Exercise-induced fatigue affects knee proprioceptive acuity and quadriceps neuromuscular function more in patients with ACL reconstruction or meniscus surgery than in healthy individuals.

PURPOSE: To observe how knee proprioceptive acuity and quadriceps neuromuscular function change during and after repeated isokinetic knee-extension exercise in patients with anterior cruciate ligament reconstruction (ACLR) or meniscus surgery. METHODS: Patients with ACLR or meniscus surgery and matched controls (n = 19 in each group) performed knee-flexion replication at 15° and 75°, and quadriceps peak torque (PT), central activation ratio (CAR) and rate of torque development (RTD) at baseline and immediately after every five sets of isokinetic knee-extension exercise (times 1-5). RESULTS: Compared to the baseline, the ACLR and control groups displayed errors in knee-flexion replication at 75° only at time 5 (115.9-155.6%; p ≤ 0.04, d ≥ 0.97), whereas the meniscus surgery group exhibited errors at all time points (142.5-265.6%; p ≤ 0.0003, d ≥ 1.4). Significant percentage reductions in quadriceps CAR were observed between times 4 and 5 in the ACLR group (-5.8%; p = 0.0002, d = 0.96), but not in the meniscus surgery (-1.4%; n.s.) and control (0.1%; n.s.) groups. Significant percentage reductions in quadriceps RTD were observed between times 4 and 5 in the ACLR (-24.2%; p = 0.007, d = 0.99) and meniscus surgery (-23.0%; p = 0.01, d = 0.85) groups, but not in the control group (-0.2%; n.s.). CONCLUSION: Patients with ACLR or meniscus surgery displayed a greater loss in knee proprioceptive acuity and quadriceps neuromuscular function during and after exercise than healthy individuals. Evidence-based interventions to enhance exercise-induced fatigue resistance should be implemented following ACLR or meniscus surgery, aiming to prevent proprioceptive and neuromuscular changes within the knee joint and quadriceps. LEVEL OF EVIDENCE: III.

Gluteal Central Activation in Females With Patellofemoral Pain: A Preliminary Study.

CONTEXT: Lesser hip muscle strength is commonly observed in females with patellofemoral pain (PFP) compared with females without PFP and is associated with poor subjective function and single-leg squat (SLS) biomechanics. Hip muscle weakness is theorized to be related to PFP, suggesting centrally mediated muscle inhibition may influence the observed weakness. The central activation ratio (CAR) is a common metric used to quantify muscle inhibition via burst superimposition. However, gluteal inhibition has yet to be evaluated using this approach in females with PFP. The study objectives are to (1) describe gluteal activation in the context of subjective function, hip strength, and squatting biomechanics and (2) examine the relationship of gluteal activation with subjective function and squatting biomechanics in females with PFP. DESIGN: Cross-sectional. METHODS: Seven females with PFP (age = 22.8 [3.6] y; mass = 69.4 [18.0] kg; height = 1.67 [0.05] m, duration of pain = 6-96 mo) completed this study. Subjective function was assessed with the Anterior Knee Pain Scale, while fear-avoidance beliefs were assessed with the Fear-Avoidance Belief Questionnaire physical activity and work subscales. Biomechanical function was assessed with peak hip and knee angles and moments in the sagittal and frontal planes during SLS. Gluteus medius (GMed) and gluteus maximus (GMax) activation were assessed with the CAR. Descriptive statistics were calculated, and relationships between variables were assessed with Spearman rho correlations. RESULTS: The CAR of GMed and GMax was 90.5% (8.1%) and 84.0% (6.3%), respectively. Lesser GMed CAR was strongly associated with greater hip adduction during SLS (ρ = -.775, P = .02) and greater fear-avoidance beliefs-physical activity subscale (ρ = -.764, P = .018). CONCLUSION: We found a wide range in GMed and GMax activation across females with PFP. Lesser GMed activation was associated with greater hip adduction during SLS and fear of physical activity, suggesting that gluteal inhibition should be assessed in patients with PFP.

Biomechanics Differ for Individuals With Similar Self-Reported Characteristics of Patellofemoral Pain During a High-Demand Multiplanar Movement Task.

