Neuromuscular electric stimulation in patellofemoral dysfunction: riterature review

Abstracts

A disfunção femoropatelar é uma deficiência bastante comum entre indivíduos jovens que acomete, principalmente, o sexo feminino e pode ser caracterizada por dor, edema e creptação retropatelar. Sistematizar o conhecimento em relação ao aumento da força muscular do quadríceps e alívio de dor em pacientes com disfunção femoropatelar, através da utilização da estimulação elétrica neuromuscular e exercícios resistidos. Trata se de um estudo de revisão narrativa da literatura no período de 2005 a 2011. Os critérios de inclusão foram artigos de intervenção, dos últimos seis anos, nos idiomas inglês, espanhol e português, que utilizaram o fortalecimento muscular e a eletroestimulação neuromuscular para reabilitação obtidos através de buscas nos bancos de dados eletrônicos Medline, Lilacs e na biblioteca Bireme. A busca bibliográfica resultou em 28 referências, destes foram excluídos nove de acordo com os objetivos e critérios de inclusão e foram selecionados 16 artigos para leitura dos resumos e posterior análise. A Estimulação Elétrica Neuromuscular (EENM) de média frequência pode ser utilizada associada a exercícios resistidos como coadjuvante no tratamento da disfunção femoropatelar (DFP), tanto para se obter um reequilíbrio muscular quanto para o alívio da dor.

Condromalácia da patela; Joelho; Músculo quadríceps

REVISION ARTICLE

Faculdade Social da Bahia - Salvador, BA, Brazil

Mailing address

ABSTRACT

Patellofemoral dysfunction is a fairly common deficiency among young individuals that primarily affects females and may be characterized by pain, swelling and retropatellar crepitation. The purpose of this review of literature from the period between 2005 and 2011 was to systematize knowledge in relation to the increase in quadriceps muscle strength and pain relief in patients with patellofemoral dysfunction, using neuromuscular electrical stimulation and resistance exercises. The inclusion criteria were intervention articles from the past six years, in English, Spanish and Portuguese, which used muscle strengthening and neuromuscular electrical stimulation for rehabilitation obtained through searches in the electronic databases Medline and Lilacs and in the Bireme library. The bibliographic search yielded 28 references, of which nine were excluded in accordance with the aims and inclusion criteria while 16 articles were selected for reading of the abstracts and subsequent analysis. Mediumfrequency Neuromuscular Electrical Stimulation (NMES) can be used in association with resistance exercises as an adjuvant in the treatment of patellofemoral dysfunction (PFD), both to achieve muscle rebalance and for pain relief.

Keywords: Chondromalacia patellae. Knee. Quadriceps muscle.

INTRODUCTION

Internal knee joint problems are numerous and their consequences compromise the function and the quality of life of individuals.¹ Chondromalacia patellae is characterized by pain, edema and retropatellar crepitation,² and is produced by repeated abnormal compressive action on the articular cartilage. This abnormal compression is derived from the non-congruence and from the decrease of the patellofemoral joint contact area (PFJ) when a patellar subluxation or dislocation is caused by a poor anatomical or biomechanical relationship.³

Freire et al.⁴ report that the incidence of patellofemoral dysfunction increases according to the age bracket, with greater frequency in female patients with associated obesity. Other factors such as instability, fracture, patellar subluxation, increase of the quadriceps angle (Q angle), inefficient vastus medialis muscle, poor post-traumatic alignment, excessive lateral pressure syndrome and posterior cruciate ligament injury can increase the incidence. Belchior et al.⁵ report that this pathology constitutes 25% of the injuries that compromise the knee and 5% of all sports injuries, which represents a common complaint, in 20% of the population and mainly affects young females between 15 and 25 years of age.

A study conducted by Fonseca et al.⁶ reports that the main factor that provokes patellofemoral dysfunction is abnormal lateral traction of the patella, due to a neuromuscular imbalance between the vastus medialis obliquus (VMO) and vastus lateralis (VL) muscles; accordingly, muscle strengthening based on VMO and VL rebalancing could reduce discomfort in patients with Patellofemoral Pain Syndrome (PFPS), which corroborates the results of Cabral et al.,⁷ where they demonstrated that treatment based on quadriceps strengthening enables an improvement of the signs and symptoms exhibited by patients.

