Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2015 Jun;22(3):270-7.
doi: 10.1016/j.knee.2014.11.013. Epub 2014 Dec 10.

Combination of eccentric exercise and neuromuscular electrical stimulation to improve quadriceps function post-ACL reconstruction

Lindsey K Lepley  1 , Edward M Wojtys  2 , Riann M Palmieri-Smith  3
Affiliations

Combination of eccentric exercise and neuromuscular electrical stimulation to improve quadriceps function post-ACL reconstruction

Lindsey K Lepley et al. Knee. 2015 Jun.

Abstract

Background: Neuromuscular electrical stimulation (NMES) has been shown to reduce quadriceps activation failure (QAF), and eccentric exercise has been shown to lessen muscle atrophy post-ACL reconstruction. Given that these are two critical components of quadriceps strength, intervention combining these therapies may be effective at reinstituting quadriceps function post-reconstruction. Thus, the aim of this study was to evaluate the effectiveness of a combined NMES and eccentric exercise intervention to improve the recovery of quadriceps activation and strength post-reconstruction.

Methods: Thirty-six individuals post-injury were placed into four treatment groups (N&E, NMES and eccentrics; E-only, eccentrics only; N-only, NMES-only; and STND, standard of care) and ten healthy controls participated. N&E and N-only received the NMES protocol 2× per week for the first 6 weeks post-reconstruction. N&E and E-only received the eccentric exercise protocol 2× per week beginning 6 weeks post-reconstruction. Quadriceps activation was assessed via the superimposed burst technique and quantified via the central activation ratio. Quadriceps strength was assessed via maximal voluntary isomeric contractions (Nm/kg). Data was gathered on three occasions: pre-operative, 12-weeks-post-surgery and at return-to-play.

Results: No differences in pre-operative measures existed (P>0.05). E-only recovered quadriceps activation better than N-only or STND (P<0.05). N&E and E-only recovered strength better than N-only or the STND (P<0.05) and had strength values that were similar to healthy at return-to-play (P>0.05).

Conclusion: Eccentric exercise was capable of restoring levels of quadriceps activation and strength that were similar to those of healthy adults and better than NMES alone.

Level of evidence: Level 3, Parallel longitudinal study.

Keywords: ACL; Eccentric; Electrostimulation; Rehabilitation; Strength training.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) diagram. NMES= neuromuscular electrical stimulation, RTP=return-to-play.
Figure 2
Figure 2
Study testing timeline. Upon confirmation of ACL rupture, ACL patients were place into one of four groups. Prior to ACL reconstruction, all ACL patients underwent a pre-operative testing session consisting of quadriceps muscle strength and activation measurements. ACL patients in the combined NMES and eccentric exercise (N&E) and NMES (N-only) groups began the 6-week NMES therapy protocol immediately post-surgery. At six weeks post-operative, the N&E and eccentric (E-only) groups began the eccentric strengthening program. Patients in the standard of care (STND) group did not receive either intervention. Quadriceps strength and activation measurements were collected again at 12-weeks post-surgery as well as return-to-play. Healthy participants participated in only one testing session (return-to-play) where quadriceps activation and strength were measured.
Figure 3
Figure 3
Patient receiving the NMES treatment (A) and performing the eccentric leg press (B).
Figure 4
Figure 4
Pre-operative-to-12-weeks post-surgery percent change in quadriceps activation plotted against percent change in quadriceps strength (P=0.02)
Figure 5
Figure 5
Pre-operative-to-Return-to-Play percent change in quadriceps activation plotted against percent change in quadriceps strength (P=0.03).
See this image and copyright information in PMC

References

    1. Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med. 2008;27(3):405–24. - PubMed
    1. Schmitt LC, Paterno MV, Hewett TE. The Impact of Quadriceps Femoris Strength Asymmetry on Functional Performance at Return to Sport Following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2012;42(9):750–9. - PMC - PubMed
    1. Keays SL, Bullock-Saxton J, Newcombe P, Keays AC. The relationship between knee strength and functional stability before and after anterior cruciate ligament reconstruction. J Orthop Res. 2003;21:231–7. - PubMed
    1. Hurley MV, Jones DW, Wilson D, Newham DJ. Rehabilitation of quadriceps inhibition due to isolated rupture of the anterior cruciate ligament. Journal of Orthopaedic Rheumatology. 1992;5:145–54.
    1. Tourville TW, Jarrell KM, Naud S, Slauterbeck JR, Johnson RJ, Beynnon BD. Relationship Between Isokinetic Strength and Tibiofemoral Joint Space Width Changes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2014;42(2):302–11. - PMC - PubMed

Publication types