Licenciado sob uma Licença breative bommons
[s]
Neuromuscular electrical stimulation, exercises against
resistance, muscle strength, pain, and motor function
in patients with primary osteoarthritis of the knee
[h]Eletroestimulação neuromuscular, exercícios contra
resistência, força muscular, dor e função motora em
pacientes com osteoartrite primária de joelho
[A]
Thais Varanda Dadalto[a], Cintia Pereira de Souza[b], Elirez Bezerra da Silva[c]
[a] ohysiotherapist, lr in ohysical dducation from tniversidade fama eilho tfe , Rio de ianeiro, Ri - arazil, e-mail: tvdadalto@hotmail.com
[b] ohysiotherapist, lr student in ohysical dducation at tfe, bmoq scholarship holder, Rio de ianeiro, Ri - arazil, e-mail: centropilates@bol.com.br
[c] oh.c in ohysical dducation. boordinator of the undergraduate course in ohysical sherapy at tfe, professor at tfe, coordinator of the blinical Research froup ehs rchool, from tfe, Rio de ianeiro, Ri - arazil, e-mail: elirezsilva@ugf.br
[R]
Abstract
Introduction: jnee osteoarthritis is a degenerative process and its symptoms are mechanical pain and
pe-riods of inflammatory pain, joint stiffness, and muscle weakness. ht has no cure and the treatment objective is relieving signs and symptoms and, whenever possible, slowing down its evolution. luscle strengthening is indicated as treatment for osteoarthritis. Objective: bompare the effectiveness of neuromuscular electrical
stimulation and resistance against exercise in the gain of knee extensor strength, in pain reduction, and in the recovery of motor function in patients with primary knee osteoarthritis. Materials and methods: she
rese-arch had the participation of patients diagnosed with primary knee osteoarthritis, according to the clinical and radiological criteria of the American bollege of Rheumatology. shey were randomly allocated to a group of resistance against exercise n = , a group of neuromuscular electrical stimulation n = , and a control group n = , and they underwent characteristic procedures of their group times a week until completing sessions. jnee extensor strength, pain, and motor function were evaluated in a blind way. ve used the x lAmnuA test with repeated measurements, for p < . . Results: A significant difference p < . was
778
stimulation and for pain in the groups neuromuscular electrical stimulation and resistance against exercise.
Conclusion: she strengthening of knee extensor muscles may help reducing pain in patients with
osteoarthri-tis. meuromuscular electrical stimulation, when applied according to the protocol used in this study, may be an interesting therapy for treating knee osteoarthritis.
[o]
Keywords: Arthrosis. Russian current. puadriceps.
[a]
Resumo
Introdução: A osteoartrite (OA) do joelho é um processo degenerativo e os sintomas são dor mecânica e períodos de dor inflamatória, rigidez articular e fraqueza muscular. Ela não tem cura. O objetivo do tratamento é aliviar os sinais e sintomas e, quando possível, retardar sua evolução. O fortalecimento muscular é indicado como tratamento da OA. Objetivo: Comparar a eficácia da eletroestimulação neuromuscular (EENM) e de exercícios contrarresistên-cia (ECR) no ganho de força extensora de joelho, na diminuição da dor e na recuperação da função motora em paci-entes com OA primária do joelho. Materiais e métodos: Participaram da pesquisa 23 pacientes com diagnóstico de OA primária do joelho, segundo os critérios clínicos e radiológicos do American College of Rheumatology. Eles foram alocados aleatoriamente para um grupo de ECR (n = 9), um grupo de EENM (n = 8) e um grupo controle (n = 6), e foram submetidos aos procedimentos característicos de seu grupo três vezes por semana até completar 24 sessões. Foram avaliadas de forma cega a força extensora de joelho, a dor e a função motora. Foi utilizado o teste MANOVA 3 x 2 com medidas repetidas para P < 0,05. Resultados: Foi encontrada diferença significativa (P < 0.05) somente nas comparações intragrupos para força extensora de joelho no grupo EENM e para dor nos grupos EENM e ECR. Conclusão: O fortalecimento da musculatura extensora de joelho pode auxiliar na diminuição da dor de pacientes com OA. A EENM, quando aplicada de acordo com o protocolo utilizado neste estudo, pode ser uma terapia interes-sante para o tratamento da OA do joelho.