"Russian electrical stimulation " arose in 1976 with the goal of obtaining greater muscle performance, through the use of a medium-frequency alternating current, with 2,500Hz, on elite athletes with the objective of achieving muscle strength gains of 30 to 40%.^8-10 Bril et al.¹¹ in his study with 15 healthy patients of both sexes, achieved gains of muscle strength and trophism by associating "Russian stimulation" with resistance exercises. A study carried out by Pelizzari et al.¹² demonstrated that the use of medium-frequency neuromuscular electrical stimulation (NMES) produced an increase in muscle mass in a dog with induced muscular atrophy. In a study conducted by Modli el al.¹³, the author informs that neuromuscular electrical stimulation has been used for many years in rehabilitation, especially in the treatment of denervated muscles, muscular atrophies or to increase muscle strength.

This study is vital, since the work to increase muscle strength interferes in knee instability, probably leading to a decrease in patellofemoral pain. The aim of the present study is to systematize knowledge about the use of neuromuscular electrical stimulation on the quadriceps associated with resistance exercises, to increase muscle strength and to reduce pain in patients with patellofemoral dysfunction.

MATERIALS AND METHODS

This study consists of a narrative review of the literature from the period from 2005 to 2011. The first step was a bibliographical survey using the keywords: chondromalacia patellae, knee, quadriceps muscle and their correlated versions in English and Spanish in the databases Medline and Lilacs and in the Bireme library. For the reading selection of the abstracts we included intervention articles from the last six years, which used muscle strengthening and neuromuscular electrical stimulation for rehabilitation. At this point we excluded the literature review articles, articles from outside the 2005-2011 period and articles that presented other pathologies associated with chondromalacia. After the selection of the included abstracts the articles were read in full for the analysis.

RESULTS

The bibliographic search yielded 28 references, obtained through the keywords patellofemoral dysfunction, knee, quadriceps muscle, neuromuscular electrical stimulation and their respective correlated versions in English. Nine references were excluded from this total according to the inclusion objectives and criteria and 16 articles were selected for reading of the abstracts. No studies were found in Spanish and the predominant methodology was that of controlled intervention articles. The searches indicated a larger number of publications in the year 2008. The information on the results found in the articles is summarily described in Table 1.

Indexed articles written in English and Portuguese were included in the review, with those addressing the effects of NMES and of muscle strengthening on patients with Patellofemoral Dysfunction (PFD) prevailing.

DISCUSSION

The use of "Russian electrical stimulation" associated with resistance exercises in patients with patellofemoral dysfunction (PFD), products strength gains and consequently pain relief. Augusto et al.¹⁴ verified that the intensity of muscle activation increases with the use of neuromuscular electrical stimulation (NMES), which makes it suitable in cases of PFD, since the greater incidence of this dysfunction is related to muscular imbalance, which corroborates the study by Bevilaqua-Grossi et al.,¹⁵ where a difference is observed in the reflex activation time between the Vastus Medialis Obliquus (VMO) and Vastus Lateralis Obliquus (VLO) muscles, both in healthy individuals and in patients with PFD. Santos et al.¹⁶ compare the vastus medialis obliquus (VMO), vastus lateralis longus (VLL) and vastus lateralis obliquus muscle activation time during a walk on the treadmill with 27 individuals, 15 of whom were healthy and 12 had PFD. At the end of the study they observed a difference between VMO and VLL, where in the individuals with PFD the activation order started with VLL followed by VLO and finally VMO, while in the individuals without PFD the order was inverted, starting with VMO, followed by VLO and lastly VLL. This study shows that the imbalance between the lateral and medial musculature will predispose to the appearance of PFD. Cabral et al.¹⁷, through a controlled study, with a total of eight sessions, verified that open kinetic chain (OKC) and closed kinetic chain (CKC) exercises bring about important improvements in the main signs and symptoms presented by patients with PFD. Nakagawa et al.¹⁸ conducted a study on 14 patients of both sexes with PFD. The intervention group (G1) performed additional strengthening of the hip abductors and lateral rotators associated with reinforcement of the quadriceps and the control group (G2) performed only quadriceps reinforcement. At the end of the study they ascertained that (G1) had achieved improvement in torque during knee extension, in the electromyographic activity of the gluteus medius and in the symptomatology of the pain perceived, while (G2) only achieved an improvement in torque for knee extension. Therefore, these studies show us the considerable importance of muscle strengthening in obtaining better balance between patella and femur, diminishing the degenerative processes and consequently the pain symptomatology.

