Athrogenic muscle inhibition (AMI) • What is AMI and what ...
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1 Anil Bhave, PT Director Gait Laboratory Clinical Director Orthopedic Rehabilitation Rubin Institute of Advanced Orthopedics Sinai Hospital, Baltimore, Maryland Muscle Activation deficits Athrogenic muscle inhibition (AMI) • What is AMI and what causes it? Bhave 2017 Simple formula Bhave 2017 Quadriceps Arthrogenic Muscle Inhibition: Neural Mechanisms and Treatment Perspectives David Andrew Rice, BHSc,* and Peter John McNair, PhD† Conclusions: AMI remains a significant barrier to effective rehabilitation in patients with arthritis and following knee injury and surgery. Gaining a better understanding of AMI’s underlying mechanisms will allow the development of improved therapeutic strategies, enhancing the rehabilitation of patients with knee joint pathology. Arthrogenic muscle Inhibition • Pain • Joint effusion • Age (Central activation deficit) • Instability • Habitual Limp leads to quads avoidance gait Bhave 2017 Bhave 2017
Transcript of Athrogenic muscle inhibition (AMI) • What is AMI and what ...
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Anil Bhave, PTDirector Gait LaboratoryClinical Director Orthopedic RehabilitationRubin Institute of Advanced OrthopedicsSinai Hospital, Baltimore, Maryland
Muscle Activation deficitsAthrogenic muscle inhibition
(AMI)
• What is AMI and what causes it?
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Simple formula
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Quadriceps Arthrogenic Muscle Inhibition:Neural Mechanisms and Treatment PerspectivesDavid Andrew Rice, BHSc,* and Peter John McNair, PhD†
Conclusions: AMI remains a significant barrier to effective rehabilitation in patients with arthritis and following knee injury and surgery. Gaining a better understanding of AMI’s underlying mechanisms will allow the development of improved therapeutic strategies, enhancing the rehabilitation of patients with knee joint pathology.
Arthrogenic muscle Inhibition
• Pain
• Joint effusion
• Age (Central activation deficit)
• Instability
• Habitual Limp leads to quads avoidance gait
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CAR (Central Activation Ratio)Age related
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Mechanisms Undlerlying Quadriceps Weakness in KneeOsteoarthritisSTEPHANIE C. PETTERSON1,2, PETER BARRANCE3, THOMAS BUCHANAN4, STUARTBINDER-MACLEOD2, and LYNN SNYDER-MACKLER
Med Sci Sports March 2008
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Habitual limp
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Knee Flexion Lever Arm
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What about touniquet?
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EMG changes in 18/25 patients post menisectomy
• EMG changes temporary
• 16/18 resolved in 6 months
• Direct correlation exists between EMG abnormality and duration of tourniquet inflation and patient’s recovery time
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Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A
Randomized Trial.Dennis DA1, Kittelson AJ, Yang CC, Miner TM, Kim
RH, Stevens-Lapsley JE.
• Quad weakness 11.3 Nm for 3 months
• No effect on hamstrings
• Small difference in blood loss
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Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty.
Liu D1, Graham D2, Gillies K3, Gillies RM4.Knee Surg Relat Res. 2014 Dec;26(4):207-13. doi:
10.5792/ksrr.2014.26.4.207. Epub 2014 Dec 2
• Increased pain in tourniquet group
• No difference in ROM, strength, Oxford Knee score
• Quad strength compromised up to 6 months as studied by surface EMG
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Bottom line about tourniquet?
• More than 2 hours
• Max optimal pneumatic pressure 270 to 290 mm/hg
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What are the long term effects of AMI
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Functional problems after TKA
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Quadriceps strength 98 OA (55 to 72 yrs.) compared to Fearon F (1989) data on 79
asymptomatic patients
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Male OA Malenormal
Female OA Femalenormal
Male OA
Male normal
Female OA
Female normal
(Force/BW)*100Bhave 2017
Difficulty in post TKA patients ( 661 patients 1‐4 year f/u
% of patients with difficulty
Limp or difficulty in gait 53%
Difficulty with stairs 54%
Difficulty getting out of car 38%
Difficulty getting out of chair 31%
Difficulty in participating in recreational activity 50%
Stiffness and pain 41%
Clin Orthop Relat Res. 2014 Jan;472(1):133-7.
High level of residual symptoms in young patients after total knee arthroplasty.Parvizi J, Nunley RM, Berend KR, Lombardi AV Jr, Ruh EL, Clohisy JC, Hamilton WG, Della Valle CJ, Barrack R
Need for prehabilitation and rehabilitation in TKA
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The Effect of a Prehabilitation Exercise Program on Quadriceps Strength for Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Pilot StudyCarly McKay, PhD, Harry Prapavessis, PhD, Timothy Doherty, PhDAmerican Academy of Physical Medicine and Rehabilitation1934‐1482/12/$36.00 Vol. 4, 647‐656, September 2012
Brace patients
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Brace and NMESCohort
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Use of Extension assist brace post TKA
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NMES How strong
Maximally tolerated
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Physical Therapist
•Can we be Masters of Disasters?
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Need to innovate
because routine did not work well
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Case 1
Arthrogenic muscle inhibition with ROM
deficit
June 2013
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PCL, LCL,MCL complete and partial ACL rupture
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Post reconstruction Infection
August 2013
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Post Infection contracture
December 2013
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Bracing and Therapy protocol
• EXT guardian brace all day long
• Removable extension splint all night
• PT 1-2 times a week
• NMES at home 2 times day in bed
• Hip strengthening in brace
• WALKING in guardian brace two crutches to one crutch to no device
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CKD +Sport EXT
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Full extension
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PT ROM Progress
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Transitioned to Guardian sports brace and
Sports specific PT
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PT progress
May 2014
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Return to non contact sports
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Sports specific perfomance
• Strength equal to the opposite side (Isokinetic testing)
• Single hop for distance with in 5 cms of normal
• Full ROM• Lateral jump equal to opposite
side Bhave 2017
Return to non contact sports
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Case 2 Valgus knee deformity
beware of peroneal nerve
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Post CKD and PT
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Happy Patient
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Case 4Congenital Knee flexion
contracture
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Custom solution
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Improved Gait
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Case 5: Knee Flexion Contracturewith Grade 2 Quads
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Initial Rx
• BoNT –A , Hamstrings.
• Serial casting 1 week X 2.
• PT started 2 times a week after serial cast removal.
• Home NMES Unit
• Once a week TDN/IMT
• Walking brace fitting 2 weeks after PT start.
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Initial brace fitting400 KFC, 350 Quad Lag
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Patient with 25° of knee flexion contracture andGrade 3- quadriceps strength with 40°active extension lag
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Patient with 15° of Knee flexion contracture andGrade 3- quadriceps strength with 40° active extension lag
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Thank You
[email protected]@lifebridgehealth.org
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