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Documenti di Professioni
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CLINICAL COMMENTARY
muscle impairments are not well dened and are an understudied area of
postoperative care.1 Of particular interest to rehabilitation professionals is the
acute profound postoperative decit in
quadriceps muscle strength5,42,52,55,67,70,79,85
TIODEFI?I0 The number of total knee arthroplasty (TKA) surgeries performed each year is predicted to steadily increase. Following TKA surgery,
self-reported pain and function improve, though
individuals are often plagued with quadriceps
muscle impairments and functional limitations.
Postoperative rehabilitation approaches either are
not incorporated or incompletely address the muscular and functional decits that persist following
surgery. While the reason for quadriceps weakness
is not well understood in this patient population, it
has been suggested that a combination of muscle
atrophy and neuromuscular activation decits contribute to residual strength impairments. Failure
to adequately address the chronic muscle impairments has the potential to limit the long-term functional gains that may be possible following TKA.
1
Clinical Faculty (Instructor), Department of Physical Therapy, University of Utah, Salt Lake City, UT; Physical Therapist, Department of Orthopedics, University of Utah, Salt Lake
City, UT. 2 Assistant Professor, Department of Physical Therapy, Eastern Washington University, Cheney, WA. 3 Associate Professor (Clinical), Department of Physical Therapy,
University of Utah, Salt Lake City, UT; Physical Therapist, Department of Orthopedics, University of Utah, Salt Lake City, UT. 4 Associate Professor, Department of Orthopedics,
University of Utah, Salt Lake City, UT. 5 Associate Professor, Department of Physical Therapy, University of Utah, Salt Lake City, UT; Adjunct Associate Professor, Department
of Exercise and Sport Sciences, University of Utah, Salt Lake City, UT; Adjunct Associate Professor, Department of Orthopedics, University of Utah, Salt Lake City, UT. Address
correspondence to Dr Paul C. LaStayo, Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108. E-mail: paul.lastayo@health.utah.edu
246 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
J78B;'
H[\[h[dY[
5
Berman (n = 68)
C[Wd7][
63
J_c[
Preoperative
J[ijCeZ[
?dlebl[ZDc
Kd_dlebl[ZDc
Isokinetic 60/s
35.5
59.9
41
39.1
67.0
42
3-6 mo postoperative
Lorentzen42 (n = 60)
74
Preoperative
Isokinetic 30/s
3 mo postoperative
6 mo postoperative
Rodgers (n = 20)
68
79.0
15
29
3 mo postoperative
39.0
52.0
25
6 mo postoperative
42.0
53.0
21
Preoperative
Isokinetic 60/s
Preoperative
Isometric 75
3 mo postoperative
6 mo postoperative
Mizner52 (n = 40)
64
15
29
52.0
3 mo postoperative
74
67.0
78.0
67.0
Isokinetic 120/s
1.5 mo postoperative
Lorentzen42 (n = 60)
57.0
55.0
37.0
Preoperative
67
:_[h[dY[
74.6
102.4
27
56.9
101.7
44
29
73.9
103.4
66.0
87.0
24
55.0
92.0
40
29
65.0
92.0
183.7
225.6
19
1 mo postoperative
70.7
222.8
68
2 mo postoperative
95.7
228.1
58
3 mo postoperative
148.8
231.7
36
6 mo postoperative
179.9
228.9
21
Preoperative
Isometric 75
GK7:H?9;FIM;7AD;II
<EBBEM?D=JA7
journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2008 | 247
J78B;(
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:_[h[dY[
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Berman5,
CLINICAL COMMENTARY
7-12 mo
50.5
71.0
29
13-23 mo
Isokinetic, 60/s
55.9
69.2
13
l24 mo
57.0
68.2
Huang29,
6-13 y
Isokinetic, 120/s
48.4
Isokinetic, 180/s
36.3
Walsh85,
1.7 y
Isokinetic, 90/s
57.0
64.5
Isokinetic, 120/s
54.5
63.0
Silva72,??