Jennifer et al.¹⁹ conducted a study with 19 women with PFD and noted that the strengthening at eight weeks of the proximal hip muscles improves knee stability, reducing pain and improving functional capacity.

Belchior et al.²⁰, when comparing the difference between the quadriceps angle in 20 female individuals allocated in two groups, one with 10 symptomatic individuals and the other with 10 asymptomatic individuals, at two different times, first with the quadriceps relaxed then in maximum voluntary isometric contraction (MVIC), verified that the mean values of the Q angle for the asymptomatic individuals were 17.15º in relaxation and 14.5º in MVIC, while the symptomatic individuals presented 21.45º and 15.8º, respectively. These results show that in a state of relaxation there is a significant difference in the value of the Q angle between symptomatic and asymptomatic individuals and that this difference is not present in a state of maximum isometric contraction of the quadriceps muscle; accordingly, it is believed that this procedure, associated with exercise performed with the straight leg raise (SLR) will be able to minimize patellar malalignment.

Muscle imbalance is considered one of the risk factors for patellar malalignment.¹ Bevilaqua-Grossi et al.²¹ assessed the electrical activity of the vastus medialis obliquus, vastus lateralis and vastus lateralis longus muscles at 45º and 60º of isometric flexion in 30 female patients (15 clinically healthy and 15 with patellofemoral pain syndrome), and it was noted that there was no difference in the muscle activation. Thus, it is believed that squatting exercises at the angulations studied provide balance between the medial and lateral portions of the dynamic patellar stabilizers, particularly in patients with PFD, and that they can be indicated during the rehabilitation program.

The association of NMES with resistance exercise demonstrates significant results in the recovery of individuals with PFD. Silva et al.²² conducted a study with nine male individuals for eight weeks, comparing the effects of the use of neuromuscular electrical stimulation associated with strength training with exercise for lower limbs with leg press and leg extension machine, verifying greater effectiveness with the strength training associated with electrical stimulation, making this method more efficient as a muscle strengthening aid, both for aesthetic purposes and for rehabilitation of the lower limbs.

Duarte et al.²³ conducted a study on the effect of stretching of the ischiotibial muscles associated with neuromuscular electrical simulation for gain of hip flexion. At the end of the treatment they ascertained that there was no significant increase in the range of motion in the control group and in comparing the (G2) group that performed passive stretching with (G3) which performed passive stretching associated with Russian electrical stimulation, concluded that G3 contributed to a greater increase in the range of motion of hip flexion. This result suggests that in a patellofemoral dysfunction caused by muscle shortening, "Russian electrical stimulation" can be an adjuvant therapeutic resource in this treatment.

Avila et al.²⁴ verified the effect of neuromuscular electrical stimulation associated with an isokinetic training program (Ex) with a dynamometer in men and women. At the end of the study they noted that both genders increased their peak torque, with no difference between Ex and Ex + NMES, and asserted that NMES associated with eccentric quadriceps contraction does not obtain any additional advantage in torque over isolated eccentric contraction. While Bily et al. ²⁵ conducted a study for a year with 38 patients diagnosed with PFD allocated in two groups. (G1) performed just exercises and (G2) exercises + NMES at 40 Hz. At the end they observed a decrease in pain and an increase in the quadriceps torque in both groups, with no statistically significant difference between G1 and G2. These results may be a result of the frequency used, since 50Hz could show a better result as it selects in a proportional manner both the phasic and tonic fibers and due to the longer follow-up, during which neural adaptation may have occurred. Santos et al.,²⁶ with the intention of observing muscle conditioning, carried out a study comparing passive home based electrical stimulation versus resistance exercises. However, their results showed that the group that performed passive electrical stimulation did not obtain a significant increase in strength or in the perimeter of the quadriceps muscles, while, on the other hand, the group that performed resistance exercises obtained a significant increase in the strength and in the perimeter of the quadriceps. It is believed that electrical stimulation only has its effects potentiated for gain of strength when associated with resistance exercises.

