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The Immediate Effects of Focal Knee Joint Cooling & TENS

• n Quadriceps Activation in

Participants with Tibiofemoral Osteoarthritis

Brian G. Pietrosimone, M.Ed, ATC EATA Meeting and Clinical Symposia January 10, 2009 bpietrosimone@virginia.edu

Quadriceps Inhibition

The inability to activate the quadriceps following knee joint injury is common in a variety of knee injuries.

– Anterior Knee Pain

Suter et al. Clinical Biomechanics.1998.

– ACL Injury

Urbach et al. Unfallchirug. 2000. Urbach et al. Med Sci Sport Ex. 1999. Snyder- Mackler et al. J Bone and Joint Surg Am. 1994.

– Total Knee Arthroplasty

Mizner et al. Phys Ther. 2003 Mizner et al. J Bone and Joint Surg Am. 2005

– Meniscus Injury or Meniscectomy

Shakespeare et al. Clin Physiol. 1985.

– Osteoarthritis

Pap et al. Journal of Ortho Research. 2004 Lewek et al. Journal of Ortho Research. 2004 Petterson et al. Med Sci Sport Ex. 2008.

Arthrogenic Muscle Inhibition

• Decreased motor neuron pool excitability in an

uninjured muscle surrounding an injured joint, modulated by both pre and postsynaptic inhibitory mechanisms.

Palmieri et al. J Electromyogr Kinesiol. 2004. Palmieri et al. Knee Surg Sports Traumatol Arthrosc. 2005.

• Recent evidence that supraspinal mechanisms may

contribute.

Heroux et al. Knee Surg Sports Traumatol Arthrosc. 2006. Urbach et al. Muscle Nerve. 2005.

• Contributes to activation deficits & muscle weakness

Pap et al. Journal of Ortho Research. 2004 Lewek et al. Journal of Ortho Research. 2004 Petterson et al. Med Sci Sport Ex. 2008. Mizner et al. Phys Ther. 2003 Mizner et al. J Bone and Joint Surg Am. 2005

The Underlying Clinical Impairment

• Activation deficits last for years following

resolution of injury

Urbach et al. Med Sci Sport Exerc.1999. Lewek et al. Clinical Biomechanics.2002. Suter et al. Clinical biomechanics.1998. Chmielewski et al. Journal of Ortho Research.2004.

• Quadriceps inhibition contributes to altered

gait and landing kinematics useful in distributing forces

Torry et al. Clinical Biomech. 2000. Palmieri- Smith et al. Am J Sports Med. 2007.

• Possible precursor to osteoarthritis

Hurley et al. Rheumatic Disease Clinics of North America. 1999. Hurley et al. Rheum & Arthri. 2003. Becker et al. Journal of Ortho Research.2004.

Disinhibitory Modalities

• Patients with inhibition may need more

specialized therapy

Suter et al. Clinical Biomechanics.1998. Petterson et al. Med Sci Sport Ex. 2008.

• A modality that could increase motor neuron

pool excitability would allow for more optimal rehabilitation by allowing for more normalized motor neuron firing patterns

Hopkins & Ingersoll. J Sport Rehabilitation. 2000. Hopkins et al. J Athl Train. 2002.

Focal Knee Joint Cooling and TENS

3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 P r e t e s t P

• s

t t e s t 1 5 3 4 5 6

Time H-Reflex (mV)

Facilitation (Cryotherapy) Disinhibition (Transcutaneous Electrical Nerve Stimulation) Inhibition (Caused by Artificial Knee Joint Effusion)

Hopkins JT, Ingersoll CD, Krause BA, Edwards JE, Cordova ML. Cryotherapy and TENS decrease arthrogenic muscle inhibition of the Vastus Medialis following knee joint effusion. J Athl Train. 2001; 37:25-31.

Increased Muscle Activation in Healthy Subjects

Knee Cooling Control 0.73 0.69 0.74 0.69 0.73 0.79 0.79 0.77 0.5 0.6 0.7 0.8 0.9 1 10 20 30 40 50

* *

┼

Time (Minutes)

Central Activation Ratio

Joint Cooling Joint Re- Warming

Pietrosimone BG & Ingersoll CD. Society for Neuroscience. November 2007.

The Tibiofemoral Osteoarthritis Model

• Effects millions of people each year

Jordan et al. The Journal of Rheumatology. 2007. Dillon et al. The Journal of Rheumatology, 2006.