2.8 y
94.7
Berth6,
Preoperative
66.3
81.9
84.8
79.4
Postoperative (2.8 y)
16
60.7
20
49.9
27
88.0
12
35
82.0
13
34
136.8
31
105.0
19
37
19
GkWZh_Y[fiCkiYb[7Yj_lWj_ed
<W_bkh[<ebbem_d]JA7
Quadriceps muscle weakness in patients
with OA of the knee is attributed in part
to failure of voluntary muscle activation
(ie, muscle inhibition).79 The failure of
voluntary activation of skeletal muscle
is dened as the inability to produce all
available force of a muscle despite maximal voluntary effort.36,75,76 There are 2
common techniques for equating failure of voluntary activation: twitch interpolation and burst superimposition.
The twitch interpolation procedure is
performed by superimposing a single or
multiple pulses on various intensities of
muscle contractions from 0% (resting)
to 100% maximal voluntary contraction
(MVC). Failure of voluntary activation is
computed as 1 (superimposed twitch
at MVC/superimposed twitch at rest). A
burst superimposition technique is more
commonly used to determine the levels
of voluntary activation54,57,78 by super-
248 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
TABLE 2
CLINICAL COMMENTARY
Reference
Time
Berman5,
7-12 mo
Test Mode
Isokinetic, 60/s
TKA (Nm)
Uninvolved (Nm)
Healthy (Nm)
Difference
Difference
Uninvolved (%)
Healthy (%)
50.5
71.0
29
13-23 mo
55.9
69.2
13
l24 mo
57.0
68.2
Huang29,
6-13 y
Isokinetic, 120/s
48.4
Isokinetic, 180/s
36.3
Walsh85,
1.7 y
Isokinetic, 90/s
57.0
64.5
Isokinetic, 120/s
54.5
63.0
Silva72,??
2.8 y
94.7
Berth6,
Preoperative
66.3
81.9
84.8
79.4
Postoperative (2.8 y)
16
60.7
20
49.9
27
88.0
12
35
82.0
13
34
136.8
31
105.0
19
37
19
248 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
MVIC + E
MVIC
Force (N)
300
CAR =
250
MVIC
212 N
= 0.86
=
MVIC + E 246 N
200
150
100
1
Time (s)
GkWZh_Y[fi7jhef^o<ebbem_d]WJA7
Sarcopenia, the progressive loss of muscle mass with aging, is a fundamental
contributor to disability in the elderly
population.83 The quadriceps muscle activation failure present in patients with OA
may be contributing to muscle atrophy,
as neuromuscular inhibition prevents full
muscle activation and potentially blunts
the stimulus necessary to maintain muscle
mass.31 Clinicians sense both activation
failure and atrophy occur in those with
TKA, though there are very few reports
which have assessed muscle size changes
prior to or following TKA. Quadriceps atrophy of 5% to 20% has been reported in
the rst month after surgery compared to
preoperative values.54,62,67 A recent report
journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2005 | 249
CLINICAL COMMENTARY
tion in their physical function 1 year after surgery.13 Functional outcome scores
reported via questionnaires indicate an
improvement in quality of life following
surgery, but actual physical performance
measures and the individuals perception
of functional ability remain worse than
the age-matched healthy population.18,59
Individuals 1 year after a TKA surgery
perceived their functional ability to be
approximately 80% of a group of similar age. In another self-report study only
50% of the TKA recipients considered
their knee function normal compared
to their healthy peers.59 Likewise, quadriceps weakness does not correlate well
with patient perceptions of function.52
Self-report scores of physical function
in this population tend to correspond
to what patients experience (like pain
or perceived exertion) when performing
activities, rather than their actual ability
to complete an activity.81,84 Improvement
in self-report physical function is often
most strongly associated with improvements in pain.81
While quadriceps weakness may have
a limited association with perceived
functional ability, it tends to have a
strong relationship with performance.52
Quadriceps weakness in older adults
has been associated with an increased
fall risk,73 decreased gait speed,5,37,55,60,85
and impaired stair-climbing ability.85
Like with other elderly patient cohorts,
strength is an important predictor of
functional abilities32,39 in patients who
have TKA.53 Once more, bodily pain
scores do not seem to limit functional
performance from 1 month to 6 months
after surgery.52 Even though knee range
of motion (ROM) is also considered to
be important in early phases of therapy
for enhancing functional performance,
there is little evidence that function is
related to knee ROM.50,52 Rehabilitation
following a TKA should still be directed
towards pain control and improving knee
ROM, but a focus on exercises to address
quadriceps muscle impairments appears
necessary to achieve the best functional
abilities.8,52,79
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Physical countermeasures have been successful in improving knee pain, strength,
and joint stability in those with knee
OA who were not yet planning to have
a TKA.11,12,20 For those who go on to a
TKA, preoperative quadriceps strength
is a strong predictor of functional performance 1 year after surgery.53 Furthermore,
individuals with more extensive signs of
OA have more quadriceps weakness.73 If
quadriceps weakness could be addressed
prior to TKA surgery, then perhaps patients might experience a better overall
functional level.