Pelizzari et al.¹² conducted a study with eight dogs where they proposed to observe the effect of NMES on induced atrophy of the quadriceps, and at the end of the study observed that NMES associated with activities provides an increase in muscle mass in dogs with induced muscular atrophy. In a study conducted with 20 soccer players, by Billot et al.,²⁷ they ascertained that the electrical stimulation of the quadriceps associated with training (isometric, concentric and eccentric), results in better muscle strength, a better concentric torque and a better kicking speed. These results also suggest that NMES can be used for injured athletes to decrease or eliminate the effects of detraining.

Matheus et al.,¹⁰ aiming to verify the effects of NMES on muscular atrophy, conducted a study with 60 rats to analyze the effects of neuromuscular electrical stimulation during immobilization of the gastrocnemius muscle in lengthening and shortening positions and after analyzing the results of the study, noticed that the lengthened immobilization of the muscles delays the atrophy process and that the electrical stimulation performed during this period will contribute to the prevention of the mechanical properties. A possible explanation for the effects of NMES on muscular atrophy in humans lies in the presence of the distancing of the sarcomeres associated with stimulation of the motor units that lead to a delay in atrophy.

FINAL CONSIDERATIONS

The result of this review allows us to observe that when PFD is caused by muscular imbalance, the use of medium-frequency NMES can be associated with resistance exercises as an adjuvant in the treatment; both to achieve muscle rebalance as for pain relief. Moreover, it can be used both for muscle strengthening and for aesthetics. Finally, it is necessary to conduct further intervention studies for a better understanding of this type of therapy.

