Influence of Self-managed Rehabilitation on Work Efficiency in Active Duty Military With a Knee Injury

Abstract Introduction Knee injuries associated with intense physical training are one of the most frequent injuries associated with medical encounters for military members. The purpose of this study was to evaluate four approaches to physiotherapy rehabilitation and their effects on work efficiency in active duty military with a knee injury. The four groups included neuromuscular electrical stimulation (NMES), walking with a weighted vest (WALK), combined NMES/Walk, and standard physiotherapy rehabilitation. All groups received standard physiotherapy rehabilitation. We have previously reported that quadriceps muscle strength improved over 18 weeks in the study for the three interventions relative to standard rehabilitation alone. This report presents results from an examination of work efficiency as evaluated during a step test while measuring oxygen utilization. Methods A randomized controlled trial was conducted, with repeated outcome measures of work efficiency assessed at baseline, 3, 6, 12, and 18 weeks. The sample consisted of 67 active duty service members between the ages of 18 and 50 years with a knee injury. Participants were randomized to one of the four approaches to physiotherapy rehabilitation: (1) NMES was applied to the quadriceps muscle four times per week, for 30 minutes (15 minutes to each leg), consisting of 15 quadriceps muscle contractions per leg; (2) graduated strength walking using a weighted vest (WALK) was for 30 minutes, 3 to 4 days a week; (3) combined NMES with strength walking received both the NMES therapy and the weighted vest walking; and (4) standard physiotherapy consisted of progressive exercise with the number and type of sessions not controlled by the study. All four groups received the standard physiotherapy for a knee injury. The primary outcome was work efficiency, as measured by oxygen utilization during a 2-minute self-paced step test over 18 weeks. The primary analysis used repeated measures, linear mixed-effects models with a random effect for subject. Results Both the number of steps performed and gross work efficiency improved during the study for all three intervention groups. For gross work efficiency, standard rehabilitation improved 12%, WALK showed a 19% improvement, NMES increased by 24%, and the NMES/Walk group improved by 40%. Conclusions All groups showed improved submaximal exercise efficiency based on oxygen utilization, with the intervention groups showing a greater improvement in work efficiency as compared to standard rehabilitation. Knee injuries can be problematic for active duty members because of reduced mobility leading to deconditioning and associated declines in work efficiency. Rehabilitative programs, including those described in this study, may minimize loss of work efficiency and fitness and promote a quicker recovery.

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Quadriceps Activation Following Knee Injuries: A Systematic Review

Journal of Athletic Training ◽

10.4085/1062-6050-45.1.87 ◽

2010 ◽

Vol 45 (1) ◽

pp. 87-97 ◽

Cited By ~ 245

Author(s):

Joseph M. Hart ◽

Brian Pietrosimone ◽

Jay Hertel ◽

Christopher D. Ingersoll

Keyword(s):

Anterior Cruciate Ligament ◽

Knee Injury ◽

Data Extraction ◽

Cruciate Ligament ◽

Knee Injuries ◽

Quadriceps Muscle ◽

Control Group ◽

Data Sets ◽

Weighted Mean ◽

Anterior Cruciate

Abstract Context: Arthrogenic muscle inhibition is an important underlying factor in persistent quadriceps muscle weakness after knee injury or surgery. Objective: To determine the magnitude and prevalence of volitional quadriceps activation deficits after knee injury. Data Sources: Web of Science database. Study Selection: Eligible studies involved human participants and measured quadriceps activation using either twitch interpolation or burst superimposition on patients with knee injuries or surgeries such as anterior cruciate ligament deficiency (ACLd), anterior cruciate ligament reconstruction (ACLr), and anterior knee pain (AKP). Data Extraction: Means, measures of variability, and prevalence of quadriceps activation (QA) failure (<95%) were recorded for experiments involving ACLd (10), ACLr (5), and AKP (3). Data Synthesis: A total of 21 data sets from 18 studies were initially identified. Data from 3 studies (1 paper reporting data for both ACLd and ACLr, 1 on AKP, and the postarthroscopy paper) were excluded from the primary analyses because only graphical data were reported. Of the remaining 17 data sets (from 15 studies), weighted mean QA in 352 ACLd patients was 87.3% on the involved side, 89.1% on the uninvolved side, and 91% in control participants. The QA failure prevalence ranged from 0% to 100%. Weighted mean QA in 99 total ACLr patients was 89.2% on the involved side, 84% on the uninvolved side, and 98.5% for the control group, with prevalence ranging from 0% to 71%. Thirty-eight patients with AKP averaged 78.6% on the involved side and 77.7% on the contralateral side. Bilateral QA failure was commonly reported in patients. Conclusions: Quadriceps activation failure is common in patients with ACLd, ACLr, and AKP and is often observed bilaterally.

