ESTIM for Motor - Quadriceps Contraction

 

Problem:

Your patient is a 60 yo male 6 weeks s/p right TKA. He is having difficulty obtaining a good quadriceps contraction. You are considering using estim to assist with his rehab.

 

Justification:

A systematic review performed by Kittelson et al concluded that the use of NMES as a post operative strengthening modality can significantly improve strength, physical functioning, and overall physical health by facilitating motor recruitment of the quadriceps muscle, particularly the type II fibers, that are left weakened from nonuse and deficits in volitional activation following TKA. Lewek et al presented a case study of a 66-year-old man who reported a return to independent ADLs, decreased pain, and increased quadriceps strength after a combined intervention of NMES and a volitional strength training program. His progress was determined to be faster than patients of similar medical background whom had only participated in strength training protocols for TKA rehabilitation.  Stevens-Lapsley et al found in a randomized controlled trial of 66 patients that the use of NMES in conjunction with standard post-operative rehabilitation initially improved quadriceps strength, functional performance, and knee extension significantly more than standard rehabilitation by itself. Furthermore, these gains remained clinically meaningful one year after surgery.

 

Procedure:

The more specific guidelines established by Stevens-Lapsley et al will be utilized for the NMES treatment. The involved lower limb will be secured with a Velcro strap to a stable chair so that the hip rests in ~85˚ of flexion and the knee rests in 60˚ of flexion. Self-adhesive electrodes (7.6x12.7cm) will be placed on the distal medial and proximal lateral portions of the anterior thigh, marking their placement for continuity of treatment. A symmetric biphasic current will be administered using the EMPI 300PV stimulator NMES device set at 50 pps for 15 seconds with a 3 second ramp time and a 45 second off-time for a 250 µsec pulse duration. This treatment will be performed for 15 NMES repetitions twice a day for a duration of 6 weeks. Should the NMES device be unavailable in the home environment for the patient, then treatment will be reduced to a still effective 3 time per week.2 NMES treatment will be followed with volitional strengthening exercises for the quadriceps.1, 2, 3

 

Outcomes:

With the goal of the treatment being to improve a quadriceps contraction, Maximum voluntary isometric contraction (MVIC) of the quadriceps will be measured bilaterally. The MVIC will be performed with the knee stabilized at 60˚ in an electromechanical dynamometer.3 The doublet interpolation technique will be used to measure voluntary muscle activation of the involved quadriceps. The TUG test, Stair-Climbing Test (SCT) and 6MW test will be used to provide functional outcome measures. Special attention will be paid to the SCT and 6MWT for their strong representation of post-operative quadriceps strength and functional performance.1 These measures and assessments will be performed at the initial evaluation and 1, 3, and 6 weeks after the start of treatment. The 36-Item Short-Form Health Survey questionnaire and WOMAC will be administered at initial evaluation, 3 weeks and 6 weeks to determine improvements in health-related quality of life and self-perceived level of disability.3

 

References:

 

1. Kittelson AJ, Stackhouse SK, Stevens-Lapsley JE. Neuromuscular electrical stimulation after total joint arthroplasty: a critical review of recent controlled studies. Eur J Phys Rehabil Med. 2013;49(6):909-20.

2. Lewek M, Stevens J, Snyder-Mackler L. The use of electrical stimulation to increase quadriceps femoris muscle force in an elderly patient following a total knee arthroplasty. Phys. Ther. 2001;81(9):1565-71.

3. Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trail. Phys. Ther. 2012;92(2):210-26.