Treatment Rationale
Problem: 60 year-old male, 6 weeks status post right TKA. He is having difficulty obtaining a good quadriceps contraction.
Justification: Steven-Lapsley et al.(4) performed a study that compared a traditional rehabilitation program to a rehabilitation program with the addition of NMES to the quadriceps muscle in patients who had received unilateral TKA. It was reported that the rehabilitation group with NMES had significant improvements in quad strength, Timed Up and Go (TUG) time, Stair-climbing test (SCT) time, 6 minute walk test (6MWT) distance, global rating scale (GRS), and active range of motion (AROM) in knee extension after 3.5 weeks of treatment compared to the control group. The NMES group also had better quad activation than the control group at this time. At 52 weeks the measurements were taken again and quad strength, TUG, SCT, 6MWT, GRS, SF-36 MCS and WOMAC were favoring the NMES group. Marmon et al.(2) performed a study on patients after unilateral TKA to discover if there was a dose response curve and the influences of NMES treatment on the quadriceps muscle strength and activation. They discovered that the strength, activation, and cross sectional area of the quadriceps muscle improved with the use of NMES after TKA. Lewek et al.(1) performed a case report on a 66-year-old man who had a TKA. The NMES treatment replaced the stretching and strengthening program that he had been doing. The study showed improvements in his quadriceps femoris force production from the use of NMES and he was able to return to recreational golfing without any pain. In a case report by Petterson et al.(3), a 62 year old man who had a TKA was able to improve his quadriceps force production and volitional activation with the use of NMES as well as a resistance strength training program.
Procedure: I will be using the NMES procedure that was followed in the study by Stevens-Lapsley et al.(4) The patient’s leg will be secured with Velcro straps at 85 degrees hip flexion and 60 degrees of knee flexion. Two self-adherent, flexible rectangle electrodes (7.6 cm x 12.7 cm) will be place on the distal medial and proximal lateral anterior thigh. Using a portable Empi 300PV stimulator, the treatment will be set to a biphasic current, symmetrical waveform with 50 pps for 15 seconds with a 3 second ramp up time and a 45 second off time. The intensity is the maximal amount the patient can tolerate and the pulse duration is 250 microseconds. The treatment will consist of 15 contractions generated from the NMES. This will be performed two times a day for 6 weeks. It is best to start this treatment the same week as surgery, but since this patient is 6 weeks post operation, it is best to start immediately.
Outcomes: Many outcomes were used in the studies, but for this patient I will use the maximal volitional isometric contraction (MVIC) of the quadriceps muscle, the WOMAC, and the TUG. Using these three outcomes will allow me to have a strength outcome, a specific knee impairment outcome, and a functional outcome. The outcomes will be assessed at the initial treatment, 3 weeks, and 6 weeks.
References:
1.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):1565-1571.
2. Marmon AR, Snyder-Mackler L. Quantifying Neuromuscular Electrical Stimulation Dosage after Knee Arthroplasty. J Life Sci Lib Ill. 2011;5(8):581-583.
3. Petterson S, Snyder-Mackler L. The Use of Neuromuscular Electrical Stimulation to Improve Activation Deficits in a Patient With Chronic Quadriceps Strength Impairments Following Total Knee Arthroplasty. J Orthop Sports Phys Ther. 2006;36(9):678-685. doi:10.2519/jospt.2006.2305.
4. 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 Trial. Phys Ther. 2012;92(2):210-226. doi:10.2522/ptj.20110124.