Evidence Based Medicine nella riabilitazione dei pazienti con ... · isometric tests indicates that...

Evidence Based Medicine nella

riabilitazione dei pazienti con alterazioni

del tono-trofismo muscolare

Prof. Calogero FOTI, MD, FEBPRM

Cattedra di Medicina Fisica e Riabilitazione

Sefora CODAZZA, MD

Formazione Specialistica

Rossella VISCITO, MD

Dottoranda

Dipartimento di Scienze Cliniche e Medicina Traslazionale

Università di Roma Tor Vergata

C.FOTI: EBM nella riabilitazione dei pazienti con alterazioni del tono-trofismo muscolare Roma, 27 Novembre 2015

Sessione

EVIDENZE SCIENTIFICHE NELLA RIABILITAZIONE MUSCOLO-SCHELETRICA

Rehabilitation Plan

PROTECTION AGAINST UNDUE STRESS

NEED FOR STRESS TO RETARD ATROPHY


Sports Rehabilitation

Clinical Program

I PHASE

PAIN – ROM – (WEIGHT BEARING) – STRENGTHENING EXERCISE

II PHASE

FUNCTIONAL EXERCISE (PROPRIOCEPTION, PLIOMETRY, DRILL)

III PHASE

BACK TO THE FIELD

MUSCLE

EVALUATION

MUSCLE

EVALUATION


Sport Rehabilitation

Clinical Program

I PHASE


II PHASE



PAIN

ROM

STRENGTHENING EXERCISE


Clinical Program

I PHASE


PAIN

ROM

STRENGTHENING EXERCISE


Clinical Program

I Phase


PAIN

ROM

STRENGHTENING EXERCISE


Clinical Program

I Phase



Clinical Program

I PHASE


MUSCLE

STRENGTH

EVALUATION


II PHASE


PROPRIOCEPTION

PLYOMETRY

DRILLING EXERCISE


Clinical Program

II PHASE

Roma, 27 Novembre 2015C.FOTI: EBM nella riabilitazione dei pazienti con alterazioni del tono-trofismo muscolare


Clinical Program

II PHASE

PROPRIOCEPTION

PLYOMETRY

DRILLING EXERCISE



Clinical Program

II PHASE

PROPRIOCEPTION

PLYOMETRY

DRILLING EXERCISEC.FOTI: EBM nella riabilitazione dei pazienti con alterazioni del tono-trofismo muscolare Roma, 27 Novembre 2015


Clinical Program

MUSCLE

STRENGTH

EVALUATION


II PHASEFUNCTIONAL EXERCISE (PROPRIOCEPTION, PLIOMETRY, DRILL)

III PHASEBACK TO THE FIELD

FUNCTIONAL EXERCISE

SAFE RETURN TO FULL ACTIVITY


MUSCLE TESTINGDaniels, Williams, Worthingam

0 none contraction1 palpable contraction, none movement2 movement in absence of force of gravity - full ROM3 movement against force of gravity - full ROM4 movement against force of gravity and moderate resistance - fullROM5 normal strength

Medical Research Council, War Memor. n.7, 1943, from

“Aids to the investigation of the peripheral nerve injuries”, London, repr.1970


Cealing Effect


Contraction types

Anisometric• Concentric

–Isotonic–Isokinetic

• Eccentric–Isotonic–Isokinetic

Anisometric• Concentric

–Isotonic–Isokinetic

• Eccentric–Isotonic–Isokinetic

IsometricIsometric


ISOMETRIC FORCE

musclecontraction in

a staticcondition


Isometric Test

Bad None movement

None mechanical work

None power

Bad Vasoconstriction at low tension

(Barcroft, 1960)