CONTEXT: Patellofemoral pain (PFP) is often categorized by researchers and clinicians using subjective self-reported PFP characteristics; however, this practice might mask important differences in movement biomechanics between PFP patients. OBJECTIVE: To determine whether biomechanical differences exist during a high-demand multiplanar movement task for PFP patients with similar self-reported PFP characteristics but different quadriceps activation levels. DESIGN: Cross-sectional design. SETTING: Biomechanics laboratory. PARTICIPANTS: A total of 15 quadriceps deficient and 15 quadriceps functional (QF) PFP patients with similar self-reported PFP characteristics. INTERVENTION: In total, 5 trials of a high-demand multiplanar land, cut, and jump movement task were performed. MAIN OUTCOME MEASURES: Biomechanics were compared at each percentile of the ground contact phase of the movement task (α = .05) between the quadriceps deficient and QF groups. Biomechanical variables included (1) whole-body center of mass, trunk, hip, knee, and ankle kinematics; (2) hip, knee, and ankle kinetics; and (3) ground reaction forces. RESULTS: The QF patients exhibited increased ground reaction force, joint torque, and movement, relative to the quadriceps deficient patients. The QF patients exhibited: (1) up to 90, 60, and 35 N more vertical, posterior, and medial ground reaction force at various times of the ground contact phase; (2) up to 4° more knee flexion during ground contact and up to 4° more plantarflexion and hip extension during the latter parts of ground contact; and (3) up to 26, 21, and 48 N·m more plantarflexion, knee extension, and hip extension torque, respectively, at various times of ground contact. CONCLUSIONS: PFP patients with similar self-reported PFP characteristics exhibit different movement biomechanics, and these differences depend upon quadriceps activation levels. These differences are important because movement biomechanics affect injury risk and athletic performance. In addition, these biomechanical differences indicate that different therapeutic interventions may be needed for PFP patients with similar self-reported PFP characteristics.

Knee Joint and Quadriceps Dysfunction in Individuals With Anterior Knee Pain, Anterior Cruciate Ligament Reconstruction, and Meniscus Surgery: A Cross-Sectional Study.

CONTEXT: While arthrogenous muscle inhibition associated with knee injuries is evident, the relative magnitude of functional deficiency related to each individual knee pathology is unclear. OBJECTIVE: To compare the knee joint and quadriceps dysfunction among patients with anterior knee pain (AKP) without surgical history and those with surgical history (anterior cruciate ligament reconstruction [ACLR]; meniscus surgery) without current AKP, with matched healthy controls. DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: A total of 66 patients with knee pathologies and 30 controls. MAIN OUTCOME MEASURES: Pain perception and lower-extremity functional outcomes were assessed. Knee joint function was measured by replication tests. Quadriceps function was measured by strength, voluntary activation, and torque-generating capacity. RESULTS: Patients with AKP reported greater pain perception compared with the other knee conditions (4.3 vs 0.1 of 10 in Numeric Pain Rating Scale, P < .0001). Compared with the controls: (1) patients with AKP showed a greater error on knee-flexion replications at 75° (2.9° vs 5.4°, P = .002), (2) patients with AKP and ACLR showed less quadriceps strength (AKP: 3.3 vs 2.6 N·m/kg, P = .002; ACLR: 3.3 vs 2.7 N·m/kg, P = .02) and voluntary activation (AKP: 0.982 vs 0.928, P < .0001; ACLR: 0.982 vs 0.946, P = .003), and (3) all knee pathologies reported lower scores on functional outcomes (79 vs 65 of 80 points in Lower-Extremity Functional Scale, P < .0001) and showed less quadriceps torque-generating capacity (10.7 vs 7.8 N·m/s/kg, P < .0001). Among the knee pathologies, patients with AKP showed less quadriceps voluntary activation compared with the patients with meniscus surgery (0.928 vs 0.964, P = .03). CONCLUSION: As patients with AKP had an additional impairment in knee joint flexion replications and reported a less score in functional outcomes, knee pain may produce a greater impact on functional deficiency.

Muscle hypotrophy, not inhibition, is responsible for quadriceps weakness during rehabilitation after anterior cruciate ligament reconstruction.

