Home-based motor imagery intervention improves functional performance following total knee arthroplasty in the short term: a randomized controlled trial

Abstract

Background: Motor imagery (MI) is effective in improving motor performance in the healthy asymptomatic adult population. However, its possible effects among older orthopaedic patients are still poorly investigated. Therefore, this study explored whether the addition of motor imagery to routine physical therapy reduces the deterioration of quadriceps muscle strength and voluntary activation (VA) as well as other variables related to motor performance in patients after total knee arthroplasty (TKA).

Methods: Twenty-six patients scheduled for TKA were randomized to either MI practice combined with routine physical therapy group (MIp) or to a control group receiving physical therapy alone (CON). MIp consisted of maximal voluntary isometric contraction (MViC) task: 15 min/day in the hospital, then 5 times/week in their homes for 4 weeks. MViC and VA of quadriceps muscle, knee flexion and extension range of motion, pain level, along with a Timed Up-and-Go Test (TUG) and self-reported measure of physical function (assessed using the Oxford Knee Score questionnaire [OKS]) were evaluated before (PRE) and 1 month after surgery (POST).

Results: Significantly better rehabilitation outcomes were evident on the operated leg for the MIp group compared to CON: at POST, the MIp showed lower strength decrease (p = 0.012, η² = 0.237) and unaltered VA, significantly greater than CON (p = 0.014, η² = 0.227). There were no significant differences in knee flexion and extension range of motion and pain level (p > 0.05). Further, MIp patients performed better in TUG (p < 0.001, η² = 0.471) and reported better OKS scores (p = 0.005, η² = 0.280). The non-operated leg showed no significant differences in any outcomes at POST (all p > 0.05). In addition, multiple linear regression analysis showed that failure of voluntary activation explained 47% of the quadriceps muscle strength loss, with no significant difference in perceived level of pain.

Conclusion: MI practice, when added to physical therapy, improves both objective and subjective measures of patients' physical function after TKA, and facilitates transfer of MI strength task on functional mobility.

Trial registration: Retrospectively registered on ClinicalTrials.gov NCT03684148.

Keywords: Cognitive training; Knee osteoarthritis; Mental simulation; Muscle activation; Physical function; Rehabilitation; Total knee replacement.

Fig. 1

Flow chart of participant enrolment, randomised group allocation, and final analysis

Fig. 2

Motor imagery training setup

Fig. 3

Experimental setup for the measurement of isometric strength and voluntary activation of the quadriceps femoris muscle

Fig. 4

Mean percent changes (and standard deviations) from baseline in knee extensor muscles strength (a, b) and voluntary activation (c, d) in motor imagery practice (MIp) and control (CON) groups following total knee arthroplasty surgery

Fig. 5

Mean percent changes (and standard deviations) from baseline in Timed Up-and-Go test (a), and Oxford Knee Score questionnaire (b) in motor imagery practice (MIp) and control (CON) groups following total knee arthroplasty surgery

Fig. 6

Linear regression analysis of the contribution of the change in voluntary activation to the change in the strength of the quadriceps muscle of the operated leg