Phys Ther. 2005; 35: 424-436
        • Yoshida Y.
        • Mizner R.L.
        • Ramsey D.K.
        • Snyder-Mackler L.
        Examing outcomes from total knee arthroplasty and the relationship between quadriceps strength and knee function over time.
        Clin Biomech. 2008; 23: 320-328
        • Marmon A.R.
        • Milcarek B.I.
        • Snyder-Mackler L.
        Associations between knee extensor power and functional performance in patients after total knee arthroplasty and normal controls without knee pain.
        Int J Sports Phys Ther. 2014; 9: 168-178
        • Palmieri-Smith R.M.
        • Villwock M.
        • Downie B.
        • Hecht G.
        • Zernicke R.
        Pain and effusion and quadriceps activation and strength.
        J Athl Train. 2013; 48: 186-191
        • Hurley M.V.
        • Jones D.W.
        • Newham D.J.
        Arthrogenic quadriceps inhibition and rehabilitation of patients with extensive traumatic knee injuries.
        Clin Sci. 1994; 86: 305-310
        • Rice D.A.
        • McNair P.J.
        Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives.
        Semin Arthritis Rheum. 2010; 40: 250-266
        • Jakobsen T.L.
        • Kehlet H.
        • Husted H.
        • Petersen J.
        • Bandholm T.
        Early progressive strength training to enhance recovery after fast-track total knee arthroplasty: a randomized controlled trial.
        Arthritis Care Res. 2014; 66: 1856-1866
        • Bade M.
        • Struessel T.
        • Dayton M.
        • et al.
        Early high-intensity versus low-intensity rehabilitation after total knee arthroplasty: a randomized controlled trial.
        Arthritis Care Res. 2017; 69: 1360-1368
        • Reeves N.D.
        • Maffulli N.
        A case highlighting the influence of knee joint effusion on muscle inhibition and size.
        Nat Clin Pract Rheumatol. 2008; 4: 153-158
        • Stevens-Lapsley J.E.
        • Balter J.E.
        • Wolfe P.
        • Eckhoff D.G.
        • Kohrt W.M.
        Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial.
        Phys Ther. 2012; 92: 210-226
        • Lynch A.D.
        • Logerstedt D.S.
        • Axe M.J.
        • Snyder-Mackler L.
        Quadriceps activation failure after anterior cruciate ligament rupture is not mediated by knee joint effusion.
        J Orthop Sports Phys Ther. 2012; 42: 502-510
        • Stratford P.
        Electromyography of the quadriceps femoris muscles in subjects with normal knees and acutely effused knees.
        Phys Ther. 1982; 62: 279-283
        • Soderberg G.L.
        • Minor S.D.
        • Arnold K.
        • et al.
        Electromyographic analysis of knee exercises in healthy subjects and in patients with knee pathologies.
        Phys Ther. 1987; 67: 1691-1696
        • Duchateau J.
        • Enoka R.M.
        Neural control of lengthening contractions.
        J Exp Biol. 2016; 219: 197-204
        • Behm D.G.
        • St-Pierre D.M.
        • Perez D.
        Muscle inactivation: assessment of interpolated twitch technique.
        J Appl Physiol (1985). 1996; 81: 2267-2273
        • Kennedy D.M.
        • Stratford P.W.
        • Wessel J.
        • Gollish J.D.
        • Penney D.
        Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty.
        BMC Musculoskelet Disord. 2005; 6: 3
        • Rosnow R.L.
        • Rosenthal R.
        Computing contrasts, effect sizes, and counternulls on other people's published data: general procedures for research consumers.
        Psychol Methods. 1996; 1: 331
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Eearlbaum Associates, Hillsdale1988
        • Palmieri R.M.
        • Weltman A.
        • Edwards J.E.
        • et al.
        Pre-synaptic modulation of quadriceps arthrogenic muscle inhibition.
        Knee Surg Sports Traumatol Arthrosc. 2005; 13: 370-376
        • Palmieri R.M.
        • Ingersoll C.D.
        • Edwards J.E.
        • et al.
        Arthrogenic muscle inhibition is not present in the limb contralateral to a simulated knee joint effusion.
        Am J Phys Med Rehabil. 2003; 82: 910-916
        • Palmieri-Smith R.M.
        • Kreinbrink J.
        • Ashton-Miller J.A.
        • Wojtys E.M.
        Quadriceps inhibition induced by an experimental knee joint effusion affects knee joint mechanics during a single-legged drop landing.
        Am J Sports Med. 2007; 35: 1269-1275
        • Avramidis K.
        • Karachalios T.
        • Popotonasios K.
        • Sacorafas D.
        • Papathanasiades A.A.
        • Malizos K.N.
        Does electric stimulation of the vastus medialis muscle influence rehabilitation after total knee replacement?.
        Orthopedics. 2011; 34: 175
        • Pietrosimone B.G.
        • Saliba S.A.
        • Hart J.M.
        • Hertel J.
        • Kerrigan D.C.
        • Ingersoll C.D.
        Effects of transcutaneous electrical nerve stimulation and therapeutic exercise on quadriceps activation in people with tibiofemoral osteoarthritis.
        J Orthop Sports Phys Ther. 2011; 41: 4-12
        • Pietrosimone B.G.
        • Hart J.M.
        • Saliba S.A.
        • Hertel J.
        • Ingersoll C.D.
        Immediate effects of transcutaneous electrical nerve stimulation and focal knee joint cooling on quadriceps activation.
        Med Sci Sports Exerc. 2009; 41: 1175-1181
        • Pua Y.H.
        The time course of knee swelling post total knee arthroplasty and its associations with quadriceps strength and gait speed.
        J Arthroplasty. 2015; 30: 1215-1219