PURPOSE: Quadriceps weakness is common after anterior cruciate ligament reconstruction (ACLR). Limited neuromuscular activation may have a role in the weakness. The purpose of this study was to use peripheral magnetic stimulation to measure changes in quadriceps inhibition in patients during rehabilitation from ACLR. METHODS: Ten patients (7M/3F; age 35 ± 8 years; BMI 26.0 ± 4.8 kg/m2) who had ACLR with patellar tendon autograft were recruited. At 3 and 6 months postoperatively, patients' knee extension peak torque was measured during maximum voluntary isometric contraction (MVIC), magnetic stimulation-evoked contraction, and MVIC augmented with superimposed burst magnetic stimulation to the femoral nerve. All tests were done bilaterally at 30° and 65° of knee flexion on a dynamometer. Central activation ratio was calculated by dividing the peak torque before stimulation by peak torque after stimulation. RESULTS: Patients had marked deficits in MVIC, with improvement from 3 to 6 months that was more apparent at 65° versus 30° (P < 0.05). There was significant deficit in stimulation-evoked torque on the involved side that diminished over time, and this change occurred differently between the two angles (P < 0.05). Central activation ratio was lower on the involved side versus the noninvolved side and this effect was more prominent at 3 versus 6 months: combining the angles, mean central activation ratio on the involved and noninvolved sides, respectively, was 91.4 ± 7.6% and 97.5 ± 5.3% at 3 months, and 93.0 ± 7.8% and 95.8 ± 6.8% at 6 months. CONCLUSIONS: At 3 and 6 months after ACLR, there were significant deficits in quadriceps strength and activation. Quadriceps activation levels were high (> 90%) for both sides at both time points. The substantial strength deficits at this postoperative period may be largely due to muscle atrophy with limited contribution from central inhibition. Rehabilitation interventions to normalize quadriceps strength should emphasize hypertrophic stimuli as opposed to neuromuscular activation strategies. LEVEL OF EVIDENCE: II, prospective cohort study.

Quadriceps and Patient-Reported Function in ACL-Reconstructed Patients: A Principal Component Analysis.

CONTEXT: Assessment of physical function for individuals after anterior cruciate ligament reconstruction (ACL-R) is complex and warrants the use of diverse evaluation strategies. To maximize the efficiency of assessment, there is a need to identify tests that provide the most meaningful information about this population. OBJECTIVE: To investigate underlying constructs of quadriceps muscle function that uniquely describe aspects of performance in patients after ACL-R and establish clinical thresholds for measures able to classify patients with and without ACL-R. DESIGN: Cross-sectional. SETTING: Research laboratory. Patients (or Other Participants): Seventy-two patients with a primary, unilateral ACL-R (32 males and 40 females, age = 26.0 [9.3] y, time since surgery = 46.5 [58.0] mo) and 30 healthy controls (12 males and 18 females, age = 22.7 [4.6] y). INTERVENTION(S): Quadriceps function was assessed bilaterally during 1 study visit. MAIN OUTCOME MEASURES: Isokinetic strength (peak torque, total work, and average power) at 90° and 180°/s, maximal voluntary isometric contraction torque, fatigue index, central activation ratio, Hoffmann reflex, and active motor threshold. Principal component analyses were performed for the involved limb, contralateral limb, and limb symmetry. Receiver-operator characteristic curve analyses were conducted to determine the diagnostic utility of each variable. Binary logistic regression was used to predict group membership (ACL-R vs healthy). RESULTS: Three components of peripheral, central, and combined (peripheral and central) muscle function were identified, explaining 70.7% to 80.5% of variance among measures of quadriceps function. Total knee-extensor work at 90°/s (≥18.4 J/kg), active motor threshold (≥39.5%), and central activation ratio (≥94.7%) of the involved limb were strong predictors of patient status and correctly classified 83.5% of patients with ACL-R (P < .001). CONCLUSIONS: Unique constructs of peripheral, central, and combined muscle function exist in patients with ACL-R. Total knee-extensor work at 90°/s, active motor threshold, and central activation ratio consistently explained a significant portion of variance in measures of quadriceps function, demonstrated acceptable to excellent diagnostic utility, and predicted group membership with 72.8% to 83.5% accuracy.

Neuromuscular Adaptations to Low-Load Blood Flow Restricted Resistance Training.

