Rev. bras. ortop. vol.49 número6

w w w . r b o . o r g . b r

Original

Article

Proprioceptive

deficit

in

individuals

with

unilateral

tearing

of

the

anterior

cruciate

ligament

after

active

evaluation

of

the

sense

of

joint

position

夽

,

夽夽

Victor

Cossich

_,

_Frédéric

_Mallrich

,

Victor

Titonelli

,

Eduardo

Branco

de

Sousa

,

Bruna

Velasques

,

José

Inácio

Salles

a_{NeuromuscularResearchLaboratory,NationalInstituteofTraumatologyandOrthopedics(INTO),RiodeJaneiro,RJ,Brazil}

b_{DepartmentofBiosciences,SchoolofPhysicalEducationandSports(EEFD),FederalUniversityofRiodeJaneiro(UFRJ),RiodeJaneiro,}

RJ,Brazil

c_{NeurophysiologyandAttentionNeuropsychologyLaboratory,InstituteofPsychiatry,FederalUniversityofRiodeJaneiro(IPUB/UFRJ),}

RiodeJaneiro,RJ,Brazil

d_{InstituteofAppliedNeurosciences(INA),RiodeJaneiro,RJ,Brazil}

e_{BrazilianVolleyballConfederation(BV),RiodeJaneiro,RJ,Brazil}

a

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t

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n

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o

Articlehistory: Received12June2013 Accepted30July2013

Availableonline27October2014

Keywords:

Anteriorcruciateligament Somatosensorysystem Knee

a

b

s

t

r

a

c

t

Objective:Toascertainwhethertheproprioceptivedeficitinthesenseofjointposition con-tinues tobepresentwhenpatientswithalimbpresentingadeficientanteriorcruciate ligament(ACL)areassessedbytestingtheiractivereproductionofjointposition,in com-parisonwiththecontralaterallimb.

Methods:TwentypatientswithunilateralACLtearingparticipatedinthestudy.Theiractive reproductionofjointpositioninthelimbwiththedeficientACLandinthehealthy con-tralaterallimbwastested.Meta-positionsof20%and50%ofthemaximumjointrangeof motionwereused.Proprioceptiveperformancewasdeterminedthroughthevaluesofthe absoluteerror,variableerrorandconstanterror.

Results:Significantdifferencesinabsoluteerrorwerefoundatbothofthepositions evalu-ated,andinconstanterrorat50%ofthemaximumjointrangeofmotion.

Conclusion: Whenevaluated intermsofabsoluteerror,theproprioceptivedeficit contin-uestobepresentevenwhenanactiveevaluationofthesenseofjointpositionismade. Consequently,thissenseinvolvesactivityofbothintramuscularandtendonreceptors.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

Pleasecitethisarticleas:CossichV,MallrichF,TitonelliV,deSousaEB,VelasquesB,SallesJI.Déficitproprioceptivoemindivíduoscom rupturaunilateraldoligamentocruzadoanteriorapósaavaliac¸ãoativadosensodeposic¸ãoarticular.RevBrasOrtop.2014;49:607–612. 夽夽

WorkdevelopedinNeuromuscularResearchLaboratory,NationalInstituteofTraumatologyandOrthopedics(INTO),RiodeJaneiro, RJ,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](B.Velasques).

http://dx.doi.org/10.1016/j.rboe.2013.07.003

Déficit

proprioceptivo

em

indivíduos

com

ruptura

unilateral

do

ligamento

cruzado

anterior

após

a

avaliac¸ão

ativa

do

senso

de

posic¸ão

articular

Palavras-chave: LCA

Sistemasomatossensorial Joelho

r

e

s

u

m

o

Objetivo: VerificarseodéficitproprioceptivonoSPApermanecequandopacientescomum membroLCAdeficientesãoavaliadospormeiodotestedereproduc¸ãoativadaposic¸ão articular,emcomparac¸ãocomomembrocontralateral.

Métodos: Participaramdoestudo20pacientescomrupturaunilateraldoLCA.Foifeitoo testedereproduc¸ãoativadaposic¸ãoarticularnomembroLCAdeficienteecontralateral saudável.Foramusadasasposic¸õesmetade20%e50%daamplitudearticularmáxima. Odesempenhoproprioceptivofoideterminadopormeiodosvaloresdeerroabsoluto(EA), errovariável(EV)eerroconstante(EC).