• Has been established as having AMI

Stevens et al. Journal of Ortho Research.2003. O’Reilly et al. Ann Rheum Dis. 1998. Petterson et al. Med Sci Sport Ex. 2008.

• Also been established as having disability that has

been linked to quadriceps dysfunction

Deluzio et al. Gait & Posture. 2007. Astephen et al. J Biomechanics. 2007. Lewek et al. Gait & Posture. 2006. Al- Zahrani et al. Dis and Rehabil. 2002.

Purpose

• To determine the immediate effects of focal

knee joint cooling and TENS on quadriceps activation and torque production in participants with tibiofemoral knee

• steoarthritis.

Methods: Experimental Design

Blinded, Randomized Controlled Trial Independent variables: – Group (Focal knee joint cooling, TENS, Control) – Time (Pretest, Posttests 20,30 &45 minutes post initial intervention) Main Outcome Measure: – Quadriceps Central Activation Ratio Secondary Outcome Measure: – Quadriceps Torque Production – Visual Analog Scores During MVIC

Methods: Participants

Inclusion Criteria

• Ages 18- 80
• Previous evidence of tibiofemoral
• steoarthritis (Radiographic, MRI,

Arthroscopy) Exclusion Criteria

• History of Rheumatoid Arthritis
• Cold Allergy/ Raynaud’s
• History of orthopaedic surgery or

injury in the past 6 months

• Knee replacement in the knee

being tested

• Other nerve or muscle

abnormalities IRB Approved (HSR#13215) Informed consent form signed by all subjects

39 Participants Qualified based on History 3 Participants Excluded No Activation Deficit 36 Participants Randomly Allocated to Group

Control 12 Participants Knee Cooling

1 Participant Removed

• Unable to perform MVIC

TENS

2 Participants Removed

• Unable to perform MVIC
• Premature removal of TENS

Focal Knee Joint Cooling 11 Participants TENS 10 Participants

Subject Demographics

Age (years) Height (cm) Mass (kg) Male/Female Control n = 12 54 ± 9.91 166.37 ± 13.07 92.14 ± 25.37 5 M/ 7 F Focal Joint Cooling n =11 58 ± 8.44 176.41 ± 8.29 83.18 ± 17.98 6 M/ 5 F TENS n = 10 57 ± 12.5 174.18 ± 10.78 92.77 ± 21.30 6 M/ 4 F

Injury History & Self Reported Function

Hx of injury/ Surgery (%) WOMAC Pain WOMAC Function WOMAC Total Control n = 12 83 % 3.42 ± 2.15 39 ± 10.77 59.25 ± 17.63 Focal Joint Cooling n =11 81% 3.36 ± .67 35.82 ± 11.47 57.45 ± 14.71 TENS n = 10 70% 2.6 ± .84 32.7 ± 12.71 52 ± 16.67 * None of the groups were significantly different in WOMAC scores or subscales

Positioning on Dynamometer

• Back 85° of flexion
• Axis of rotation –

lateral femoral condyle

• Knee was positioned

at 70° of knee flexion

• Subject crossed arms
• ver chest during

MVIC

Pietrosimone BG et al. Am J Physical Med & Rehab. 2008. Pietrosimone BG & Ingersoll CD. Society for Neuroscience. November 2007.

Electrode Placement

• The anode is placed
• ver the proximal

Vastus lateralis

• The cathode is placed
• ver the distal Vastus

medialis oblique

• Both carbon backed

electrodes were strapped down

Snyder-Mackler et al.. Med Sci Sports Exerc. 1993;25(7):783- 789. Mizner et al.. J Bone Joint Surg Am. May 2005;87(5):1047-1053. Hart et al . Journal of Athletic Training. 2006. 41(11): 79-86.

Applications of Interventions

• Applied by experienced certified athletic

trainers.

• All ATCs applying the treatments were

given verbal and written instructions on exactly how to apply the treatment.