Sale DG, MacDougall D: Specificity in strength training: a review for coach

and athlete. Can J Appl Sport Sci 6:87-92, 1981

The most important criterion

in selecting a test is specificity

The low relationship between dynamic and

isometric tests indicates that muscular

measures are specific to the test modality

rather than general qualities


Isometric test

Not specific to the performance of most human movements that

require dynamic activation of musculature through a

movement range

That is

No relationship between jumping

performance and isometric force in

Finnish national male volleyball team

Mero A, Luhtanen P, Viitasalo J at al: poor correlation between isometric tests and dynamic performance:

relationship to muscle activation. Eur J App Physiol 63:352-357, 1996


Forza Isometrica e sEMG

Isometric Force and EMG

Mechanical and Electrical differences between isometric and anisometric contraction


ISOMETRIC FORCE

Poorly correlated to dynamic force


Isokinetic Force

Accomodating

Resistance along the

entire range of motion

at the maximum effort

degree by degree


Pre-stretching

Eccentric and soon after

concentric contraction of the

antagonist/agonist muscles

• Increasing work and power

• Increasing efficiency


Stretch Shortening Cycle

• Reuse of elastic energy

• Neural Facilitation induced by

stretch reflex

• less than 100 ms between eccentric and concentric contraction



Isokinetic Actuators don’t

permit SSC

• less than 100 ms between eccentric and concentric contraction


sEMG durante il movimento

isocinetico

Isokinetic Movement and sEMG


13 rad/s: knee

angular velocity

during soccer kick

CFC.FOTI: EBM nella riabilitazione dei pazienti con alterazioni del tono-trofismo muscolare Roma, 27 Novembre 2015

Strenght/Velocity RelationshipIsokinetic Curve


Strenght/Velocity RelationshipIsoinertial Curve


Isokinetic Evaluation

Good Good riproducibility

Good Clinical safety

Bad Unnatural movement induced by

strumentation

Bad None stretch-shortening cycle


Isoinertial Exercise

The External resistance is

constant throughout the

range of motion


He works against Force of Gravity

Force of Gravityinfluenced Mankind in reaching standing

position

Force of Gravityinfluenced great artists

in creating theirmasterpieces


She can lift5kg x

10cm butlittle power= 10W

Same work,

different

velocity


This big bee

can lift

5kg x 10cm

but

great power

= 100WC.FOTI: EBM nella riabilitazione dei pazienti con alterazioni del tono-trofismo muscolare Roma, 27 Novembre 2015

Same work,

different

velocity

Iso-inertial testFree load

Motion without great tension

PAIN FREERoma, 27 Novembre 2015C.FOTI: EBM nella riabilitazione dei pazienti con alterazioni del tono-trofismo muscolare

Power developed during leg-extension exercises performed by a female basketball player with a total load of

10kg (including weight estimated for the thigh), presented in function of time. The operated leg (O)

demonstrated lower power requiring longer development time than the other leg (N)


Power developed during leg-extension exercises performed by a female basketball player with a total load of

10kg (including weight estimated for the thigh), presented in function of time. The operated leg (O)

demonstrated lower power than the other leg (N)


ISOINERTIAL DEVICEMUSCLE LAB BOSCO SYSTEM

System accuracy∆v% = 0.863%

∆F% = 0.291%

∆P% = 1.158%

Reproducibilitysame day from 0.57 to 0.84

day to day from 0.85 to 0.97

Specificitystrong correlation

Force velocity relationship


Device based on a precise

measurement of load

displacements of any

machine using gravitational

loads as external resistance

ISOINERTIAL DEVICE


Device allows the calculation of

velocity, force and power during

concentric, eccentric and stretch-

schortening cycle activity,

through a sensor consisting of an

infrared photo interrupter

ISOINERTIAL DEVICE


a) Shuttle including

i.r. photo

interrupters

b) Trach bar

including code strip

c) Microcomputer

d) Moving loads

ISOINERTIAL DEVICE


IsoinertialIsoinertialIsoinertialIsoinertial

EvalutationEvalutationEvalutationEvalutation

C. Bosco, A.

Belli, M. Astrua,

C. Foti et al:

A dynamometer

for evaluation

of dynamic

muscle work

Eur J Appl

Physiol (1995)

70:379-386


Isoinertial Evaluation

Benchmark

• Average Force (N)

• Average Power (W)

• Time to peak power (ms)

• Average linear velocity (m/s)

• Four iEMG signals


0

20

40

60

80

100

120

10 20 30 40 50 60 70 80 90 100

A.U.