Low-load blood flow restricted (BFR) resistance exercise has been suggested to be as effective as moderate and high-load resistance training for increasing muscle size and strength. The purpose of the study was to evaluate the effects of 6 weeks of HL or low-load BFR resistance training on neuromuscular function, strength, and hypertrophy of the knee extensors. Eighteen participants aged 18-22 years old were randomized to one of three training groups: moderate load (ML: 70% of 1 repetition maximum [1-RM]); BFR (20% 1-RM with a vascular restriction set to ~180 mmHg); and a control group (CON) that did not exercise. Participants performed leg extension (LE) and leg press exercises 3 times per week for 6 weeks. Measurements of isometric torque, LE 1-RM, central activation, electrically evoked torque, and muscle volume of the knee extensors were obtained before and after training. Isometric peak torque did not change following the training (p = 0.13). LE 1-RM improved in the ML (34 ± 20%; d = 0.78) and BFR (14 ± 5%; d = 0.67) groups compared to the CON group (0.6 ± 8%; d = 0.09; time x group interaction p = 0.02). Muscle volume increased in the ML (5.6%; d = 0.19) and BFR groups (2.5%; d = 0.09) with no change in the CON group (time x group interaction p = 0.001). There were no changes in central activation and evoked torque in any groups following the training (p > 0.05). Strength and hypertrophy were evident following ML and BFR resistance training programs indicating that both modalities are effective, although ML training appears to be a more potent and efficient. Neuromuscular changes were not evident and warrant more research.

Noninvasive brain stimulation enhances sustained muscle contractions by reducing neuromuscular fatigue: implications for rehabilitation.

Neuromuscular fatigue is due, in part, to central processes that involve failure of the nervous system to drive muscles maximally during exercise. A recent study by Abdelmoula, Baudry, and Duchateau (Neuroscience 322: 94-103, 2016) showed that noninvasive brain stimulation can mitigate neuromuscular fatigue, however, does not rely on enhanced corticospinal excitability of the primary motor cortex. These findings are of high clinical importance because rehabilitative therapies are necessary to mitigate neuromuscular fatigue for patients with central nervous system disorders.

Specific joint angle dependency of voluntary activation during eccentric knee extensions.

INTRODUCTION: This study compared voluntary activation during isometric, concentric, and eccentric maximal knee extensions at different joint angles. METHODS: Fifteen participants performed isometric, concentric, and eccentric protocols (9 contractions each). For each protocol, the central activation ratio (CAR) was randomly measured at 50°, 75°, or 100° of knee joint angle (0° = full knee extension) using superimposed supramaximal paired nerve stimulations during contractions. RESULTS: CAR increased between 50° and 100° during isometric (93.6 ± 3.1 vs. 98.5 ± 1.4%), concentric (92.4 ± 5.4 vs. 99.2 ± 1.2%), and eccentric (93.0 ± 3.5 vs. 96.6 ± 3.8%) contractions. CAR was lower during eccentric than both isometric and concentric contractions at 75° and 100°, but similar between contraction types at 50°. CONCLUSIONS: The ability to activate muscle maximally is impaired during eccentric contractions compared with other contraction types at 75° and 100°, but not at 50°. Muscle Nerve 56: 750-758, 2017.

Greater intracortical inhibition associates with lower quadriceps voluntary activation in individuals with ACL reconstruction.

Decreased voluntary activation contributes to quadriceps weakness following anterior cruciate ligament reconstruction (ACLR). Alterations in neural excitability are likely responsible for reductions in quadriceps voluntary activation, and may be due to specific alterations in intracortical inhibition and facilitation. Therefore, we sought to determine if intracortical inhibition (SICI) and intracortical facilitation (ICF) associate with quadriceps voluntary activation in individuals with ACLR. Twenty-seven participants with a primary, unilateral ACLR were enrolled in this study. Bilateral central activation ratio (CAR) and paired-pulse transcranial magnetic stimulation were used to assess quadriceps voluntary activation, as well as SICI and ICF in the vastus medalis, respectively. Pearson Product Moment correlations were used to determine the association between CAR and (1) SICI, and (2) ICF in each limb. Lesser CAR associated with lesser SICI amplitude (r = 0.502, P = 0.008) in the ACLR limb. No associations in the contralateral limb were significant. Our results suggest greater intracortical inhibition associates with lesser voluntary activation in individuals with ACL. Implementing interventions that target intracortical inhibition may aid in restoring quadriceps voluntary activation following ACLR.

Slower but not faster unilateral fatiguing knee extensions alter contralateral limb performance without impairment of maximal torque output.