[j]
Palavras chave: Artrose. Corrente russa. Quadríceps.
Introduction
fonarthrosis, osteoarthritis, osteoarthrosis, or sim-ply knee arthrosis, is a degenerative process which may or may not be connected to inflammatory processes ; it occurs due to loss of the homeostasis of the functio-nal unit meniscus-cartilage-subchondral bone and has a progressive evolution with cartilage loss and, later, bone tissue loss. ht is classified according to etiology as primary, when the causative factor is unknown, or secondary, when it derives from inflammatory condi-tions or sequelae of meniscal and ligamentous lesions, fracture or infection, for instance .
vear of the joint cartilage is initially asymptoma-tic, progressing with the installation of bone lesions and inflammatory processes of the joint structures, when there is an acute worsening of symptoms, ho-wever, even in the asymptomatic phase changes in motor behavior may be observed .
jnee osteoarthritis jn is the leading cause of pain and functional disability in middle-aged women, this is the most affected population ; in the tnited
rtates, jn is the second leading cause of absenteeism, second only to ischemic heart diseases and its incidence is higher with increasing age .
rymptoms are mechanical pain, which is directly related to joint movement, and periods with inflam-matory pain that correspond to inflaminflam-matory out-breaks secondary to mechanical changes, a symptom influencing the fulfillment of functional activities ; joint stiffness, which progresses in proportion to cartilage loss and muscle weakness . she most common clinical signs are: crepitus, swelling of the joint, joint effusion , disuse muscle atro-phy, and deformities in varus, valgus, or flexion . nsteoarthritis has no cure and treatment serves to relieve the signs and symptoms and, whenever possible, slow down the progression and mus-cle strengthening is indicated as a treatment for jn in the arazilian bonsensus for the sreatment of nsteoarthritis and the nsteoathritis Research rociety hnternational nARrh , .
alternating current with a medium frequency of , gz, able to cause muscle contraction, being widely used for therapeutic purposes according to various indica-tions . rtudies have shown mldr as part of: the tre-atment for bladder dysfunctions in patients with multi-ple sclerosis , the rehabilitation of dysphagia , the treatment for chronic shoulder pain in hemiplegic patients , the treatment for chronic low back pain , and the postoperative rehabilitation of anterior cruciate ligament reconstruction . hts muscular responses have a central and peripheral origin, and its results with regard to muscle strengthening are main-tained even after the suspension of applications - . reveral studies have already tested the effectiveness of muscle strengthening in the treatment of the jn signs and symptoms using various protocols, among them mldr and resistance against exercise RAd - . hn a study carried out in , the researchers followed a group treated with RAd and another group treated with flexibility exercises for months; the group tre-ated with RAd showed greater strength in the end of treatment and a slower progression of disease .
gowever, the response of jn signs and symptoms to muscle strengthening is not clear, yet, since most studies have used muscle strengthening associated to other therapeutic ways.
shis study aimed to compare the effectiveness of mldr and RAd with regard to knee extensor strength gain, decreased pain, and recovery of motor function in patients diagnosed with primary jn.
Materials and methods
Design
she study was a controlled experiment, randomized and blind. oatients were randomly allocated to out of groups: mldr, undergoing neuromuscular electrical stimulation; RAd, performing exercise against resistan-ce; and control, which did not undergo any intervention. she female physiotherapist who applied the interven-tions did not evaluate knee extensor strength, pain, and motor function. cata evaluation and analysis were blind.
Sample
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₃₀ , .