Unfortunately, there is little documented success in improving the preoperative status in those planning a
TKA.19,20,82 Physical therapy interventions prior to TKA have focused on
strengthening, aerobic conditioning,
and educational programs. DLima et
al14 compared the effects of preoperative upper and lower extremity strength
250 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
Feijef[hWj_l[?dj[hl[dj_edi
There is a dearth of available evidence for
determining the best possible postoperative rehabilitation intervention, though
a limited number of reports suggest that
improvements in ROM and strength, a
lowered pain level, and improvements
in independence with activities of daily
living have resulted from such interventions. The authors of a recent randomized controlled trial comparing a
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Start of therapy
1 d postoperative
3.5 wk postoperative
8 wk postoperative
Frequency
2 times/d
3 times/wk
1-2 times/wk
16 (8 d)
18 (6 wk)
12 (8 wk)
NMES*
Yes (6 wk)
Yes*
No
Bike
5-10 min
10-15 min
5-20 min
Core exercises
Quadriceps sets
Hamstring sets
Straight-leg raise
X
X
Hip abduction
Step-ups/-downs
AROM/AAROM
Lunges
Walking
Nonweight-bearing ROM
X
X
Ankle pumps
Sit-to-stand
Abbreviations: AAROM, active assistive range of motion; AROM, active range of motion; NMES, neuromuscular electrical stimulation; ROM, range of motion; TKA, total knee arthroplasty.
* NMES parameters: 2500-Hz triangular-wave alternating current (AC), 12-s on-time, 80-s off-time,
2- to 3-s ramp-up time, knee exed to 60, 10 isometric contractions, dose set to maximally tolerated
by the patient, large (7.6 12.7 cm) self-adhesive electrodes placed on motor points of the quadriceps
femoris muscle.
journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2005 | 251
CLINICAL COMMENTARY
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Square dancing
Bicycling (stationary)
Walking
Bowling
Golf
Croquet
Horseshoes
Ballroom dancing
Shooting
Jazz dancing
Shuffleboard
Swimming
Horseback riding
7Yj_l_j_[iH[Yecc[dZ[ZM_j^Fh[l_eki;nf[h_[dY[
Bicycling (road)
Canoeing
Skiing (stationary)
Hiking
Tennis (doubles)
Rowing
Weight machines
Speed walking
7Yj_l_j_[iDejH[Yecc[dZ[Z
Racquetball
Football
Squash
Gymnastics
Rock climbing
Lacrosse
Soccer
Hockey
Singles tennis
Basketball
Volleyball
Jogging
Handball
De9edYbki_ed
Fencing
Downhill skiing
Weight lifting
252 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
IKCC7HO
.$
/$
'&$
''$
'($
')$
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'$ NIH Consensus Statement on total knee replacement December 8-10, 2003. J Bone Joint
Surg Am. 2004;86-A:1328-1335.
($ American Academy of Orthopaedic Surgeons.
Arthroplasty and Total Joint Replacement Procedures: 2003. Available at: http//www.aaos.
org/wordhtml/research/stats/arthroplasty_recent.htm. Accessed 2003.