PURPOSE: The purpose of the present study was to examine the effects of unilateral fatigue of the knee extensors at different movement velocities on neuromuscular performance in the fatigued and non-fatigued leg. METHODS: Unilateral fatigue of the knee extensors was induced in 11 healthy young men (23.7 ± 3.8 years) at slower (60°/s; FAT60) and faster movement velocities (240°/s; FAT240) using an isokinetic dynamometer. A resting control (CON) condition was included. The fatigue protocols consisted of five sets of 15 maximal concentric knee extensions using the dominant leg. Before and after fatigue, peak isokinetic torque (PIT) and time to PIT (TTP) of the knee extensors as well as electromyographic (EMG) activity of vastus medialis, vastus lateralis, and biceps femoris muscles were assessed at 60 and 240°/s movement velocities in the fatigued and non-fatigued leg. RESULTS: In the fatigued leg, significantly greater PIT decrements were observed following FAT60 and FAT240 (11-19%) compared to CON (3-4%, p = .002, d = 2.3). Further, EMG activity increased in vastus lateralis and biceps femoris muscle following FAT240 only (8-28%, 0.018 ≤ p ≤ .024, d = 1.8). In the non-fatigued leg, shorter TTP values were found after the FAT60 protocol (11-15%, p = .023, d = 2.4). No significant changes were found for EMG data in the non-fatigued leg. CONCLUSION: The present study revealed that both slower and faster velocity fatiguing contractions failed to show any evidence of cross-over fatigue on PIT. However, unilateral knee extensor fatigue protocols conducted at slower movement velocities (i.e., 60°/s) appear to modulate torque production on the non-fatigued side (evident in shorter TTP values).

Pre-operative quadriceps activation is related to post-operative activation, not strength, in patients post-ACL reconstruction.

PURPOSE: Quadriceps activation failure is considered to contribute to the weakness that lingers following anterior cruciate ligament (ACL) reconstruction. Importantly, the impact of pre-operative quadriceps activation on post-operative quadriceps function is unknown. Understanding this relationship is clinically important; as the counteractive approach clinicians should employ pre-operatively to mitigate post-operative quadriceps weakness is unclear. Accordingly, the primary purpose of this study was to investigate the relationship between pre-operative quadriceps activation and post-operative quadriceps strength and activation. METHODS: Fifty-four individuals post-ACL injury reported for testing on two occasions: prior to surgery and post-surgery once they returned to activity. Quadriceps activation was assessed using the burst superimposition technique and quantified using the central activation ratio. Quadriceps strength was assessed using isometric contractions that were performed at 90° of knee flexion. Multiple linear regressions were utilized to detect the relationships between pre-operative activation and strength and post-operative activation and strength. RESULTS: Pre-operative activation was not associated with post-operative strength (R(2) = 0.064, P = 0.186). Pre-operative quadriceps activation and strength were associated with post-operative activation (R(2) = 0.383, P ≤ 0.001) and strength (R(2) = 0.465, P ≤ 0.001), respectively. CONCLUSIONS: Individuals with better pre-operative quadriceps activation demonstrated greater post-operative activation. Similarly, individuals with better pre-operative strength demonstrated better post-operative strength. Pre-operative quadriceps activation was not a predictor of post-operative strength. From a clinical perspective, our work indicates that clinicians should utilize therapies targeting both quadriceps activation and strength prior to ACL reconstruction in order to maximize these factors post-ACL reconstruction, as pre-operative activation and strength are related to post-operative activation and strength, respectively at return-to-activity.

Increased spinal reflex excitability is associated with enhanced central activation during voluntary lengthening contractions in human spinal cord injury.

This study of chronic incomplete spinal cord injury (SCI) subjects investigated patterns of central motor drive (i.e., central activation) of the plantar flexors using interpolated twitches, and modulation of soleus H-reflexes during lengthening, isometric, and shortening muscle actions. In a recent study of the knee extensors, SCI subjects demonstrated greater central activation ratio (CAR) values during lengthening (i.e., eccentric) maximal voluntary contractions (MVCs), compared with during isometric or shortening (i.e., concentric) MVCs. In contrast, healthy controls demonstrated lower lengthening CAR values compared with their isometric and shortening CARs. For the present investigation, we hypothesized SCI subjects would again produce their highest CAR values during lengthening MVCs, and that these increases in central activation were partially attributable to greater efficacy of Ia-α motoneuron transmission during muscle lengthening following SCI. Results show SCI subjects produced higher CAR values during lengthening vs. isometric or shortening MVCs (all P < 0.001). H-reflex testing revealed normalized H-reflexes (maximal SOL H-reflex-to-maximal M-wave ratios) were greater for SCI than controls during passive (P = 0.023) and active (i.e., 75% MVC; P = 0.017) lengthening, suggesting facilitation of Ia transmission post-SCI. Additionally, measures of spinal reflex excitability (passive lengthening maximal SOL H-reflex-to-maximal M-wave ratio) in SCI were positively correlated with soleus electromyographic activity and CAR values during lengthening MVCs (both P < 0.05). The present study presents evidence that patterns of dynamic muscle activation are altered following SCI, and that greater central activation during lengthening contractions is partly due to enhanced efficacy of Ia-α motoneuron transmission.