Focal Joint Cooling Intervention

Length = 20 - minutes Two 1.5 liter bags of crushed ice were applied to the anterior and posterior knee and secured with a elastic wrap

Hopkins et al. Journal of Athletic Training. 2001;37(1):25-31 Hopkins JT. Journal of Athletic Training.2006;41(2): 177- 184. Pietrosimone BG & Ingersoll CD. Society for Neuroscience. 2007. Pietrosimone et al. National Athletic Trainers’ Association Annual Symposium . 2008

Transcutaneous Electrical Nerve Stimulation

• TENS 210(T)

(Mettler Electronics Corp., Anaheim, CA)

• Continuous biphasic

pulsatile current

• Pulse Rate = 150 Hz
• Pulse duration = 150μsec
• Amplitude = Submotor

Transcutaneous Electrical Nerve Stimulation

• Skin Preparation
• Four, 2x2 self adhesive

electrodes

• Currents were crossed
• Accommodation addressed
• Applied for 45-minutes

TENS Application Duration

• TENS therapy continued for 45 minutes
• Previous research has reported MNPE to be

increased only when TENS is applied

Hopkins et al. Journal of Athletic Training. 2001;37(1):25-31

• Cryotherapy has a re-warming period suggesting that

therapeutic effect lasts longer than the cooling intervention

Maintaining the Blind

• Blind Random Allocation
• Investigator Blinded to

Intervention – Investigator left room – Curtain was used

• Experienced Independent

researcher analyzed the data

Measuring the Amount of Quadriceps Voluntary Activation

• Two to three measurements were

conducted at each time in the time series (~ 60 seconds apart)

• Posttests 20, 30 & 45 minutes post initial

intervention

• Subjects performed a maximal voluntary

isometric contraction augmented by a supramaximal stimulus

Burst Superimposition

Force Tracing

Calculating Central Activation Ratio (CAR)

MVIC MVIC + SIB

CAR =

~10 ms

Motor Neurons Activated Total Motor Neurons Available

Assessment of Pain

• MVIC without a

stimulus conducted at each time interval

• “How did your knee

feel during the MVIC”

Absolutely no pain Worst pain imaginable

10 cm Visual Analog Scale

Statistical Analysis

• Three separate, 3 x 3 repeated measures ANOVA were used detect

differences in percent change scores for CAR, VAS & Torque between groups over time

• One – Way ANOVAs were used as post hoc tests to determine differences
• Pearson Product Moments were squared to determine the how much

variance in change in CAR was attributed to changes in pain.

• A priori alpha levels were set at P < 0.05
• Standardized effect sizes were calculated for:
• 1. Maximal voluntary contractions (Nm)
• 2. CARs
• 3. VAS

SPSS for windows (Version 11.5.1; SPSS, Chicago, Illinois)

CAR Results

0.81 0.87 0.91 0.91 0.94 0.81 0.77 0.8 0.79 0.84 0.86 0.91

0.6 0.7 0.8 0.9 1 1.1

Pretest 20 30 45 Focal Knee Joint Cooling Control TENS

* *

┼

* P< .05 † P = .057

CAR Percent Change Scores

0.81 5.9 5.76 9.06 9.7 6.41 11.25

• 3.54
• 10
• 5

5 10 15 20

Focal Knee Joint Cooling TENS Control

30 min 20 min 45 min

* * * * ┼

* P< .05 † P = .09

MVC Normalized to Mass

0.5 1 1.5 2 2.5 3 3.5 Pretest 20 min 30 min 45 min Normalized Newton-Meters Focal Knee Joint Cooling TENS Control

MVC Percent Change Scores

15.43 13.89 17.39 7.95 11.31 13.07

• 2.32

0.69 3.76

• 15
• 10
• 5

5 10 15 20 25 30 Focal Knee Joint Cooling TENS Control 20 min 45 min 30 min

Visual Analog Scale Percent Change

60.28 37.15 29.06

• 6.16

2.61 17.41

• 29
• 20.85

32.1

• 150
• 100
• 50

50 100 150

Change In VAS

Control Focal Knee Joint Cooling TENS

20 45 30

Minutes

The Association of VAS on CAR

TENS Focal Knee Joint Cooling Control 20 Minutes r2= .137 P = .293 r2= .269 P = .617 r2= .023 P = .640 30 Minutes r2= .038 P = .590 r2= .046 P = .527 r2= .018 P = .681 45 Minutes r2= .003 P = .874 r2= .002 P = ..907 r2= .293 P = .069

CAR Effect Sizes

1.21 0.93 .96 1.48 1.19 1.25 0.5 1 1.5 2 2.5 20 minutes 30 minutes 45 minutes TENS Focal Joint Cooling

(.28 to 2.05) (.48 to 2.36) (.04 to 1.76) (.24 to 2.05) (.06 to 1.78) (.29 to 2.11)