)$ Avramidis K, Strike PW, Taylor PN, Swain ID. Effectiveness of electric stimulation of the vastus
medialis muscle in the rehabilitation of patients
after total knee arthroplasty. Arch Phys Med
Rehabil. 2003;84:1850-1853.
*$ Beaupre LA, Lier D, Davies DM, Johnston DB.
The effect of a preoperative exercise and education program on functional recovery, health
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Rheumatol. 2004;31:1166-1173.
+$ Berman AT, Bosacco SJ, Israelite C. Evaluation
of total knee arthroplasty using isokinetic testing. Clin Orthop Relat Res. 1991;106-113.
,$ Berth A, Urbach D, Awiszus F. Improvement of
voluntary quadriceps muscle activation after
total knee arthroplasty. Arch Phys Med Rehabil.
2002;83:1432-1436.
-$ Berth A, Urbach D, Neumann W, Awiszus F.
'*$
'+$
',$
'-$
'.$
'/$
(&$
('$
Strength and voluntary activation of quadriceps femoris muscle in total knee arthroplasty
with midvastus and subvastus approaches.
J Arthroplasty. 2007;22:83-88. http://dx.doi.
org/10.1016/j.arth.2006.02.161
Brander VA, Mullarkey CF, Stulberg SD. Rehabilitation After Total Joint Replacement for
Osteoarthritis: An Evidence-Based Approach.
Philadelphia, PA: Hanley & Belfus, Inc; 2001.
Brandt KD, Heilman DK, Slemenda C, et al. A
comparison of lower extremity muscle strength,
obesity, and depression scores in elderly
subjects with knee pain with and without radiographic evidence of knee osteoarthritis. J
Rheumatol. 2000;27:1937-1946.
Chmielewski TL, Stackhouse S, Axe MJ, SnyderMackler L. A prospective analysis of incidence
and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete
acute anterior cruciate ligament rupture. J
Orthop Res. 2004;22:925-930. http://dx.doi.
org/10.1016/j.orthres.2004.01.007
Deyle GD, Allison SC, Matekel RL, et al. Physical
therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of
supervised clinical exercise and manual therapy
procedures versus a home exercise program.
Phys Ther. 2005;85:1301-1317.
Deyle GD, Henderson NE, Matekel RL, Ryder
MG, Garber MB, Allison SC. Effectiveness
of manual physical therapy and exercise in
osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000;132:173-181.
Dickstein R, Heffes Y, Shabtai EI, Markowitz E.
Total knee arthroplasty in the elderly: patients
self-appraisal 6 and 12 months postoperatively.
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DLima DD, Colwell CW, Jr., Morris BA, Hardwick
ME, Kozin F. The effect of preoperative exercise
on total knee replacement outcomes. Clin Orthop Relat Res. 1996;174-182.
Ettinger WH, Jr., Afable RF. Physical disability
from knee osteoarthritis: the role of exercise
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1994;26:1435-1440.
Evans WJ. Exercise training guidelines for the
elderly. Med Sci Sports Exerc. 1999;31:12-17.
Ferri A, Scaglioni G, Pousson M, Capodaglio P,
Van Hoecke J, Narici MV. Strength and power
changes of the human plantar exors and knee
extensors in response to resistance training in
old age. Acta Physiol Scand. 2003;177:69-78.
Finch E, Walsh M, Thomas SG, Woodhouse LJ.
Functional ability perceived by individuals following total knee arthroplasty compared to agematched individuals without knee disability. J
Orthop Sport Phys Ther. 1998;27:255-263.
Fitzgerald GK. Therapeutic exercise for
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Fitzgerald GK, Oatis C. Role of physical therapy
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Fitzgerald JD, Orav EJ, Lee TH, et al. Patient
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[
(($
()$
(*$
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(-$
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)($
))$
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CLINICAL COMMENTARY
http://dx.doi.org/10.1002/art.21465
)+$ Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The
functional outcomes of total knee arthroplasty.
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http://dx.doi.org/10.2106/JBJS.D.02714
),$ Kent-Braun JA, Le Blanc R. Quantitation of
central activation failure during maximal voluntary contractions in humans. Muscle Nerve.