Muscle activation varies with contraction mode in human spinal cord injury.

INTRODUCTION: To better understand volitional force generation after chronic incomplete spinal cord injury (SCI), we examined muscle activation during single and repeated isometric, concentric, and eccentric knee extensor (KE) maximal voluntary contractions (MVCs). METHODS: Torque and electromyographic (EMG) activity were recorded during single and repeated isometric and dynamic KE MVCs in 11 SCI subjects. Central activation ratios (CARs) were calculated for all contraction modes in SCI subjects and 11 healthy controls. RESULTS: SCI subjects generated greater torque, KE EMG, and CARs during single eccentric vs. isometric and concentric MVCs (all P < 0.05). Torque and EMG remained similar during repeated eccentric MVCs; however, both increased during repeated isometric (>25%) and concentric (>30%) MVCs. CONCLUSIONS: SCI subjects demonstrated greater muscle activation during eccentric MVCs vs. isometric and concentric MVCs. This pattern of activation contrasts with the decreased eccentric activation demonstrated by healthy controls. Such information may aid development of novel rehabilitation interventions.

Can Arthrogenic Muscle Inhibition Exist in Peroneal Muscles Among People with Chronic Ankle Instability? A Cross-sectional Study.

BACKGROUND: Ankle sprains lead to an unexplained reduction of ankle eversion strength, and arthrogenic muscle inhibition (AMI) in peroneal muscles is considered one of the underlying causes. This study aimed to observe the presence of AMI in peroneal muscles among people with chronic ankle instability (CAI). METHODS: Sixty-three people with CAI and another sixty-three without CAI conducted maximal voluntary isometric contraction (MVIC) and superimposed burst (SIB) tests during ankle eversion, then fifteen people with CAI and fifteen without CAI were randomly invited to repeat the same tests to calculate the test-retest reliability. Electrical stimulation was applied to the peroneal muscles while the participants were performing MVIC, and the central activation ratio (CAR) was obtained by dividing MVIC torque by the sum of MVIC and SIB torques, representing the degree of AMI. RESULTS: The intra-class correlation coefficients were 0.77 (0.45-0.92) and 0.92 (0.79-0.97) for the affected and unaffected limbs among people with CAI, and 0.97 (0.91-0.99) and 0.93 (0.82-0.97) for the controlled affected and unaffected limbs among people without CAI; Significant group × limb interaction was detected in the peroneal CAR (p = 0.008). The CARs were lower among people with CAI in the affected and unaffected limbs, compared with those without CAI (affected limb = 82.54 ± 9.46%, controlled affected limb = 94.64 ± 6.37%, p < 0.001; unaffected limb = 89.21 ± 8.04%, controlled unaffected limb = 94.93 ± 6.01%, p = 0.016). The CARs in the affected limbs were lower than those in the unaffected limbs among people with CAI (p = 0.023). No differences between limbs were found for CAR in the people without CAI (p = 0.10). CONCLUSIONS: Bilateral AMI of peroneal muscles is observed among people with CAI. Their affected limbs have higher levels of AMI than the unaffected limbs.

Passive heating-induced changes in muscle contractile function are not further augmented by prolonged exposure in young males experiencing moderate thermal stress.

