Beruflich Dokumente
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C OPYRIGHT 2010
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Isometric evaluation of hip and knee muscle strength can be a useful objective assessment tool in the clinic and
may be preferred over other forms of dynamic muscle testing, such as isokinetic assessment or variable-resistance
weight-lifting.
Assessment of isometric strength with use of a handheld dynamometer requires little skill and is easily administered, relatively inexpensive, valid, reliable, and functional; thus, it could be easily integrated into routine clinical
examinations.
Surface electrical stimulation, electromyography, and ultrasonography can be used in conjunction with isometric
muscle testing for the identification of neuromuscular factors influencing muscle force generation.
Further research is warranted to investigate the neural and/or muscular impairments associated with hip and knee
muscle weakness in orthopaedic populations, with the ultimate goal of improving rehabilitation strategies.
Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of
his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
doi:10.2106/JBJS.I.00305
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Outcomes
Submaximal
Type of contraction
Voluntary only
Stimulated only
Voluntary with superimposed stimulation
Testing mode
Manual muscle testing
Handheld (stabilized) dynamometer (Fig. 1)
Isometric dynamometry
Isokinetic dynamometry
Additional techniques
Electrical stimulation
Electromyography
Ultrasound
Experimental recommendations
Familiarization and practice
Visual feedback of performance
Standardized verbal encouragement
Clear instructions
Several repeat trials
Negligible pretension
Other factors to control
Device calibration
Gravity correction
Time-of-day effect
Residual fatigue effect
Test-retest reliability
Sampling rate
Lever arm length
Pain
maximum load that can be lifted once (i.e., dynamic variableresistance weight-lifting), or (3) as the peak torque during an
isokinetic concentric or eccentric contraction17. However, there
is no general agreement about whether muscle strength should
be assessed with isometric, weight-lifting, or isokinetic testing in
orthopaedic practice.
Measurement of muscle strength under isometric conditions can be a useful objective assessment tool for the evaluation of hip and knee function in the clinic18 because it is rapidly
and easily administered and is relatively inexpensive; therefore,
it may be preferred over the other forms of dynamic muscle
testing, such as isokinetic assessment or variable-resistance
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Fig. 1
Clinical assessment of isometric maximal voluntary contraction strength in knee extension (A) and hip
abduction (B) with use of a handheld dynamometer. Note the positioning of the subject, the placement of
the dynamometer, and the stabilization of the subject under the two conditions. (See Table II for the test
steps and instructions.)
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underlie muscle weakness are described, with particular reference to orthopaedic research.
Isometric Muscle-Strength Assessment
Table I presents the important factors that must be carefully
controlled to ensure valid quantification of hip and knee muscle
strength.
Testing Modes
Four main testing modes that rely on testing tools of different
technology and cost can be adopted for the evaluation of
isometric muscle strength.
Manual muscle testing is the most commonly used mode
in routine clinical examinations, despite certain limitations
such as poor validity and inaccuracy of subjective ratings4. It is
a semiquantitative method, in which muscle strength is subjectively given a grade. For example, both on the classic 0 to 5point scale4 and on the expanded 0 to 12-point scale20, the
lowest grade indicates no contractility or muscle activation and
the highest grade represents complete motion against gravity
with full resistance.
Handheld dynamometry (Fig. 1), which can be considerably improved by the use of stabilized dynamometers23, is
probably the best mode for hip and knee assessments in
clinical use24, despite the absence of online visual feedback
regarding force data. Handheld dynamometers (Chatillon;
AMETEK, Largo, Florida; Lafayette Instrument, Lafayette,
Indiana; and MicroFET, Hoggan Health Industries, West Jordan, Utah) can be used to precisely quantify muscle force in
actual units (i.e., newtons, kilograms, or pounds). With some
modern devices, it is also possible to store force data for
subsequent analyses.
Isometric dynamometry, done with a custom-built or
commercially available chair (e.g., a Tornvall chair) equipped
with strain-gauge load cells mounted in series with a force
output axis, allows force data to be stored. Gravity correction
and online visual feedback regarding force data are generally
possible with these devices.
Isokinetic dynamometry devices, which can be set in isometric mode, allow optimal standardization of testing procedures and direct recording of torque data. As is the case for
handheld and isometric dynamometry, regular calibration
ensures the accuracy of isometric measurements. Despite
their high cost, isokinetic machines (Biodex Medical Systems,
Shirley, New York; CON-TREX, CMV AG, Dubendorf, Switzerland; Cybex, Medway, Massachusetts; HUMAC NORM,
CSMi, Stoughton, Massachusetts; and Kin Com, Isokinetic
International, Harrison, Tennessee) are frequently available to
physiotherapists.
Test Procedures
Several recommendations, based on experimental evidence,
should be followed to obtain a valid assessment of isometric
strength. These criteria, which have been described in detail
elsewhere25,26, include appropriate familiarization and practice
(generally incorporated into a standardized warm-up), visual
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Details
Subject positioning
Instructions
Practice/familiarization/
warm-up trials
Dynamometer positioning
Maximal trials
2 (or 3) contractions of
3-5 seconds, separated
by 30 seconds
Dynamometer reading
(preferably in newtons)
Pain assessment
Lever-arm-length
measurement
Maximal torque
calculation
newtons) to obtain the maximal torque. After each contraction, the level of pain is quantified with use of a 0 to 10-point
visual analog scale. It is recommended that the average torque
and pain level be reported on the medical examination form.
These steps are summarized in Table II.
