Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures

Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy

Effects of Whole-Body Electromyostimulation on Physical Fitness and Health in Postmenopausal Women

La menopausa s’associa amb un deteriorament de la forma física juntament amb guanys de pes i massa grassa, que poden resultar de canvis hormonals relacionats amb la menopausa, malalties associades a l’envelliment i una disminució del temps d’activitat física. Aquesta situació adversa deixa a les dones postmenopàusiques un risc elevat de desenvolupar resultats adversos per a la salut que condueixen a una dependència en un futur proper i a una baixa qualitat de vida. S'ha establert que l'activitat física té un paper fonamental en la prevenció d'aquest deteriorament físic. Per tant, l’electromioestimulació del cos sencer (WB-EMS) podria ser una metodologia d’èxit com a entrenament per millorar la forma física i la salut en dones postmenopàusiques. L'objectiu d'aquesta tesi era: (1) Analitzar els resultats obtinguts de la investigació existent sobre WB-EMS i provar el nivell d'evidència de cadascun dels estudis per comprendre l'estat del problema i identificar possibles mètodes d'investigació en el futur. ; (2) Establir un protocol compatible amb una rigorosa metodologia científica per estudiar els efectes del WB-EMS. (3) Analitzar si el WB-EMS és adequat per a la prevenció i el tractament del deteriorament físic postmenopàusic. En conseqüència, aquesta tesi es presenta en un compendi de quatre publicacions, amb diferents dissenys i metodologies: la primera d’elles presenta una revisió sistemàtica dels efectes del WB-EMS sobre la salut i el rendiment. El segon presenta un disseny d’un protocol que permet avaluar, des d’una perspectiva àmplia i multivariable, la influència d’un programa d’entrenament WB-EMS de 10 setmanes sobre la condició física i la salut mitjançant un disseny de grup paral·lel de 2 braços amb seguiment. . Els dos restants, discuteixen els resultats d’una fase experimental on es va dur a terme l’esmentat protocol amb dones postmenopàusiques. Els resultats d’aquesta investigació suggereixen que hi ha una manca d’estudis controlats aleatoris i que els estudis existents presenten un nivell de risc de biaix moderat a elevat, cosa que fa necessària la realització d’assaigs de control que abordin aquesta qüestió des d’una perspectiva científica i rigorosa. A més, el WB-EMS mostra un efecte aïllat favorable en el desenvolupament de la força dinàmica de les cames, agilitat i resistència cardiovascular, però no en la força del braç dinàmic, la velocitat de la marxa, l’equilibri o la flexibilitat de les dones postmenopàusiques. La principal contribució d’aquest treball és l’evidència que, sota la supervisió d’un tècnic d’activitat física, el programa d’entrenament proposat basat en WB-EMS superposat podria ser adequat per a dones postmenopàusiques que tenen dificultats per realitzar exercici físic continu. Seria una metodologia adequada per desenvolupar la seva resistència aeròbica, així com la seva capacitat funcional. D’aquesta manera, a causa d’aquesta millora de la forma física, reduirien el risc de caigudes, el deteriorament cardiovascular i la dependència, cosa que milloraria la seva qualitat de vida.La menopausia se asocia con un deterioro de la condición física junto con el aumento de peso y masa grasa, que pueden derivarse de cambios hormonales relacionados con la menopausia, enfermedades asociadas al envejecimiento y disminución del tiempo de actividad física. Esta situación adversa deja a las mujeres posmenopáusicas en un mayor riesgo de desarrollar resultados de salud adversos, que conduzcan a una dependencia futura y una baja calidad de vida. Se ha establecido que la actividad física juega un papel fundamental en la prevención de este deterioro físico. Así, la electroestimulación de cuerpo entero (WB-EMS) podría ser una metodología exitosa como entrenamiento para mejorar la condición física y la salud en mujeres posmenopáusicas. Los objetivos de esta tesis fueron: (1) Analizar los resultados obtenidos de la investigación existente sobre WB-EMS y probar el nivel de evidencia de cada uno de los estudios para comprender el estado del tema e identificar posibles métodos de investigación en el futuro; (2) Establecer un protocolo compatible con una metodología científica rigurosa para estudiar los efectos de WB-EMS; (3) Analizar si WB-EMS es adecuada en la prevención y tratamiento del deterioro físico posmenopáusico. En consecuencia, esta tesis se presenta en un compendio de cuatro publicaciones, utilizando