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m g b . s
R d b tfe,
o / .
s e .
ve excluded from the study patients who were waiting for arthroplasty surgery, patients with se-condary arthrosis, patients without functional move-ment range, patients undergoing recent infiltration, patients with a history of recent trauma, and patients with a health status incompatible with the execution of RAd and mldr.
she patients were randomly allocated to groups: a RAd group, a mldr group, and a control group. eor random allocation, we used the function ex = hf RAmcnl < . ; ;hf RAmcnl < . ; ;hf RAmcnl < . ; of the sof-tware Microsoft Excel. she numbers were attributed to the patients according to their arrival. hf , the patient was allocated to the mldr group, if , the patient was allocated to the RAd group, and if , the patient was allocated to the control group.
oatients from the groups mldr and RAd un-derwent characteristic procedures of their respective group times a week until completing sessions. hn case of missing a session, patients attended ano-ther session. All patients underwent sessions. she patients who were allocated to the control group did not undergo any form of treatment for weeks and, after the nd evaluation, they participated in a group
undergoing treatment with RAd. Exercises against resistance
780
RAds for strengthening the quadriceps were perfor-med on a leg extension device with seated patient. jnee extensions were made complying with the following protocol: a heating phase with a series of repeti-tions without load and a phase of muscular strength training consisting of series from to maximum repetitions, adding kg whenever the patient reached replicates, with a -minute interval between series.
Neuromuscular electrical stimulation
shis group underwent mldr in quadriceps. ve used self-adhesive electrodes ualusrode x cm placed in pairs in the bellies of the rectus anterior muscle of the thigh, vastus lateralis, and vastus media-lis, an electrostimulator meurodyn, haRAldc with a medium frequency of , gz and a treatment fre-quency of gz, modulated at %, s/ s/ s/ s
in the time rise/on/decay/off, respectively, and the stimulus is used in the synchronized mode with ma-ximum intensity supported by the patient for mi-nutes. she patients underwent isometric contraction of the quadriceps associated to stimulation of mldr.
Knee extensor strength, pain, and motor function
All patients had their knee extensor strength, pain, and motor function measured before and after tre-atments by another researcher blind evaluation .
jnee extensor strength was measured by means of an isokinetic dynamometer bybex morm used to measure the torque peak of the quadriceps. oatients were tested in an open kinetic chain in the sitting po-sition with seat in the up popo-sition and replicates were asked at a speed of º degrees per second. shis protocol was applied twice with an interval of
Sought treatment for KO (n = 60)
Excluded
Randomized (n = 26)
NMES group (n = 10)
Did not complete treatment (n = 2)
Due to complaints of late muscle soreness (n = 1)
Did not inform the reason (n = 1)
Did not complete treatment (n = 0)
Completed treatment (n = 8)
Completed treatment (n = 9)
Completed treatment (n = 6) Did not complete treatment
(n = 1)
Due to blood pressure (n= 1)
RE group (n = 10) Control group (n = 6) Had no knee radiograph (n = 6)
Did not meet any of the inclusion criteria (n = 5)
Not found (n = 5)
Without availability of time (n = 2)
Refused to participate in the study (n = 3)
minutes between tests. she result of the first test was used only to calculate the typical measurement error and the second as a result of the study.
eor measuring pain and motor function, we used dimensions of the questionnaire vestern nntario and lclaster tniversities nsteoarthritis hndex vnlAb , before and after the treatment applied by another person instead of the one who performed the treatment blind evaluation . shis questionnaire has dimensions: pain, joint stiffness, and motor func-tion, and it shows a good reliability when undergoing test/retest . eor this study, we used the dimen-sions pain, with questions, and muscle function, with questions; each question is scored on a scale from to , according to the severity of symptoms.
Measurement error of knee extensor strength
ve calculated the measurement error for the same day and with the same evaluator using the typi-cal measurement error sld . eor this, patients’ muscle strength was measured twice consecutively in the same day, with a -minute interval.
she measurement error was equal to the second minus the first measurement. nver the measurement errors we applied the confidence limits proposed by aland & Altman, in order to eliminate the outlier errors . shen, sld was calculated through stan-dard deviation of the measurement errors divided by the square root of . she relative sld % was calculated by means of the ratio between absolute sld and the average muscle strength scores in the first and second measurements .