Techniques and Procedures to Evaluate
Neuromuscular Mechanisms of Force
Besides isometric torque recordings, which allow rapid force
and force control to be investigated, surface electrical stimulation, electromyography, and ultrasonography are three of the
main techniques that can be easily combined with isometric
actions to explore the mechanisms underpinning forcegenerating capacity. They are largely adopted to investigate the
sarcopenia-related problems in geriatric medicine36,37, and
their use in orthopaedic populations is infrequent19,38,39. In the
specific case of orthopaedic research, these noninvasive techniques could help in the determination of the etiology of muscle
weakness (i.e., whether it is due to neural and/or muscular
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Fig. 2
Assessment of submaximal force control ability. The image shows the hip flexor torque-time (top) and rectus femoris
electromyographic (EMG) activity-time (bottom) traces during twenty-second submaximal isometric contractions on the
involved and uninvolved sides of a female patient six weeks after a total hip arthroplasty (through the anterior approach).
The horizontal lines indicate the target torque (25% of the maximal voluntary contraction [MVC]). Steadiness (i.e., the
standard deviation of the actual torque divided by the mean, expressed as a percentage) and accuracy (i.e., the absolute
difference between the actual and target torques) are better on the uninvolved side (4.2% and 0.097 Nm) than they are
on the involved side (23.5% and 0.302 Nm). Note that impaired force control on the involved side is accompanied by
large fluctuations in electromyographic activity.
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Fig. 3
Assessment of muscle activation (A) and excitation-contraction coupling properties (B). The image shows the quadriceps
torque-time (top) and vastus lateralis electromyographic (EMG) activity-time (bottom) traces on the involved side during a
four-second maximal voluntary isometric effort with a superimposed electrical stimulus (first arrow from the left). The same
stimulation (a 1-msec single pulse at 50 mA) is delivered one second after the end of the contraction (second arrow). The
two stimuli evoke, respectively, a superimposed (a) and a resting (b) twitch. In B, the twitch torque and M-wave traces,
whose characteristics (duration and amplitude) allow investigation of excitation-contraction coupling, are magnified
(shaded area at approximately 5 seconds in lower panel of A). The central activation ratio, calculated as maximal
voluntary contraction/(maximal voluntary contraction 1 a) 100, is ;85%, and the voluntary activation level, calculated
as (1 2 [a/b]) 100, is ;65%. Note that the two formulas provide considerably different muscle-activation scores.
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or root mean square) could be expressed relative to a standardized contraction (e.g., the highest maximal voluntary
contraction) or, better, to the size of the M wave to enable
peripheral mechanisms to be excluded from the interpretation
of the data and therefore to provide a valid index of central
activation.
The maximal M wave (lower panel of Fig. 3, B), which is
obtained with supramaximal single stimulation of the nerve
trunk, is evoked by the recruitment of all motor axons and
therefore provides an estimate of the response given by the
whole motor neuron pool. Its amplitude is a measure
of transmission across the neuromuscular junction and
muscle membrane excitability. Maximal M-wave amplitude
is also used as a normalization standard for reflex potentials.
These responses, which are largely overlooked in the orthopaedic community, can offer insights into the plasticity of
spinal and tendinous structures associated with disuse and
immobilization56. Hoffmann reflexes, evoked by selective
(submaximal) stimulation of Ia afferents contained in the
corresponding mixed nerve, allow investigation of motor
neuron excitability and/or presynaptic inhibition of Ia afferent
nerves. Spinal reflexes can also be evoked as a result of transient stretches, which can be produced in a reliable way with
use of electromagnetic hammers or special ergometers, to
obtain, respectively, the tendon reflex and the stretch reflex. In
contrast to the Hoffmann reflex, the tendon and stretch reflexes do not bypass the muscle spindles, and therefore they are
influenced by both peripheral (i.e., tendon stiffness) and
central (i.e., synaptic efficiency) factors. Using this methodology, Melnyk et al.57 recently provided evidence that a subjective feeling of knee instability (i.e., so-called giving-way)
following anterior cruciate ligament rupture is associated
with altered stretch-reflex excitability of the hamstring
muscles, but not with mechanical knee instability. Specifically, they demonstrated that certain patients with anterior
cruciate ligament injuries (i.e., those with symptoms of
giving-way) had a longer latency of the medium-latency reflex
in response to quick tibial translation than did patients who do
not have these symptoms. Joint stability (as assessed with an
arthrometer) did not differ between the two groups.
IN
Ultrasonography
In addition to neural and muscular function, the mechanical
properties and morphology of human tendons, as assessed in vivo
with use of B-mode ultrasonography, have been shown to undergo
substantial alterations (e.g., reduced stiffness and altered thickness) with chronic disuse58. Ultrasonography, a relatively new
technique that could be particularly attractive for orthopaedic
applications, can also be used to investigate muscle architecture (fascicle length and pennation angle) both at rest and
during muscle contractions59. Bleakney and Maffulli60 recently
reported considerable architectural alterations (longer fascicle
length and a smaller pennation angle) in the vastus lateralis of
thirteen male patients with a tibial or femoral fracture treated
with intramedullary nailing. Ultrasonography could also be
used as an alternative to magnetic resonance imaging, which is
expensive, for the quantitative assessment of muscle atrophy39,60 and for the investigation of changes in muscular size
and architecture following various rehabilitation programs.
Overview
The most simple and reliable assessment of hip and knee
muscle function in orthopaedic practice and research is direct
quantification of isometric muscle strength with use of standardized procedures. In clinical practice this requires the systematic incorporation of handheld dynamometers into routine
examinations, and in research settings it requires the combined
use of different noninvasive techniques to investigate how
muscular and/or neural impairments contribute to muscle
weakness in orthopaedic populations. n
NOTE: The author thanks Anne F. Mannion, Mario Bizzini, Nicola Casartelli, Julia Glatthorn, Franco
M. Impellizzeri, Romuald Lepers, and Michael Leunig for reading the manuscript and offering
useful suggestions.
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