The influence of various methods of physiotherapy on volitional muscle activation of the quadriceps femoris muscle after anterior cruciate ligament rupture

Uvod: Poškodbi in rekonstrukciji sprednje križne vezi sledi šibkost mišice quadriceps femoris. K šibkosti mišice naj bi bistveno prispevali njena atrofija in zmanjšana sposobnost hotene aktivacije. Slednja se pojavi zaradi zmanjšanja centralnih prilivov v mišico, ki so posledica sprememb v spinalnorefleksni in kortikospinalni živčni poti. Zmanjšana centralna aktivacija mišice naj bi bila predvsem zaščitni mehanizem telesa pred nadaljnjimi poškodbami, vendar žal preprečuje učinkovito rehabilitacijo in vrnitev v aktivnosti oziroma šport. Vztrajala naj bi tudi več let po poškodbi. Namen: Namen diplomskega dela je ugotoviti učinek rehabilitacije in ustreznih terapevtskih postopkov na spremembo centralne aktivacije ter inhibicijo mišice quadriceps femoris pri osebah po poškodbi sprednje križne vezi. Metode dela: Diplomsko delo je izvedeno z metodo sistematskega pregleda strokovne in znanstvene literature. Iskanje literature je potekalo v podatkovni bazi PubMed s pomočjo ključnih besed. Iskanje člankov ni bilo omejeno z letom objave ali specifično terapevtsko obravnavo oziroma rehabilitacijskim protokolom. Rezultati: V diplomsko delo smo vključili osem člankov. V štirih raziskavah so ugotavljali spremembo centralne aktivacije mišice quadriceps femoris po splošnem rehabilitacijskem protokolu, v štirih pa po specifičnih fizioterapevtskih protokolih. Rezultati raziskav glede vpliva splošnega rehabilitacijskega protokola so precej različni, celo nasprotujoči. Nekatere raziskave ugotavljajo izboljšanje centralne aktivacije mišice po rehabilitaciji, nekatere pa njeno poslabšanje. Rezultati raziskav, ki so preiskovale vpliv specifičnih fizioterapevtskih protokolov, nakazujejo na veliko učinkovitost ekscentrične vadbe pri pacientih z deficitom v centralni aktivaciji po poškodbi sprednje križne vezi. Do precejšnjega izboljšanja centralne aktivacije mišice privedejo tudi kombinacije fizioterapevtskih postopkov, kot sta krioterapija pred vadbo in transkutana električna živčna stimulacija (TENS) med vadbo. Žal pri slednjih dveh protokolih avtorji niso izmerili statistično pomembne razlike v primerjavi z zgolj vadbo, vendar pa je razlika klinično pomembna. Razprava in sklep: Za čim večje izboljšanje mišične jakosti in centralne aktivacije mišice quadriceps femoris pri posameznikih po poškodbi sprednje križne vezi se predlaga v rehabilitacijski oziroma fizioterapevtski program vključiti ekscentrično vadbo, krioterapijo pred vadbo in transkutano električno stimulacijo med vadbo (TENS). Za trdnejše ugotovitve bi bilo potrebno v pregled literature vključiti večje število raziskav. Ostaja potreba po večjem številu raziskav, ki bi preiskovale učinek fizioterapevtskih postopkov pri osebah po pretrganju sprednje križne vezi.Introduction: The weakness of quadriceps femoris muscle is a common occurrence after rupture and reconstruction of the anterior cruciate ligament. Muscle atrophy and reduced ability of voluntary activation substantially contribute to the muscle weakness. Reduced muscle activation occurs due to a decrease in central inflows to the muscle resulting from changes in spinal-reflex and corticospinal neural pathways. Reduced central muscle activation should primarily be the protective mechanism of the body against further injuries, but unfortunately it prevents effective rehabilitation and return to activity or sport. It also persists for several years after the injury. Purpose: To determine the effect of rehabilitation and appropriate therapeutic procedures on the change in central activation and inhibition of quadriceps femoris muscle in individuals after anterior cruciate ligament injury. Methods: The method that we used was a systematic review of technical and scientific literature. The literature search was conducted in the PubMed database using keywords. Results: We have included eight articles. Four studies observed a change in the central activation of quadriceps according to a general rehabilitation protocol, while four studies observed a change according to specific physiotherapeutic protocols. The results of studies where the general rehabilitation protocol was used are quite different, even contradictory. Some studies have found improvement in central muscle activation after rehabilitation, while some have found its decrease. Results of studies that investigated the effect of specific physiotherapeutic protocols indicate high efficacy of eccentric exercise in patients with a deficiency in central muscle activation after anterior cruciate ligament rupture. Considerable improvements in central muscle activation were also measured after therapies where combinations of physiotherapy procedures, such as cryotherapy before exercise and transcutaneous electrical nerve stimulation (TENS) during exercise, were used. Unfortunately in the latter two protocols authors did not measure statistically significant differences compared to mere exercise, but the difference is clinically relevant. Discussion and conclusion: In order to improve muscle strength and central activation of quadriceps femoris muscle in individuals after anterior cruciate ligament rupture a rehabilitation or physiotherapeutic program is proposed to include eccentric exercise, cryotherapy before exercise or transcutaneous electrical nerve stimulation (TENS) during exercise. For more solid findings greater number of studies should be included in the literature review. The need for further studies that would investigate the effect of certain physiotherapy procedures in subjects after anterior cruciate ligament rupture still remains