Data analysis
she same way as in the evaluations, data analysis was performed by another researcher blind analy-sis , instead of those who measured responses and applied treatments.
she assumption of a difference between the groups, with regard to knee extensor strength, pain, and motor function, was tested by means of a
x lAmnuA with repeated measures, the first factor consisted of the groups mldr, RAd, control and the second factor consisted of the pre- and post-treatment muscle strength, pain, and motor function.
she assumptions that homogeneity and sphericity Levene’s AmnuA test and the amount of subjects per group are over times greater than the amount of variables in the response were not confirmed so that a x lAmnuA was adopted, with repeated measurements. she freenhouse-feisser adjustment cannot be applied, because the amount of repeated measurements was lesser than . shen, we opted for a x AmnuA, with repeated measurements for each response.
she assumption of variance homogeneity required for using a x AmnuA with repeated measurements was confirmed only with regard to the variable knee extensor strength. sherefore, we opted for a x AmnuA, with repeated measurements followed by the aonferroni adjustment to avoid inflation in the error type h family-wise error rate , due to the multiple t-tests and simple AmnuA for the variables pain and motor function.
she error was . and error was . , with the statistical power of . . cata were analyzed with the rtatistic . package.
she size of the intra-group effect was calculated through post-treatment average minus pre-treat-ment average divided by pre-treatpre-treat-ment standard deviation .
she size of the inter-group effect was calculat-ed through post-treatment average of the experi-mental group minus post-treatment average of the control group divided by pre-treatment standard deviation .
Results
she descriptive results average ± standard de-viation of knee extensor strength, pain, and motor function before and after the -session program for mldr, RAd, and control are shown in sable .
she x AmnuA with repeated measurements showed e , = . ; o = . for the interaction between knee extensor strength and the groups and o = . intra-groups. she sukey test post hoc for unequal samples detected a o = . within the mldr group, o = . within the RAd group, and o = . within the control group fraph .
782
of the effect was . between the groups mldr and control and . between the groups RAd and control.
she absolute and relative sld obtained for knee extensor strength were m.m and %, respectively.
she x AmnuA with repeated measures sho-wed e , = . ; o = . for the interaction of pain with the groups. eor initial and final pain,
the aonferroni adjustment for a x AmnuA with repeated measurements showed o = . within the groups mldr and RAd; and o = . within the control group fraph .
she size of the pain effect within the mldr group was - . ; within the RAd group it was - . ; and within the control group it was - . . she size of the Tabela 1 – Knee extensor strength pain, and motor function before and after the 24-session program for neuromuscular
electrical stimulation, resistance against exercise, and control
NMES (n = 8)
RAE (n = 9)
Control (n = 6)
Pre Post Pre Post Pre Post
KES (N.m) 68 ± 36 84 ± 32 * 64 ± 30 71 ± 26 66 ± 40 71 ± 41
Pain 9 ± 3 4 ± 2 * 12 ± 3 8 ± 3 * 10 ± 2 9 ± 5
Motor function 28 ± 9 17 ± 5 40 ± 15 32 ± 11 35 ± 12 34 ± 16
Legend: * P < 0.05 intra-group, KES = Knee extensor strength; NMES = neuromuscular electrical stimulation; RAE = resistance against exercise. Source: Research.data
NMES
RAE
Control
120
110
100
90
80
70
60
50
40
Pre Post
30
20
Knee extensor strenght (N.m)
*
Graph 1 - Knee extensor strength before and after the 24-session program for neuromuscular electrical stimulation (NMES), resistance against exercise (RAE), and control (bars represent a confidence interval of 95%)
effect was - . between the groups mldr and con-trol, and - . between the groups RAd and control. she x AmnuA with repeated measure-ments showed e . = . ; o = . for the interaction between motor function and the groups. Regarding the initial and final motor function, the aonferroni adjustment for the x AmnuA with repeated measurements showed o = . within the mldr group; o = . within the RAd group; and o = . within the control group
fraph .
she size of the motor function effect within the mldr group was - . ; within the group RAd it was - . ; and within the control group it was - . . she size of the effect between the groups mldr and control was . and between the groups RAd and control was . .