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Self-Managed Strength Training for Active Duty Military With a Knee Injury: A Randomized Controlled Pilot Trial

Military Medicine ◽

10.1093/milmed/usy347 ◽

2019 ◽

Vol 184 (7-8) ◽

pp. e174-e183 ◽

Cited By ~ 2

Author(s):

Laura A Talbot, Col, USAFR (Ret.) ◽

Emily Brede ◽

Marquita N Price ◽

Pilar d Zuber ◽

E Jeffrey Metter

Keyword(s):

Knee Flexion ◽

Knee Injuries ◽

Knee Extensor ◽

Knee Extension ◽

Active Duty ◽

Group Differences ◽

Significant Group ◽

Active Duty Military ◽

Significant Difference ◽

Injured Knee

Abstract Introduction Knee injuries among active duty military are one of the most frequent musculoskeletal injuries and are often caused by exercise or intense physical activity or combat training. These injuries pose a threat to force readiness. Our objective was to assess feasibility (including recruitment and retention rates) of three self-managed strengthening strategies for knee injuries and determine if they resulted in improvements in lower extremity strength, function, pain, and activity compared to usual physical therapy (PT) in military members. Methods A pilot study using a randomized controlled trial was conducted at three outpatient military medical treatment facilities. After baseline testing, 78 active duty military members with a knee injury were randomized to 1–4 trial arms: (1) neuromuscular electrical stimulation (NMES) applied to the quadriceps muscle; (2) graduated strength walking using a weighted vest (WALK); (3) combined NMES with strength walking (COMBO); (4) usual PT alone. All groups received usual PT. The primary outcome was the rates of change in knee extensor and flexor strength over 18 weeks. Secondary outcomes explored the rates of change in functional performance, pain, and activities of daily living scale (ADLS). The primary analysis for the endpoints used repeated measures, linear mixed-effects models. This study was approved by Institutional Review Boards at all facilities. Results The randomized sample (N = 78) included 19 participants in the PT-only, 20 in the WALK, 19 in the NMES and 20 in the COMBO groups. At baseline, there were no group differences. Fifty of the participants completed the 18-week study. The completers and non-completers differed at baseline on injury mechanism, with more completers injured during sports (45% vs 29%), and more non-completers during military training (36% vs 18%). Also, they differed in uninjured knee extension (completers 28% weaker), and uninjured knee flexion (completers 22% weaker). Adherence for self-reported daily step logs showed that the WALK group was 15% below goal and COMBO group 6% below goal. The 300 PV muscle stimulator showed the NMES group completed 34% of recommended stimulation sessions and the COMBO group 30%. Knee extension strength in the injured knee found only the COMBO group having a statistically higher improvement compared to PT-only (Change over 18 weeks: 10.6 kg in COMBO; 2.1 kg in PT-only). For the injured knee flexion changes, only the COMBO showed significant difference from PT-only (Change over 18 weeks: 7.5 kg in COMBO; −0.2 kg in PT-only). Similarly, for the uninjured knee, only the COMBO showed significant difference from PT-only in knee extension (Change over 18 weeks: 14.7 Kg in COMBO; 2.7 kg in PT-only) and knee flexion (Change over 18 weeks: 6.5 kg in COMBO; −0.2 kg in PT-only). Overall pain improved during the study for all groups with no significant group differences. Similarly, function and ADLS significantly improved over 18 weeks, with no significant group differences. Conclusions Knee extensor strength improvements in the COMBO group were significantly higher compared to usual PT. Pain, functional measures, and ADLS all improved during the study with no group differences. Further research is required to confirm these findings.

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