KG

ISOINERTIAL GRAPH

N

W

TPP

Displ


sEMG HELPS TO

STUDY

RELATIONSHIP

BETWEEN NERVE

AND MUSCLE

SYSTEM


Neuromuscular Efficiency

Antalgic Inhibition

Isoinertial Evaluation


Muscle Injuries: Is there a

necessity of Imaging?

Ultrasound Imaging in Sports

Medicine

The growing emphasis on the health and fitness

over the years has resulted in increases in both the

number and kind of sport-related injuries



Medicine

Musculoskeletal Ultrasound (MSUS) and Magnetic

Resonance imaging (MRI) have been the mainstay

of sports-injury imaging armamentarium.



Medicine

Better• Less expensive

• More widely accessible

• Real time dynamic imaging

• High resolution

• Simultaneous comparison

• Sonopalpation



Medicine

Worst

• User dependency

• Incomplete evaluation of the whole anatomy

due to its inhability to visualize

structures/pathologies inside the bony tissues


Muscle Injuries: Is there a

necessity of Imaging?

Indeed all the Imaging Procedures are not fully

functional; it means that they don’t give response

about the capacity of the injuried muscle to

produce power during a sports effort


HAMSTRING INJURIES EARLY DIAGNOSIS

Hamstring strains are the most common injuries in athletes


• H/Q Ratio < 60% with isokinetic device

was considered able to detect hamstring

lesions

• Force developed during eccentric work at

extremely high speed cannot be compared

with the force during isokinetic motion

• Isokinetic test cannot predict hamstring

injuries


HAMSTRING INJURIES EARLY DIAGNOSIS

Hamstring Functional Jump Test

Electrodes Disposition

Biceps

femoris

Rectus Femoris


Normal EMGrms signal


Abnormal EMGrms signal


EMGrms ratio Q/H > 1 no damage



EMGrms ratio Q/H < 1 Subclinic Functional Alteration



C. Foti, MD

Physical and Rehabilitation Medicine

Tor Vergata University

Rome, Italy

KACLiR Test in Knee instability: what’s new?


Analyze a new component in the evaluation of the functional stability of the knee

KACLiR TEST

Why?

Knee

Anterior

Cruciate

Ligament

Reconstruction

K

A

C

Li

R

TESTRoma, 27 Novembre 2015C.FOTI: EBM nella riabilitazione dei pazienti con alterazioni del tono-trofismo muscolare

• Aim of the present research is to introduce a new procedure to determine the amount of functional recovery after knee joint surgery

• We propose to compare the biomechanicperformance in the leg extensor test synchronised with sEMG, the H/Q sEMG ratio in jump test and the response in the EMG activity to vibratory stimuli, in the operated and in the uninjured legs

KACLiR Test

END POINT


KACLiR TEST

Leg extension assessment for mechanical

power calculation

A diagnostic technique consisting on monitoring the muscles EMGrms activity during free load leg extension and jumps was applied for identify strength and imbalance deficit of the operated (OL) and non operated (NOL) legs


KACLiR TEST

Whole body vibration treatment procedure

Diagnostic technique consisting on monitoring the

muscles EMGrms activity during vibration

was applied for identify altered neural strategies of

motoneuron pool recruitment

(Nemes ® Bosco System)


- Patients operated with ACL reconstruction (tested from 6 to 270 wks

after surgery)

- Subjects with previous surgery of the lower limbs and spine

- Concomitant disease contralateral limb or systemic diseases

- Surgical intervention prior to more than 1 month

- Muscle injury in the acute or subacute phases

Group A

Experimental Group

38 patients

Mean age = 21,4 ± 3.9

Group B

Control Group

14 healthy subjects

Mean age = 28 ± 6.14

Inclusion criteria

Exclusion criteria

KACLiR TEST

Materials and Methods


First step: Leg extension

Second step: Squat jump

Third step: Counter movement jump

Fourth step: EMG/WBV

KACLiR test


KACLiR testFirst step

Leg extension

EMGrms

VL sx

VM sx

VM dx

VL dx

EM

G[m

V]