Resultados: Diferenc¸assignificativasforamencontradasparaoEAemambasasposic¸ões avaliadaseparaoECem50%AAM.

Conclusão: OdéficitproprioceptivoquandoavaliadopeloEApermanecemesmoquandoa avaliac¸ãodosensodeposic¸ãoarticularéativae,consequentemente,envolveaatividadede receptoresintramuscularesetendíneos.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Appropriatekinematicsforthekneedependonthe mechan-icalstability of the joint that is providedby its static and dynamiccomponents.1,2 _{Theligaments furnishstatic}

stabi-lization and their main function isto enable normaljoint kinematicsandpreventabnormalandrotationalmovements thatcoulddamagethejointsurfaces,2_whiledynamic

stabi-lizationisgivenbycoordinatedmusclecontraction activity modulated by the neuromuscular system.3,4 _{This system}

requiresproprioceptiveinformationfromthejoint kinesthe-sia and position5–7 _{and from the force developed by the}

muscles.8–10

Thisinformationis obtainedthrough acquiringafferent signals from the peripheral mechanical receptors that are foundinthemuscles,tendons,ligaments,jointcapsulesand skin.11_{Mechanicalreceptorshavealsobeenidentifiedinthe}

anteriorcruciateligament(ACL)12_{anditisbelievedthatthese}

contributetowardproprioceptionofthejoint.13,14_Thus,

tear-ingoftheACLwouldleadtojointinstabilitynotonlybecause oftheimpairmentduetothemechanicalrestrictionbutalso becauseproprioceptionisdisturbed14,15 _{andthecapacityof}

themusclesactingonthekneetorespondadequatelytothe loadsappliedisdiminished.15,16

Proprioceptive deficits have been observed in patients with ACL tearing and have been correlated with reduced functionalcapacity.7,17_{Thesedeficitshavebeenidentifiedin}

relationtothepassivemovementdetectionthreshold(PMDT) and joint positionsense (JPS),in comparison with normal individuals18,19 _{and withthehealthy contralaterallimb.}19,20

Assessmentsof PMDT and passive JPShave been adopted preferentiallyforuseinstudies.18,21,22_{Thispracticeisbased}

on the assumption that the low angular velocities used wouldspecificallystimulatethereceptorsofthecapsuleand ligament structures without stimulating the intramuscular andtendonreceptors.In theseprocedures,the individuals’

voluntary muscle activity is not involved. However, under normal conditions ofhumanmovement, voluntarymuscle activityisalwayspresent.

There islittle evidenceto demonstratethat propriocep-tivedeficits,inthe wayinwhichthey areassessed, would adverselyaffect patientswithinsufficiencyoftheACL ora surgicallyreconstructedACL.22_{Thus,proceduresthatinvolve}

voluntary muscle action and consequently stimulation of the muscle-tendon receptors should receive greater atten-tion inevaluationson proprioception.JPSassessmentwith active positioning and reproduction may be an option for investigating proprioceptive capacity in a more functional manner. Thus,thepresent studyhad theaimof ascertain-ingwhethertheproprioceptivedeficitregardingJPScontinues whenpatientswithadeficientACLareevaluatedbymeansof atestonactivereproductionofjointposition,incomparison withthehealthycontralaterallimb.

Materials

and

methods

Subjects

Table1–Clinicalexaminations.

Lachmanandanteriordrawer

− +/+++ ++/+++ +++/+++

Lachman 5 13 2 0

Anteriordrawer 0 7 13 0

McMurrayandpivot

− +

Bocejo 1 19

Pivot 12 8

sameorthopedist(Table1).Thisstudywasapprovedbythe localethicscommitteeandthesubjectswereinformedabout theobjectivesand proceduresthroughafreeandinformed consentstatement,inaccordancewithResolution196/96of theNationalHealthCouncil.

Assessmentofjointpositionsense

Instrument

Anisokineticdynamometer(CSMI,HumacNorm)wasusedin alltheprocedures.

Positioning

Thesubjectswerepositionedseated,withthelateralcondyle ofthefemuralignedwiththeaxisofrotationoftheapparatus andtheanklefixedtoanaccessoryrodforkneeevaluation,by meansofaVelcrostrip(Fig.1).Carewastakentopositionthe poplitealfossaawayfromthelimitoftheseat,soastoenable completejointmovementandminimizeskinstimulationin thisregion.Theprecisionoftheanglemeasurementswas1◦_.