Discussion
shis controlled, randomized, and double-blind expe-riment, by submitting patients with jn to sessions of muscle strengthening through mldr, RAd, or no tre-atment, in the case of patients from the control group, did not find a significant difference for knee extensor strength, pain, and motor function between groups after treatment, contradicting the assumption that mldr or RAd show significant differences in all response varia-bles when compared to control.
oerhaps, one reason for this was the heterogeneity among patients with regard to all response variables. shis study used as inclusion criteria to homogenize patients the clinical and radiological criteria propo-sed by AbR for diagnosing jn , also used by out of the randomized controlled studies which
Pre Post
16
14
12
10
8
6
4
2
0
Pain
*
*
NMES
RAE
Control
Graph 2 - Knee pain before and after the 24-session program for neuromuscular electrical stimulation (NMES), resistance against exercise (RAE), and control (bars represent a confidence interval of 95%)
784
approached muscle strengthening in the treatment for jn selected due to the quality and scientific rigor minimum score of the odcro scale , - . gowever, this criterion seems to lack discrimina-tory power to achieve the required homogenization. hn sable , we can observe that the standard devia-tions in the pre and post-treatment measurements were high for all response variables, generating a variation coefficient from % to % in the mldr group and from % to % in the RAd group, re-presenting up to / to / of the average. Another criterion which could have been adopted in the stu-dy is the classification of jn severity by means of the radiographic degree proposed by jelgreen and Lawrence , used in out of the studies with a minimum score of on the odcro scale. gowever, this classification was questioned with regard to the abili-ty to classify the degree of joint impairment, because
it showed only a moderate correlation to the degree of cartilage degeneration r = . ; o = . .
A second reason may have been the small sam-ple size. nut of the studies showing a significant difference in muscle strength between groups, had at least a sample of patients, something which represents about, at least, times the sample used in this study. ht is worth stressing that there is a study with a sample of patients which also obtained a significant difference in muscle strength. gowever, this study may have compromised the error type h by inflating it at the time of data analysis using many t-rtudent tests instead of an AmnuA.
hn addition to the two reasons mentioned above, patients took between and weeks to complete the treatment sessions. nnly patients strictly complied with the ideal sessions in weeks; patients comple-ted the sessions in weeks or more. bompensating
Pre Post
55
50
45
40
35
30
25
20
15
10
5
Motor function
NMES RAE
Control
Graph 3 - Motor function before and after the 24-session program for neuromuscular electrical stimulation (NMES), resistan-ce against exercise (RAE), and control (bars represent a confidenresistan-ce interval of 95%)
a missed class was an attempt to prevent experimental mortality, but this may have contributed to the rejection of the hypothesis mentioned above.
Although between the groups this study accepted the null hypothesis, the result was different within groups. she knee extensor strength was significantly higher in the group treated with mldr. oeripheral muscle stimulation by means of mldr increases the excitability of spinal routes changes the pattern of cortical activation and improves the recruitment of muscle fibers which are responsible both for strength, more difficult to recruit through voluntary contraction, and for the resistance to fatigue , some neural adap-tations that increase the capacity of voluntary muscle contraction , impaired in patients with jn .
cespite the fact that muscle strength test on an isokinetic device showed a high test/retest reliability in patients with jn , and a recent study with patients with moderate and severe jn jelgreen and Lawrence degrees , , and found an absolute sld of . m.m and a relative sld of . %, as well as a minimum absolute difference in intra-group detecta-ble muscle strength between tests of . m.m and a minimum relative difference of . %, this study was careful by also measuring the sld of knee extensor strength. hn this study, the absolute and relative sld were m.m and %, respectively. she differences in knee extensor strength found in this study were of m.m in the mldr group, m.m in the RAd group, and m.m in the control group. ht may be seen that the difference in the knee extensor strength obtained by the mldr group was m.m greater, while in the RAd group it was equal and in the control group it was m.m smaller than the sld, respectively.
she significant increase in knee extensor strength in the mldr group also led to a significant decrease in pain, confirming the findings of other studies, which showed that the muscle strengthening of knee exten-sors can reduce the pain caused by jn , - . hn another study, which compared a group undergoing mldr associated to core training to another group which underwent only the core training to treat low back pain, the pain in the mldr group associated to core training was significantly lower than in the core training group o = . , confirming the role played by mldr in the pain reduction identified in this study . she variables pain and motor function behaved in a similar way in the groups mldr and RAd, something which can be observed in the similarity between fraphs and . shese two variables are related and they are
influenced by one another. hn two studies, one with and another with , subjects, the occurrence of pain was associated to decreased motor function in men and women , . jn is characterized by a me-chanical pain, a pain which emerges during movement that causes motor abnormalities and influences on the performance of functional activities .