Effect Size Point Estimates and 95% Confidence Intervals

MVC Effect Sizes

1.15 1.08 .95 0.78 0.75 0.54

• 0.5

0.5 1 1.5 2 2.5

Effect Size Point Estimates and 95% Confidence Intervals

TENS Focal Joint Cooling 20 minutes 30 minutes 45 minutes (.23 to 1.99) (-.11 to 1.62) (.04 to 1.76) (-.14 to 1.59) (.05 to 1.77) (-.33 to 1.38)

VAS Effect Sizes

• 0.38
• 0.33
• 0.1
• 0.51
• 0.59
• 0.04
• 2
• 1.5
• 1
• 0.5

0.5 1

Effect Size Point Estimates and 95% Confidence Intervals

(-1.22 to 0.48) (-1.34 to 0.36) (-1.16 to 0.53) (-1.42 to 0.29) (-.94 to .74) (-.88 to .80)

20 Minutes 30 Minutes 45 Minutes

TENS Focal Joint Cooling

Discussion: CAR

• Change Scores for CAR were significantly greater

for TENS than control for over time.

• Change scores for focal knee joint cooling were
• nly significantly greater than controls at 20

minutes, suggesting a possible re-warming effect.

• Increasing MNPE allowed for an immediate

increase in activation of the quadriceps muscle group.

CAR Effect Sizes

Focal Joint Cooling 20 minutes = 1.21 30 minutes = .93 45 minutes = .96 TENS 20 minutes = 1.48 30 minutes = 1.19 45 minutes = 1.25

• All strong effect size none of the 95%CI cross

zero

• Therefore we can be confident that there is

some therapeutic effect with TENS and focal knee joint cooling

Possible Mechanisms Behind the Increased Activation

• Spinal reflex theories suggest that increased afferent

excitatory stimulation from mechanoreceptors and thermoreceptors cause increased motor output due to a masking of inhibitory signals transmitted to the central nervous system

• Supraspinal factors have been associated with the

facilitation in the MNPE of musculature surrounding healthy joints.

Krause et al. Journal of Sport Rehabilitation. 2000;9:253- 26 Hopkins & Stencil. Journal of Orthopaedic & Sports Physical Therapy. 2002;32(12):622-627 Hopkins et al. Journal of Athletic Training. 2001;37(1):25-31 Hopkins JT. Journal of Athletic Training.2006;41(2): 177- 184.

Discussion: MVC

• Although knee extension torques associated

with TENS and Focal knee joint cooling were consistently higher than controls no significant differences were found.

– High Standard Deviations – Not Powered to detected changes in MVC

Main effects for time 1- β = .555 Main effects for group 1- β = .533 Interaction of group and time 1-β = .144

MVC Effect Sizes

• Moderate to strong effect sizes were

reported for both focal knee joint cooling and TENS

• 95% CI for TENS in all groups crossed 0

which decreases our confidence that an effect was present.

• This may be do to a relatively small sample

size

Discussion: Pain

• Small to moderate ES found at 20 & 30 min
• Changes in pain during an MVC did not

significantly predict changes in CAR

• Previous study reported CAR to have insignificant

associations with pain

Pre/Post Total KneeArthroplasty r2= .12, P = .14

Mizner et al. J Bone Joint Surg Am. May 2005;87(5):1047-1053.

20 Minutes = .5% ΔCAR Δ VAS 30 Minutes = .7% ΔCAR Δ VAS 45 Minutes = 1% ΔCAR Δ VAS

Conclusions

• This study provides evidence that focal joint

cooling and TENS has the ability to immediately increase quadriceps activation in an osteoarthritic population during an

• pen chain activity over a 45 minute period
• Percent change in VAS did not predict

percent change in CAR.

Future Research

“Increasing quadriceps strength is of only academic interest if it is not associated with improvement in function.”

• Hurley & Scott. British Journal of Rheumatology. 1998.
• Need to determine if the use of these modalities

will effect patient oriented outcomes

• Can these modalities, used following

injury/surgery, decrease the risk of post traumatic tibiofemoral OA

Acknowledgments

Funded by the Eastern Athletic Trainers’ Association Lindsay K. Drewes, MEd, ATC Kate Ritter Jackson, MEd ATC Susan A Saliba, PhD, PT, ATC Jay Hertel, PhD, ATC, FACSM, FNATA Christopher D. Ingersoll, PhD, ATC, FACSM, FNATA Joseph M. Hart, PhD, ATC