Maximumjointamplitude

TheMJAoftheflexion–extensionmovementwasdetermined bymeasuringtheamplitudebetweenthemaximumextension (0◦_{)andthemaximumflexionoftheknee.}

Jointpositionreproductiontest

Thesubjectswererequiredtoexperienceandthenreproduce jointpositions,inbothcasesthroughvoluntarymovements. Thecommandsforcarryingoutthetaskwereissuedverbally bytheevaluatorandthedirectionofmovementwasfrom flex-iontoextension.Twotargetpositionstobeexperiencedwere used:20%and50%oftheMJA(0%=maximumextension).Both limbswereevaluatedandtheorderofassessmentwas cho-senrandomly.Throughouttheprocedure,thepatientswere blindfolded.Variationsof±5◦_{aroundthetargetpositionwere} allowed.Whenthesubjectviolatedthismargin,theattempt wasdiscarded.Fiveattemptsineachtargetpositionwere per-formed(10intotal).

Determinationoftheindividualerrorandcalculationof theproprioceptiveacuity

The individual error value for each attempt made was determined through the difference between the position reproducedandthepositionexperienced.Theproprioceptive performancewasdeterminedbymeansofthevaluesofthe absoluteerror(AE),variableerror(VE)andconstanterror(CE).

Fig.1–Subjectpositionedintheisokineticdynamometer toperformthejointpositionreproductiontest(sensingof position).

SchmidtandLee23_{describedthecalculationofeachvariable}

indetail.Briefly,theAEisobtainedthroughthearithmetic meanoftheindividualerrorsinthemodulusanddetermines theindividual’saccuracyinreproducingtheposition;theVE isthestandarddeviationoftheindividualerrorsand deter-minestheconsistencyofthereproductionsmade;andtheCE isthearithmeticmeanoftheindividualerrorswiththeirsigns anddeterminesthetendencyforthepositiontobereproduced aboveorbelowthetarget(bias).

Statistical

analysis

Subjects

−16−14−12−10 −8 −6 −4 −2 0 2 4 6 8 10 12 14 16 0

2 4 6 8 10 12 14 16 18 20

Individual error (°)

Fig.2–Distributionoftheindividualerrorsinthejoint positionreproductiontest:20%MJA.Blackcirclesreferto thelimbwiththedeficientACLandwhitecirclestothe controllimb.Thecontinuouslinerepresentsthetarget positiongraphically.

Results

Timeofinjury,causeofinjuryandassociatedlesions

The mean time that elapsed until the data-gathering was 3.7±1.2years.Theinjuriesmostlyoccurredduetosprainsin situationsofday-to-daylife(45%),injuriesnotinvolving con-tactinrecreationalsoccer(35%),falls(15%)andcaraccidents (5%).Associatedlesionswereseen in14 patients:13inthe medialmeniscusandonlyoneinthelateralmeniscus.

MJA,20%MJA,50%MJAandpositionsexperienced

Themaximum joint amplitude determined forthe ACL of theaffectedlimbwas105.3◦_±11.8◦_{andforthecontrollimb,} 111.2◦_±10.2◦_{.ThetargetpositionscalculatedfortheACLat} 20%and 50%MJA were 21.1◦_±2.4◦ _and52.6◦_±5.9◦_, respec-tively.Thetargetpositionedcalculatedforthecontrolat20% and50% MJAwere 22.2◦

±2.0◦ _and55.6◦

±5.1◦_{,respectively.} Thepositionsexperiencedthatwereusedinthejointposition reproductiontestwere0.3◦_±3.8◦_and50.5◦_±7.2◦_fortheACL oftheaffectedlimb,whilethesepositionsinthecontrolwere 21.1◦

±3.0◦_and52.4◦

±5.9◦_.

Individualerrors

Thevaluesdeterminedfortheindividualerrorsare demon-stratedgraphicallyinFigs.2and3.

AE,VEandCE

ThevaluesdeterminedforAE,VEandCEarelistedinTable2. ThelimbwiththeaffectedACLgenerallydemonstratedhigher values(worsevalues).Significantdifferences werefoundin relationtotheAEinboththepositionsevaluatedandin rela-tiontoCEat50%MJA.