diferentes diseños y metodologías. La primera de ellas presenta una revisión sistemática sobre los efectos de WB-EMS en la salud y el desempeño. La segunda presenta el diseño de un protocolo que permite evaluar, desde una perspectiva amplia y multivariable, la influencia de un programa de entrenamiento WB-EMS de 10 semanas sobre la condición física y la salud, mediante un diseño de grupos paralelos de 2 brazos con seguimiento. Las dos restantes, discuten los resultados de una fase experimental donde se realizó el mencionado protocolo con mujeres posmenopáusicas. Los resultados de esta investigación sugieren que existe una falta de estudios controlados aleatorizados, y los estudios existentes exhiben un nivel de riesgo de sesgo de moderado a alto, lo que hace necesaria la realización de ensayos de control que aborden este tema desde una perspectiva científica y rigurosa. Además, WB-EMS muestra un efecto aislado favorable en el desarrollo de la fuerza dinámica de las piernas, la agilidad y la resistencia cardiovascular, pero no en la fuerza dinámica del brazo, la velocidad de la marcha, el equilibrio o la flexibilidad de las mujeres posmenopáusicas. El principal aporte de este trabajo es la evidencia de que, bajo la supervisión de un técnico de actividad física, el programa de entrenamiento propuesto basado en WB-EMS superpuesto podría ser adecuado para mujeres posmenopáusicas que tienen dificultades para realizar ejercicio físico continuo. Sería una metodología adecuada para desarrollar su resistencia aeróbica, así como su capacidad funcional. De esta forma, debido a esta mejora de la condición física, reducirían su riesgo de caídas, su deterioro cardiovascular y su dependencia, lo que mejoraría su calidad de vida.Menopause is associated with a deterioration of physical fitness along with weight and fat mass gains, which may result from menopause-related hormonal changes, aging-associated diseases, and decreased physical activity time. This adverse situation leaves postmenopausal women at a heightened risk for developing adverse health outcomes leading to a near future dependence and low quality of life. It has been established that physical activity plays a fundamental role in the prevention of this physical deterioration. Thus, whole-body electromyostimulation (WB-EMS) could be a successful methodology as a training to improve the physical fitness and health in postmenopausal women. The objectives of this thesis were: (1) To analyze the results obtained from the existing research on WB-EMS and testing the level of evidence of each of the studies to understand the status of the issue and identify possible methods of investigation in the future; (2) To establish a protocol compatible with a rigorous scientific methodology to study the effects of WB-EMS. (3) To analyze if WB-EMS is suitable in the prevention and treatment of postmenopausal physical deterioration. Accordingly, this thesis is presented in a compendium of four publications, using different designs and methodologies: the first of them presents a systematic review of the effects of WB-EMS on health and performance. The second presents a design of a protocol that allows the assessment, from a broad and multivariable perspective, the influence of a 10-week WB-EMS training program on the physical condition and health using a 2-arm parallel group design. The two remaining texts, discuss the results of an experimental phase where the mentioned protocol was carried out with postmenopausal women. Results of this research suggest that there is a lack of randomized controlled studies, and the existing studies exhibit a moderate to a high level of risk of bias, which makes necessary the realization of control trials approaching this issue from a scientific and rigorous perspective. Furthermore, WB-EMS shows a favorable isolated effect on the development of dynamic leg strength, agility, and cardiovascular endurance but did not in dynamic arm strength, gait speed, balance, or flexibility of postmenopausal women. The main contribution of this work is the evidence that, under the supervision of a physical activity technician, the proposed training program based on superimposed WB-EMS could be suitable for postmenopausal women who find it difficult to carry out continuous physical exercise. It would be an adequate methodology to develop their aerobic resistance, as well as its functional capacity. In this way, due to this physical fitness enhancement, they would reduce their risk of falls, their cardiovascular deterioration, and their dependence, what would improve their quality of life

