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PHYS THER
Vol. 83, No. 10, October 2003, pp. 947-948
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Letters and Responses

An Alternative Explanation


To the Editor:

I read with interest the recent article by Goodwin et al titled "Effectiveness of Supervised Physical Therapy in the Early Period After Arthroscopic Partial Meniscectomy" (June 2003). Although I agree with the authors that the lack of treatment effectiveness was not likely a function of poor application of intervention, the intention of my letter is to provide an alternative explanation that may help account for the results.

In the study, a positive difference in suprapatellar knee girth was found in both the intervention and control groups, thereby suggesting the presence of knee effusion in most subjects. Although it is unknown whether knee effusion was completely ameliorated 50 days postsurgery, there are data to suggest that the presence of knee effusion may potentially induce arthrogenous quadriceps femoris muscle inhibition.1,2 If postmeniscectomy reflex inhibition constitutes a partial cause of knee extensor force deficits, it follows that traditional volitional exercise, as advocated in both home and supervised physical therapy programs, would be unable to remedy this impairment completely.3

Although the authors used interventions such as cryotherapy to reduce pain and swelling, the functional deficits demonstrated in both groups 6 weeks postsurgery remain a cause for clinical concern. It is noteworthy that Snyder-Mackler et al4 demonstrated that the judicious use of neuromuscular electrical stimulation resulted in greater quadriceps femoris muscle and gait recovery than a similar regimen of volitional exercises. Although that study was performed on patients with reconstruction of their anterior cruciate ligaments, the results suggest that neuromuscular electrical stimulation could potentially short-circuit the effects of reflex inhibition, ostensibly leading to better functional outcomes.

Yong-Hao Pua, Physiotherapist

Alexandra Centre for Exercise and Sports Medicine (ACES)
Rehabilitation Department
Alexandra Hospital
Republic of Singapore
(Yong_Hao_PUA{at}Alexhosp.com.sg)

References

  1. Shakespeare DT, Stokes M, Sherman KP, Young A. Reflex inhibition of the quadriceps after meniscectomy: lack of association with pain. Clin Physiol.1985; 5:137–144.[ISI][Medline]
  2. Jones DW, Jones DA, Newham DJ. Chronic knee effusion and aspiration: the effect on quadriceps inhibition. Br J Rheumatol.1987; 26:370–374.[Abstract/Free Full Text]
  3. Hurley MV, Jones DW, Newham DJ. Arthrogenic quadriceps inhibition and rehabilitation of patients with extensive traumatic knee injuries. Clin Sci (Lond).1994; 86:305–310. Erratum in: Clin Sci (Lond) 1994; 86(6):xxii.[Medline]
  4. Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament: a prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am.1995; 77:1166–1173.[Abstract/Free Full Text]
 

Author Response:


We would like to thank Mr Pua for the interesting and informative letter in response to our article. He is correct in identifying the difference in suprapatellar knee girth 5 days after surgery in both the intervention and control groups, indicating an increased size of the injured knee. We agree that this increase is likely due to edema. To answer the query about whether knee effusion was completely ameliorated 50 days after surgery, we have analyzed our data and found that knee girth 50 days after surgery showed an injured-uninjured mean difference of 0.6 cm (SD=1.15, range=–1.5–3.0) in the intervention group. Thus, we would argue that the degree of swelling decreased from test 1 to test 2, and this decreased degree of swelling should result in decreased quadriceps femoris muscle inhibition. Furthermore, although we know that knee edema causes inhibition, we are also aware that recent work1 has shown that the relationship of knee volume to quadriceps femoris muscle inhibition is poor after anterior cruciate ligament reconstruction. We are not aware of any studies of this type in patients after arthroscopic meniscectomy.

In regard to neuromuscular electrical stimulation (NMES) after arthroscopic meniscectomy, we know of 2 studies that have evaluated the effectiveness of this modality in this patient population.2,3 Of these 2 studies, the study by Jokl et al2 was the most similar to our study. Jokl et al included "electrical stimulation to quadriceps" in their supervised treatment regimen beginning 5 days postoperatively. Stimulation was continued until the subjects were judged to have good reflex activity during a quadriceps femoris muscle set. They found no difference in isokinetic quadriceps femoris muscle torque and knee self-assessment between a supervised treatment group and a home exercise group 2, 4, and 8 weeks after surgery. Williams et al3 added a 5-day-per-week program of NMES to a supervised therapy regimen occurring 3 days per week over a 3-week period. They found that both groups (supervised treatment and home exercise) had increases in isokinetic quadriceps femoris muscle torque at 120°/s and 180°/s; however, only the group that had NMES had quadriceps femoris muscle torque increases at 240°/s and 300°/s. Looking further at their changes in mean torque, it appears that the groups may not have statistically significant differences with a larger sample (they studied 21 subjects). Knee function was not assessed in either the Jokl et al study or the Williams et al study, nor was the intensity of the NMES.

We are hesitant to conclude that NMES is not beneficial in this patient population until (1) the ideal stimulation parameters and dosage for this population are discovered and (2) such a program is evaluated.

Peter C Goodwin, Doctoral Student

Centre for Applied Biomedical Research
GKT School of Biomedical Sciences
King's College London
London, United Kingdom

Matthew C Morrissey, Lecturer

Centre for Applied Biomedical Research
GKT School of Biomedical Sciences
King's College London
Shepherd's House
Guy's Campus
London, SE1 1UL, United Kingdom
(matt.morrissey{at}kcl.ac.uk)

Rumana Z Omar, Senior Lecturer

Department of Statistical Sciences
University College London

Michael Brown, Senior I Physiotherapist

Forest Healthcare Trust
London, United Kingdom

Kathleen Southall, Physiotherapy Manager

Holly House Hospital
Buckhurst Hill, Essex, United Kingdom

Thomas B McAuliffe, Orthopaedic Consultant

Forest Healthcare Trust

References

  1. Drechsler WI, Morrissey MC, Scott OM. Quadriceps femoris function and EMG frequency after ACL reconstruction. Presented at: 14th International Congress of the World Confederation for Physical Therapy; June 7–12,2003; Barcelona, Spain.
  2. Jokl P, Stull PA, Lynch JK, Vaughan V. Independent home versus supervised rehabilitation following arthroscopic knee surgery: a prospective randomized trial. Arthroscopy.1989; 5:298–305.[Medline]
  3. Williams RA, Morrissey MC, Brewster CE. The effects of electrical stimulation on quadriceps strength and girth in menisectomy patients. J Orthop Sports Phys Ther.1986; 8:143–146.



This article has been cited by other articles:


Home page
 Br. J. Sports. Med.Home page
P C Goodwin and M C Morrissey
Supervised physiotherapy after arthroscopic partial meniscectomy: is it effective?
Br. J. Sports Med., October 1, 2005; 39(10): 692 - 692.
[Full Text] [PDF]

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