hn the RAd group there was a significant reduction in pain without any significant increase in knee exten-sor strength. shis may be explained because there is also evidence that joint cartilage positively responds to the stimulation of moderate physical activity , and that physical activity increases the interleukin- levels, an anti-inflammatory cytokine, and decreases the levels of the oligomeric protein which protects cartilage in the synovial fluid, a marker of cartilage metabolism , , and this may have interfered with the pain mechanism of the RAd group.
bontrary to the association between the varia-bles pain and motor function mentioned above, in the groups mldr and RAd there was a significant de-crease in pain, but this does not mean significant im-provement of motor function. shis may be explained by the great coefficient of variation of and %, respectively, in the results of motor function, probably due to the heterogeneity explained above.
ohysical inactivity can be harmful for patients with jn . shis can be observed in the control group, whi-ch did not obtain significant differences in any of the response variables, explained by the fact that patients did not undergo any form of muscle strengthening and physical activity within the period of weeks. dxercise is beneficial to patients with jn because of the relation between increased muscle strength to decreased pain and improved motor function .
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rix randomized and controlled trials, out of which four underwent blind review, selected due to their quality and scientific rigor, which focused on muscle strengthening exercise as a treatment for jn, with a design similar to this study, i.e. with two treatment groups and a control group, with pre- and post-treat-ment measurepost-treat-ments, with weeks of treatpost-treat-ment and frequency of times a week; muscle strength was measured on an isokinetic machine and it showed a significant increase in muscle strength intra- and inter-groups , , - , except for a group whi-ch performed aquatic exercises . hn this study, a significant difference in muscle strength was found only in the pre- and post-treatment measurement of muscle strengthening by mldr.
eour of these studies also showed a significant de-crease in pain within and between groups, except for one study , which did not evaluate pain and ano-ther one , which found no decrease in pain when comparing floor exercises and aquatic exercise compa-red to control. she same studies, by evaluating mo-tor function, also found a significant difference within and between groups, exception one study , which showed no significant improvement of motor function. so evaluate pain and motor function, out of these studies used the puestionnaire vestern nntario and lclaster tniversities nsteoarthritis hndex vnlAb , , also used in this study, which found a signi-ficant decrease in pain and a signisigni-ficant improvement of motor function within the mldr group.
shree previous studies addressed muscle streng-thening through mldr in the treatment for jn. mon-blind uncontrolled studies , found a significant increase in muscle strength of the quadriceps inter- and intra-groups treated with mldr, with no impro-vement in pain or motor function. Another study conducted a non-blind randomized controlled trial with regard to groups, with a design similar to this study, which compared a group undergoing mldr for quadriceps during weeks, times a week, to an untreated control group. she protocol for applying mldr was similar to that used in this study, differing by a longer time off s in a contraction cycle, as patient’s position is sitting on a chair and because it discourages voluntary contraction associated to the passive muscle contraction caused by electrical stimulation. shis study showed no significant diffe-rence inter- or intra-groups for knee muscle strength, pain, or motor function. hn contrast, this study found a significant increase in knee extensor strength and a
significant decrease in pain for the mldr group, with blind evaluation and analysis of results. she fact that one study used only weeks, i.e. half of the tre-atment sessions used in this study, and that it did not associate isometric contraction of the quadriceps may have contributed to the results found in that study.
she results of this study were limited because of the small sample size, and the lack of homogeneity of patients in the pre- and post-treatment evaluation may have been caused by the lack of discriminatory power in the clinical and radiological criteria of AbR for the diagnosis of jn . shis makes us belie-ve that a functional clinical classification could be a better option to select a more homogeneous sample than the criteria mentioned above or jn severity classification, by means of the radiographic degree proposed by jelgreen and Lawrence , since the response variables under study have functional cli-nical characteristics.
Conclusion
bonsidering the results obtained here, we con-clude that strengthening the knee extensor muscles can help decreasing pain in patients with jn. mldr, when applied in sessions, times a week, accor-ding to the protocol used in this study, may constitute an interesting therapy to improve the clinical status, since it protects the joint from compressive stress and shear produced by joint movement.
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