Rehabilitation in chronic respiratory diseases: In-hospital and post-exacerbation pulmonary rehabilitation: Peri-exacerbation pulmonary rehabilitation

Exacerbations of chronic obstructive pulmonary disease (COPD) that require hospitalization are important events for patients. Functional impairment and skeletal muscle dysfunction can increase the risk of hospitalization and readmission, independent of lung function. In addition, once a patient is admitted, multiple factors can lead to worsening outcome including immobility, systemic inflammation and nutritional depletion. These non‐pulmonary factors are potentially amenable to exercise therapy, as part of pulmonary rehabilitation (PR). Peri‐exacerbation PR has an important role in the management of exacerbations of COPD. In this review, we explore how functional limitation and skeletal muscle dysfunction affect patients having a severe exacerbation of COPD, the systemic impact of hospitalization on patients including potential aetiologies and the role of PR around the time of an exacerbation. This includes rehabilitation during the inpatient phase, post‐exacerbation rehabilitation and rehabilitation bridging hospital discharge. We also describe potential future developments in peri‐exacerbation PR

Neuromuscular electrical stimulation to improve muscle weakness in hip osteoarthritis: A feasibility study

Current rehabilitation practice in joint replacement surgery for the treatment of end-stage hip osteoarthritis may be ineffective at producing a level of neuromuscular activation required to induce a muscle strength adaption before and after surgery and therefore innovations are required. Neuromuscular electrical stimulation (NMES) is the elicitation of muscle contraction using electric impulses that can restore and increase skeletal muscle mass when voluntary exercise is limited due to pain during joint loading. The scoping review conducted in this integrated thesis identified i) a paucity of research exploring NMES interventions in individuals with hip osteoarthritis and ii) emerging evidence in related patient populations to support NMES for improving muscle strength and function. These findings shaped the design of a case-control study that compared lower limb strength in individuals with hip osteoarthritis to their healthy counterparts. When compared to a control group, weakness was observed in the maximal strength of the knee extensors (-22%), knee flexors (-34%) and hip abductors (-46%), but knee extensor endurance was the most considerably impaired measure in the affected (-70%) and contralateral limb (-62%) of those with hip osteoarthritis. An acceptability study followed and found that NMES of the knee extensors was tolerable and effective at producing an involuntary muscle contraction. However, it was difficult to stimulate the hip abductor muscles at an intensity acceptable to the participant due to pain and discomfort. A systematic review was later conducted to evaluate adherence levels to NMES interventions in orthopaedic populations and identify strategies to increase compliance. These strategies were combined with findings from the early experimental work to underpin a feasibility study that evaluated a six-week, home-based NMES intervention applied to improve knee extensor endurance in older adults. The intervention was successful at improving bilateral knee extensor endurance, maximal strength, mobility, and muscle size, and found high adherence to the intervention with favourable feedback from the NMES users. This study suggests that NMES of the knee extensors is a feasible and acceptable treatment modality for people with hip osteoarthritis that may lead to improvements in muscle endurance and mobility. Due to the non-weight bearing nature of NMES, this intervention could be applied before or after joint replacement surgery, and therefore these findings are important to inform current rehabilitation practice in hip osteoarthritis. Future research should involve assessing the intervention described here in a clinical setting, with a longitudinal design, to establish the long-term benefits of NMES on patient mobility

Exercise training by neuromuscular stimulation in chronic heart failure

BACKGROUND. Conventional exercise training in chronic heart failure (CHF) is safe and beneficial. Training is therefore recommended in a number of guidelines although the data upon which these recommendations are based are drawn from trials enrolling highly selected groups of CHF patients. Extrapolation of these data to a wider CHF population is difficult. Additionally, the optimal mode of training and the timing of introduction of training during a CHF patient's illness pathway is unclear. Applicability of conventional training regimes to the wider population is uncertain. This thesis explores the differing characteristics of trial and general CHF populations and describes the utility of a novel form of exercise training, neuromuscular electrical stimulation of the legs for both stable patients and those with recently decompensated symptoms, a group normally excluded from exercise training trials.METHODS. Studies 1-3 randomise stable patients to conventional bicycle training (Bike) or neuromuscular stimulation (NMS) of quadriceps and gastrocnemius leg muscles. A 6- week training programme is undertaken with functional performance assessed by 6- minute walk (6MW), quadriceps strength and fatigue testing, cardiopulmonary exercise testing and quality of life scoring. Body composition is assessed further in study 2 using dual-energy X-ray absorptionometry. Inflammatory markers are assessed before and after training in study 3. Study 4 is a controlled trial of NMS and Bike training including stable (S-CHF) and recently decompensated (RD-CHF) patients, with performance testing before and after a period of training. Study 5 explores the characteristics of a large group of CHF patients admitted to hospital with heart failure and compares the characteristics of these patients with those included in the exercise training trial described in study 4 and also with those patients included in a recent meta-analysis of exercise training trials.RESULTS. Improvements in 6MW, treadmill exercise time, quadriceps strength and fatigue were observed following both Bike and NMS training for stable patients in study 1. In study 2, a significant improvement in peak VO2 following bike training but not NMS was observed when corrected for lean muscle mass. No change in body composition following training was observed. Pro-inflammatory state was attenuated following conventional training with a significant fall in sTNFar2 in the Bike group only. NMS training resulted in significant improvement in NT-pro BNP when compared with controls and Bike patients in study 4. Overall, exercise training appeared to be effective when RD-CHF patients were included. Study 5 demonstrated that only 6.7% of the screened population was suitable for inclusion in the exercise training trial in study 4. Eligible patients were younger, more likely to be male, had fewer comorbidities and were on more optimal CHF medication than the non-eligible patients despite similar symptoms. The characteristics of the eligible patients were similar to those included in the large meta-analysis.CONCLUSIONS. NMS exercise training appears safe and effective in stable CHF patients, although it differs from Bike training in its effects on markers of inflammation. Body composition did not change following training despite functional improvements, implying qualitative changes in peripheral muscle. RD-CHF patients may benefit from training but recruitment into a trial of exercise training is difficult. NMS is more easily delivered than Bike training and it may be a useful alternative or bridging therapy for those who cannot exercise conventionally. Extrapolation of data presented in this thesis and that published in the literature needs to be viewed critically in the context of the wider CHF population as standard inclusion and exclusion criteria application in addition to the psychosocial features of those volunteering for trials results in substantially different population characteristic