Individual error (°)

Subjects

−16−14−12−10 −8 −6 −4 −2 0 2 4 6 8 10 12 14 16 0

2 4 6 8 10 12 14 16 18 20

Fig.3–Distributionoftheindividualerrorsinthejoint positionreproductiontest:50%MJA.Blackcirclesreferto thelimbwiththedeficientACLandwhitecirclestothe controllimb.Thecontinuouslinerepresentsthetarget positiongraphically.

Discussion

Theligamentshavethefunctionofmechanicallyrestricting jointamplitudeandlimitingmovementbymeansofastable arc.1,2_{Inaddition,theysupplyproprioceptiveinformation}24,25

and enabledynamicstabilizationofthejointmodulatedby the neuromuscularsystem.3,4 _{If thissystem iscomplete,it}

allowsappropriatereflexmotorresponsesanddiminishesthe possibility ofoccurrenceofabnormaljointmovements and subluxation.2,16,26

Patients with ACL injuries present proprioceptive deficits18,20 _{and it has been proposed that these deficits}

are responsibleforthefeelingsoffunctionalinstabilityand the falls reported by patients with anterior instability of the knee.27 _{Proprioception ofthe knee has been evaluated}

through passive tests6,28 _{in which the subjects’ voluntary}

muscle action has not been present. The equipment gen-erates passive movement through low angular velocities (approximately0.5◦_{/s)withtheaimofselectivelyevaluating} the capsule and ligament receptors.29 _{Stimulation of the}

intramuscular and tendon receptors occurs continuously duringvoluntarymotoractivities.Therefore,itisimportant

Table2–AE,VEandCEdeterminedfor20%and50% MJA(mean±SD).

AE VE CE

20%MJA

DeficientACL 4.3◦_±2.0◦a _3.2◦_±2.0◦ _−2.2◦_±3.3◦ Control 2.9◦_±1.3◦ _3.0◦_±1.4◦ _−0.6◦_±1.5◦

50%MJA

DeficientACL 4.2◦_±2.1◦a _2.8◦_±1.1◦ _−3.3◦_±3.1◦a

Control 3.5◦_±1.3◦ _2.8◦_±1.0◦ _−1.6◦_±2.8◦

toascertainwhetherdeficitsinjointpositionsensecontinue tobepresentwhenanactivemethodfortestingJPSisused.

Inthisstudy,weevaluatedJPSinpatientswithunilateral ACLinjuriesbyusinganisokineticdynamometerwithactive measurementsat20%and50%ofthemaximumjoint ampli-tude.Itwas decidedtouse percentages ofMJA,instead of absolutevalues, inorder to beable tomake relative com-parisonsbetweenthesubjects.30_{Significantdifferenceswere}

foundatboththepositions,usingAEfortheevaluation,and thisdemonstratesthatlimbswithadeficientACLhavelower accuracyinreproducingjointpositions,incomparisonwith thehealthycontralaterallimb.Carteretal.20_{evaluatedJPSin}

50patients withunilateralACLinjuriesusinganisokinetic dynamometerandfoundsignificantlydifferentAEbetween theinjured and controllimbs(9.42◦_±3.14◦ _and7.1◦_±2.32◦_, respectively),therebycorroboratingtheresultsofLeeetal.19

Nosignificantdifferences relatingtoVE were identified, whichdemonstratesthattheindividualspresentedthesame consistenciesinreproducingjointpositions,independentof theinjury.TheCEdeterminedforboththelimbwiththe defi-cient ACL and the healthy contralateral limb had negative values(repositioning ofthelimbbelowthetargetposition). Thisbehaviorhasalsobeenidentifiedbyourgroupin indi-vidualswhowerefreefromorthopedicinjuries(unpublished data).Inthepresentstudy,onlytheCEof50%MJAreacheda statisticaldifference.However,fromthemethodsapplied,it wasnotpossibletoobtainaphysiologicalresponseforthis behavior.VE and CEvaluesare notcommonly usedinthe literature,whichimpedescomparisonoftheresults.

Conclusion

Whentheproprioceptivedeficitisevaluatedbymeansofthe AE,itcontinuesevenwhentheassessmentofjointposition sense is active. Consequently, this involves activity of the intramuscularand tendonreceptors. Future studiesshould includecalculationofthevariableerrorandconstanterror,so astomakeitpossibletocomparetheresultsandthusexpand knowledgeofthebehaviorofthesevariables.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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