Background: We investigated the impact of 1) passive heating (PH) induced by single and intermittent/prolonged hot-water immersion (HWI) and 2) the duration of PH, on muscle contractile function under the unfatigued state, and during the development of muscle fatigue. Methods: Twelve young males volunteered for this study consisting of two phases: single phase (SP) followed by intermittent/prolonged phase (IPP), with both phases including two conditions (i.e., four trials in total) performed randomly: control passive sitting (CON) and HWI (44-45°C; water up to the waist level). SP-HWI included one continuous 45-min bath (from 15 to 60 min). IPP-HWI included an initial 45-min bath (from 15 to 60 min) followed by eight additional 15-min baths interspaced with 15-min breaks at room temperature between 75 and 300 min. Intramuscular (Tmu; measured in the vastus lateralis muscle) and rectal (Trec) temperatures were determined. Neuromuscular testing (performed in the knee extensors and flexors) was performed at baseline and 60 min later during SP, and at baseline, 60, 90, 150 and 300 min after baseline during IPP. A fatiguing protocol (100 electrical stimulations of the knee extensors) was performed after the last neuromuscular testing of each trial. Results: HWI increased Tmu and Trec to 38°C-38.5°C (p < 0.05) during both SP and IPP. Under the unfatigued state, HWI did not affect electrically induced torques at 20 Hz (P20) and 100 Hz (P100). However, it induced a shift towards a faster contractile profile during both SP and IPP, as evidenced by a decreased P20/P100 ratio (p < 0.05) and an improved muscle relaxation (i.e., reduced half-relaxation time and increased rate of torque relaxation; p < 0.05). Despite a reduced voluntary activation (i.e., -2.63% ± 4.19% after SP-HWI and -5.73% ± 4.31% after IPP-HWI; condition effect: p < 0.001), HWI did not impair maximal isokinetic and isometric contraction torques. During the fatiguing protocol, fatigue index and the changes in muscle contractile properties were larger after HWI than CON conditions (p < 0.05). Finally, none of these parameters were significantly affected by the heating duration. Conclusion: PH induces changes in muscle contractile function which are not augmented by prolonged exposure when thermal stress is moderate.

Exploring the use of bimodal transcranial direct current stimulation to enhance movement in individuals with patellofemoral pain-A sham-controlled double blinded pilot study.

Introduction: In individuals with patellofemoral pain (PFP), addressing increased knee valgus during weight-bearing activities typically involves strengthening weak hip muscles. However, recent literature highlights the role of altered descending central control in abnormal movements associated with PFP. While transcranial direct current stimulation (tDCS) has demonstrated the capacity to enhance neuroplasticity, its application targeting the corticomotor function of gluteal muscles in PFP remains unexplored. This study aimed to investigate the effects of combining bimodal tDCS with exercise on frontal plane kinematics in individuals with PFP. The hypothesis was that bimodal tDCS, specifically targeting the corticomotor function of the gluteal muscles, would augment the effectiveness of exercise interventions in improving frontal plane kinematics compared to sham stimulation. Methods: Ten participants with PFP participated in two sessions involving either bimodal tDCS or sham stimulation, concurrently with hip strengthening exercises. Weight-bearing tasks, including single leg squat, single leg landing, single leg hopping, forward step-down, and lateral step-down, were performed and recorded before and after each session. Pain visual analog scale (VAS) scores were also documented. A one-way ANOVA with repeated measures was employed to compare kinematics, while a Friedman test was used to compare VAS across the three conditions (pre-test, post-tDCS, and post-Sham). Results: We observed no significant differences in trunk lean angle, hip and knee frontal plane projection angles, or dynamic valgus index among the three conditions during the five weight-bearing tasks. VAS scores did not differ across the three conditions. Discussion and conclusion: A single session of tDCS did not demonstrate immediate efficacy in enhancing frontal plane kinematics or relieving pain in individuals with PFP. Considering observed positive outcomes in other neurological and orthopedic populations with multi-session tDCS applications, suggesting potential cumulative effects, further research is essential to explore the effects of multi-session tDCS on weight-bearing movement and underlying neurophysiology in individuals with PFP.

Quadriceps Neuromuscular Function During and After Exercise-Induced Fatigue in Patients With Patellofemoral Pain.

CONTEXT: Exercise-induced fatigue reduces muscle force production and motoneuron pool excitability. However, it is unclear if patients with patellofemoral pain (PFP) experience further loss in quadriceps neuromuscular function due to fatigue during exercise and postexercise. OBJECTIVE: To observe how quadriceps maximal strength, activation, and force-generating capacity change during and after repetitive bouts of isokinetic knee-extension exercise in patients with PFP. DESIGN: Cross-sectional study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-two patients with PFP (visual analog scale mean pain severity = 4.2 of 10 cm, mean symptom duration = 38.6 months) and 19 healthy control individuals matched on age and body mass index. MAIN OUTCOME MEASURE(S): Quadriceps peak torque (PT), central activation ratio (CAR), and rate of torque development (RTD) were assessed at baseline and immediately after every 5 sets of knee-extension exercise (times 1-5). Participants continued knee-extension exercises until the baseline quadriceps PT dropped below 50% for 3 consecutive contractions. RESULTS: No group-by-time interaction was observed for quadriceps PT (F5,195 = 1.03, P = .40). However, group-by-time interactions were detected for quadriceps CAR (F5,195 = 2.63, P= .03) and RTD (F5,195 = 3.85, P = .002). Quadriceps CAR (-3.6%, P = .04, Cohen d = 0.53) and RTD (-18.9%, P = .0008, Cohen d = 1.02) decreased between baseline and time 1 in patients with PFP but not in their healthy counterparts (CAR -1.9%, P = .86; RTD -9.8%, P = .22). Quadriceps RTD also decreased between times 4 and 5 in patients with PFP (-24.9%, P = .002, Cohen d = 0.89) but not in the healthy group (-0.9%, P = .99). CONCLUSIONS: Patients with PFP appeared to experience an additional reduction in quadriceps activation, force-generating capacity, or both during the early and late stages of exercise compared with healthy individuals. Clinicians should be aware of such possible acute changes during exercise and postexercise and use fatigue-resistant rehabilitation programs for patients with PFP.