Time[s]

0.0

0.5

1.0

1.5

11.3 12.2 13.2 14.2


EMGrmsVL sxVM sxVM dxVL dxHam sxHam dx

EM

G[m

V]

Time[s]

0.0

0.5

1.0

1.5

2.0

2.9 3.7 4.4 5.2


KACLiR testSecond step

Squat Jump

EMGrmsVL sx

VM sxVM dx

VL dx

Ham sx

Ham dx

EM

G[m

V]

Time[s]

0.0

0.5

1.0

1.5

2.0

4.94 5.94 6.95 7.95


KACLiR testThird step

Counter Movement Jump

EMGrms

VL sn

VM sn

VM dx

VL dx

EM

G[m

V]

Time[s]

0

1

2

3

4

0.01 10.01 20.00 30.00

•10 s without WBV

•30 s with WBV at 30 Hz

•10 s without WBV

(Nemes ® Bosco System)


KACLiR testFourth step

EMG/WBV

First step: Leg extension

Leg displacement,

peak velocity, and

mean velocity in the

non operated leg

(NOL) were higher

than those in the

operated leg

(OL)

KACLiR Test

RESULTS

***

**

**

0,00

1,00

2,00

3,00

4,00

5,00

6,00

7,00

peak v mean v leg displacement

(v in m/s

s in dm)

LEG EXTENSION

Operated Leg

Non-Operated

Leg

** p<0,01

*** p<0,002


Second step: Squat jump

sEMG H/Q ratio of

the operated leg was

120% higher than the

contralateral one

sEMG activity of leg

extensor muscles of


80% lower than the

contralateral one

KACLiR Test

RESULTS

*

*

0

0,05

0,1

0,15

0,2

0,25

H/Q EMGs of Quadriceps

Squat Jump

Operated Leg

Non-Operated

Leg

* p<0,05


Third step: Counter movement jump

sEMG H/Q ratio of


64% higher than the

contralateral one

sEMG activity of

quadriceps of

operated leg was 80%

lower than the

contralateral one

KACLiR Test

RESULTS

*

*

0

0,05

0,1

0,15

0,2

0,25

H/Q EMGs of Quadriceps

Counter Movement Jump

Operated Leg

Non-Operated

Leg

* p<0,05


The increase in

sEMG activity

monitored during

vibration treatment

was 100% higher

in the operated leg

than in the non

operated one

Fourth step: EMG/WBV

KACLiR Test

RESULTS


The high EMG activity noted in the operated leg might be caused by

the inappropriate function of proprioceptors

During surgery the proprioceptors were severed,

resulting in hyperactivity duringvibration treatment, mediated by

muscle spindle receptors and alpha motoneurons

(Johansonn H, Lorentzon R, Sjolander P, Sojka P, Neuro-Orthop 1990.)


Analyzing and recording sEMG behaviourof extensor muscles during vibratory

stimulation could allow the quantificationand assessment of knee impairment dueto the proprioceptors inability to function

properly after surgery

KACLiR Test

CONCLUSIONI/II


Combination of isoinertial dynamic testsand vibration stimulation both associated

to sEMG recordings may allow fordetection of impairment of neuromuscularfunctionality as well as monitoring

progress of the rehabilitation programs inKnee ACL reconstruction

KACLiR Test

CONCLUSIONII/II


Calogero Foti, Alessandro Laurini, Simone

Tiberti, Giancarlo Carli, Olga Tsarpela, Kostas Adamidis, Marco Bonifazi, Arrigo Giombini,

Joszef Tihanyi, Serge von Duvillard, Marilena

De Vita, Carmelo Bosco (2012) Leg extension test, sEMG and vibratory stimuli to assess functional recovery following knee joint surgery. Muscles, ligaments and

tendons journal 2: 2. 127-132 Apr.


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