REFERENCES

• 1. Peccin M, Ciconelli R, Cohen M. Questionário específico para sintomas do joelho "Lysholm Knee Scoring Scale" - tradução e validação para a língua portuguesa. Acta Ortop. Bras. 2006;14 (5):268-72.
• 2. Asplund C, Pierre PS. Knee pain and bicycling: fitting concepts for clinicians. Phys Sportsmed. 2004;32(4).1-10
• 3. Paar O, Riel KA. [Patella dislocation with special reference to cartilage damage]. Chirurg. 1982;53(8):508-13.
• 4. Freire M, Fernandes A, Juliano Y, Novo N, Filho M, Filho E et al Condromalácia de patela: comparação entre os achados em aparelhos de ressonância magnética de alto e baixo campo magnético. Radiol Bras. 2006;39(3):167-74.
• 5. Belchior A, Arakaki J, Bevilaqua-Grossi D, Reis F, Carvalho P. Efeitos na medida do ângulo Q com a contração isométrica voluntária máxima do músculo quadricipital. Rev Bras Med Esporte. 2006;12(1):6-10.
• 6. Fonseca ST, Cruz ABC, Lima SS, Seixas AFAM. Análise eletromiográfica dos músculos vasto medial oblíquo e vasto lateral em exercícios usados no tratamento da síndrome da dor patelofemoral. Rev Fisiot Univers SP. 2001;8(1):1-10.
• 7. Cabral CMN, Melim AMO, Sacco ICN, Marques AP. Fisioterapia em pacientes com síndrome femoropatelar: comparação de exercícios em cadeia cinética aberta e fechada. Acta Ortop Bras. 2008;16(3):180-5.
• 8. Borges FS, Valentin EC.Tratamento da flacidez e diástase do reto-abdominal no puerpério de parto normal com o uso de eletroestimulação muscular com corrente de média freqüência - estudo de caso. Rev Bras Fisioter Dermato-Funcional. 2002;1(1):1-8.
• 9. Grillo DE, Simões AC. Atividade física convencional (musculação) e aparelho eletroestimulador: um estudo da contração muscular. Estimulação elétrica: mito ou verdade? Rev Mackenzie Educ Fis Esporte. 2003;2(2):31-43.
• 10. Matheus JPC, Gomide LB, Oliveira JGP, Volpon JB, Shimano AC. Efeitos da estimulação elétrica neuromuscular durante a imobilização nas propriedades mecânicas do músculo esquelético. Rev Bras Med Esporte. 2007;13(1): 55-9
• 11. Briel AF, Pinheiro MF, Lopes L G. Influência da corrente russa no ganho de força e trofismo muscular dos flexores do antebraço não dominante. Arq Cienc Saúde Unipar. 2003;7(3):205-10.
• 12. Pelizzari C, Mazzanti A, Raiser A, Lopes A, Graça D, Salbego F et al. Estimulação elétrica neuromuscular de média freqüência (russa) em cães com atrofia muscular induzida. Ciênc Rural. 2008;38(3):736-42.
• 13. Modlin M, Forstner C, Hofer C, Mayr W, Richter W, Carraro U et al. Electrical stimulation of denervated muscles: first results of a clinical study. Artif Organs. 2005;29(3):203-6.
• 14. Augusto DDA, Ventura PP, Nogueira JFS, Brasileiro JS. Efeito imediato da estimulação elétrica neuromuscular seletiva na atividade eletromiográfica do músculo vasto medial oblíquo. Rev Bras Cineantropom Desempenho Hum. 2008;10(2):155-60.
• 15. Bevilaqua-Grossi D, Felicio LR, Leocádio LP. Análise do tempo de resposta reflexa dos músculos estabilizadores patelares em indivíduos com síndrome da dor patelofemural. Rev Bras Fisioter. 2008;12(1):26-30.
• 16. Santos GM, Ries LGK, Sperandio FF, Say KG, Pulzatto F, Pedro VM. Tempo de início da atividade elétrica dos estabilizadores patelares na marcha em sujeitos com e sem síndrome de dor femoropatelar. Fisioter Mov. 2011;24(1):125-32.
• 17. Cabral CMN, Melin AMO, Neves Sacco ICN, Marques AP. Fisioterapia em pacientes com Síndrome Femoropatelar: Comparação de exercícios em cadeia cinética aberta e fechada. Acta Ortop Bras. 2008;16(3):180-5.
• 18. Nakagawa TH, Muniz TB, Baldon RM, Maciel CD, Reiff RB, Serrão FV. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study. Clin Rehabil. 2008;22(12):1051-60.
• 19. Jennifer E, Anne Z. A Proximal Strengthening Program Improves Pain, Function, and Biomechanics in Women With Patellofemoral Pain Syndrome. Am J Sports Med. 2011;39(1):154-63.
• 20. Belchior ACG, Arakaki JC, Bevilaqua-Grossi D, Reis FA, Carvalho PTC. Efeitos na medida do ângulo Q com a contração isométrica voluntária máxima do músculo quadricipital. Rev Bras Med Esporte. 2006;12(1):6-10.
• 21. Bevilaqua-Grossi D, Felício LR, Simões R, Coqueiro KRR, Monteiro V. Avaliação eletromiográfica dos músculos estabilizadores da patela durante exercício isométrico de agachamento em indivíduos com síndrome da dor femoropatelar. Rev Bras Med Esporte. 2005;11(3):159-63.
• 22. Silva RT, Knorr LF, Lopes RF, Knorr L, Navarro F. Comparação entre os efeitos do uso de Eletroestimulação Neuromuscular associada ao treinamento de força com somente treinamento de força em exercício de membros inferiores durante oito semanas. Rev Bras Prescr Fisiol Exerc. 2007;1(5):1-10.
• 23. Duarte MG, Silva TCD. O alongamento dos isquiotibiais associado à eletroestimulação neuromuscular visando maior amplitude de movimento de flexão de quadril. Rev Movimenta. 2009;2(3):67-73.
• 24. Ávila MA, Brasileiro JS, Salvini TF. Electrical stimulation and isokinetic trainig: effects on strength and neuromuscular properties of healthy young adults. Rev Bras Fisioter. 2008;12(6):435-40.
• 25. Bily W,Trimmel L, Mödlin M, Kaider A, Kern H. Training program and additional electric muscle stimulation for patellofemoral pain syndrome: a pilot study. Arch Phys Med Rehabil. 2008;89(7):1230-6.
• 26. Santos FM, Rodrigues RGS, Trindade-Filho EM. Exercício físico versus programa de exercício pela eletroestimulação com aparelhos de uso doméstico. Rev Saúde Pública. 2008;42(1):117-22.
• 27. Billot M, Martin A, Paizis C, Cometti C, Babault N. Effects of an electrostimulation training program on strength, jumping, and kicking capacities in soccer players. J Strength Cond Res. 2010;24(5):1407-14.

Neuromuscular electric stimulation in patellofemoral dysfunction: literature review

Ricardo Lucas dos Santos; Márcia Leal São Pedro Souza; Fernanda Andrade dos Santos

Publication Dates

• Publication in this collection
  12 Apr 2013
• Date of issue
  Feb 2013

History

• Received
  04 May 2011
• Accepted
  26 July 2011