Can strength training modify voluntary activation, contractile properties and spasticity in Multiple Sclerosis?: A randomized controlled trial.

BACKGROUND: A randomized controlled trial was conducted to analyze the effects of 10 weeks of strength training (ST) on voluntary activation, muscle activity, muscle contractile properties, and spasticity in people with MS. METHODS: 30 participants were randomized to either an experimental [EG] (n = 18) or a control [CG] (n = 12) group. The EG carried out 10-weeks of ST, where the concentric phase was performed at maximum voluntary velocity. Muscle activity of the vastus lateralis (surface electromyography (sEMG) during the first 200 ms of contraction), maximal neural drive (peak sEMG), voluntary activation (central activation ratio), and muscle contractile function (via electrical stimulation) of the knee extensor muscles, as well as spasticity, were measured pre- and post-intervention. RESULTS: The EG showed a significant improvement with differences between groups in muscle activity in EMG0-200 (p = 0.031; ES = -0.8) and maximal neural drive (p = 0.038; ES = -0.8), as well as improvement in the ST group with a trend towards significance in EMG0-100 (p = 0.068; ES = -0.6). CAR increased after intervention in ST group (p = 0.010; ES=-0.4). Spasticity also improved in the ST group, with differences between group after intervention, in first swing excursion (right leg: p = 0.006; ES = -1.4, left leg: p = 0.031; ES = -1.2), number of oscillations (right leg: p = 0.001; ES = -0.4, left leg: p = 0.031; ES = -0.4) and duration of oscillations (left leg: p = 0.002; ES = -0.6). Contractile properties remain unchanged in both ST group and CG. CONCLUSIONS: 10 weeks of ST improves muscle activity during the first 200 ms of contraction, maximal neural conduction, and spasticity in people with MS. However, ST does not produce adaptations in muscle contractile properties in this population.

Estimates of voluntary activation in individuals with anterior cruciate ligament reconstruction: Effects of type of stimulator, number of stimuli, and quantification technique.

BACKGROUND: Accurate quantification of voluntary activation is important for understanding the extent of quadriceps dysfunction in individuals with anterior cruciate ligament reconstruction (ACLR). Voluntary activation has been quantified using both percent activation derived from the interpolated twitch technique and central activation ratio (CAR) derived from the burst superimposition technique, as well as by using different types of electrical stimulators and pulse train conditions. However, it is unclear how these parameters affect voluntary activation estimates in individuals with ACLR. This study was performed to fill this important knowledge gap in the anterior cruciate ligament literature. METHODS: Quadriceps strength and voluntary activation were examined in 18 ACLR participants (12 quadriceps/patellar tendon graft, 6 hamstring tendon graft; time since ACLR: 1.06 ± 0.82 years, mean ±  SD) at 90° of knee flexion using 2 stimulators (Digitimer and Grass) and pulse train conditions (3-pulse and 10-pulse). Voluntary activation was quantified by calculating both CAR and percent activation. RESULTS: Results indicated that voluntary activation was significantly overestimated by CAR when compared with percent activation (p < 0.001). Voluntary activation estimates were not affected by pulse train conditions when using percent activation; however, 3-pulse stimuli resulted in greater overestimation than 10-pulse stimuli when using CAR (p = 0.003). Voluntary activation did not differ between stimulators (p > 0.05); however, the Digitimer evoked greater torque at rest than the Grass (p < 0.001). CONCLUSION: These results indicate that percent activation derived from the interpolated twitch technique provides superior estimates of voluntary activation than CAR derived from burst superimposition and is less affected by pulse train conditions or stimulators in individuals with ACLR.