1996;19:861-869. http://dx.doi.org/10.1002/
(SICI)1097-4598(199607)19:7<861::AIDMUS8>3.0.CO;2-7
)-$ Kroll MA, Otis JC, Sculco TP, et al. The relationship of stride characteristics to pain before and
after total knee arthroplasty. Clin Orthop Relat
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).$ Kuster MS. Exercise recommendations after
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literature and proposal of scientically based
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)/$ Landers KA, Hunter GR, Wetzstein CJ, Bamman
MM, Weinsier RL. The interrelationship among
muscle mass, strength, and the ability to perform physical tasks of daily living in younger
and older women. J Gerontol A Biol Sci Med
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*&$ 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;81:1565-1571.
*'$ Ling SM, Xue QL, Simonsick EM, et al. Transitions to mobility difficulty associated with lower
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art.21858
*($ Lorentzen JS, Petersen MM, Brot C, Madsen
OR. Early changes in muscle strength after total
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*)$ Mahomed NN, Liang MH, Cook EF, et al. The
importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol. 2002;29:1273-1279.
**$ Manal TJ, Snyder-Mackler L. Failure of voluntary
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*+$ March LM, Cross MJ, Lapsley H, et al. Outcomes after hip or knee replacement surgery
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*,$ Martin SD, Scott RD, Thornhill TS. Current
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*/$ Miller M, Flansbjer UB, Downham D, Lexell J.
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+&$ Miner AL, Lingard EA, Wright EA, Sledge CB,
Katz JN. Knee range of motion after total
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arth.2003.50046
+'$ Mintken PE, Carpenter KJ, Eckhoff D, Kohrt
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+($ Mizner RL, Petterson SC, Snyder-Mackler
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of functional recovery after total knee
arthroplasty. J Orthop Sports Phys Ther.
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+)$ Mizner RL, Petterson SC, Stevens JE, Axe MJ,
Snyder-Mackler L. Preoperative quadriceps
strength predicts functional ability one year
after total knee arthroplasty. J Rheumatol.
2005;32:1533-1539.
+*$ Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler L. Early quadriceps
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of voluntary muscle activation. J Bone Joint
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org/10.2106/JBJS.D.01992
++$ Mizner RL, Snyder-Mackler L. Altered loading
during walking and sit-to-stand is affected
by quadriceps weakness after total knee arthroplasty. J Orthop Res. 2005;23:1083-1090.
http://dx.doi.org/10.1016/j.orthres.2005.01.021
+,$ Mizner RL, Snyder-Mackler L. Patients perceptions do not match functional performance or
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Conditt MA, Mathis KB. Does total knee replacement restore normal knee function? Clin
Orthop Relat Res. 2005;157-165.
,&$ Ouellet D, Moffet H. Locomotor decits before
and two months after knee arthroplasty. Ar-
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Goals:
1. Increase range of motion (ROM)
2. Decrease edema and pain
3. Gait training
4. Independence with activities of daily living (ADLs)
Exercises:
1. Seated or supine knee active range of motion (AROM)
2. Alternated ankle dorsiexion and plantar exion
3. Quadriceps sets
4. Straight-leg raise
5. Hamstring sets
6. Standing leg curls
7. Seated knee extension
8. Supported single standing for balance
9. Repeated sit-to-stand transfer training
10. Ambulating with appropriate assistive device
Modalities:
1. Ice 2-3 times per d, with lower extremity elevated for 20-30 min
journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2008 | 255
CLINICAL COMMENTARY
7FF;D:?N9EDJ?DK;:
Exercise progression:
a. Exercises are to be progressed once the patient can complete 3 sets of 10
reps of the exercise correctly and feels maximally fatigued
b. Add 0.2- to 1.5-kg weights to the exercises
c. Increase step height if showing good concentric/eccentric control
d. Increase wall slides to 60 and to 90
F^Wi[???0I[c_#_dZ[f[dZ[djf^Wi['j_c[f[hmaehX_m[[abo"*#,m[[ai
Exercises:
1. Continue all exercises in phase I as a home exercise program or a gym
membership
256 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy