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Abstract: Objectives: To identify the effects of application methods and indications of direct muscle electrostimulation on strength gain. Methods: Literature review and analysis of articles from Medline database with the following entries: muscular or neuromuscular, electromyostimulation, electrical stimulation, strengthening, strength training, immobilization, muscle dystrophy, bed-rest, bed-bound, knee or hip surgery, postoperative phase, cachexia, sarcopenia, and their French equivalent. Results: Because of its specific muscle recruitment order, different from that of voluntary contraction, direct muscle electrostimulation is theoretically a complementary tool for muscle strengthening. It can be used in healthy subjects and in several affections associated with muscle function loss. Its interest seems well-established for post-traumatic or postsurgery lower-limb immobilizations but too few controlled studies have clearly shown the overall benefits of its application in other indications. Whatever the indication, superimposed or combined electrostimulation techniques are generally more efficient than electrostimulation alone. Conclusion: Even though widely used, the level of evidence for the efficiency of electromyostimulation is still low. For strength gains, it yielded no higher benefits than traditional strengthening methods. Its interest should be tested in medical affections leading to major muscle deconditioning or in sarcopenia. [Copyright &y& Elsevier]

Abstract: Objective: The objective of this article is to review anatomical, histological and physiological muscle changes following below-knee amputation. Materials and Methods: We searched the PubMed and Reedoc databases for studies evaluating modifications of the below-knee stump and changes over time in its anatomy, volume and histology. We also looked at postamputation modifications in gait and balance. Results: Below-knee amputees show muscular atrophy on both the amputated side and nonamputated side, with fewer and smaller muscle fibres (particularly slow-twitch fibres). This amyotrophy varies in magnitude and distribution and can reach about 25% for the quadriceps (predominantly on the medial side), but is nonsignificant for the hamstrings. This amyotrophy results from the anatomical consequences of the surgical act. The loss of one or more of a muscle''s insertions or reimplantation into a nonphysiological site prompts greater atrophy. Changes in muscle activation patterns also lead to atrophy. The hamstrings replace the triceps as the main muscles for propulsion and the remaining stump muscles contract so as to ensure a good fit with the prosthesis. The below-knee amputee must adapt to a new muscular state: gait symmetry is altered, energy expenditure for walking is higher and training is needed in order to achieve optimal balance control. [Copyright &y& Elsevier]

Abstract: Aim: The aim of this study was to determine the mechanisms involved in muscle weakness in elderly patients with unilateral knee osteoarthritis. Subjects: We investigated 7 patients with unilateral knee osteoarthritis. Method: We measured knee position sense and isometric maximal voluntary contraction (MVC) of the knee extensors. Electromyographic (EMG) measurement of biceps femoris (BF), rectus femoris (RF), vastus lateralis (VL) and vastus medialis (VM) involved different levels of contraction (25, 50, 75 and 100% MVC). Neuromuscular efficiency of quadriceps was also calculated (MVC/EMG). Ultrasonography was used to investigate the VL architectural parameters at the median part of the VL for different levels of contraction (25, 50, and 75% MVC). All tests were performed on the osteoarthritic and healthy knees. Results: The quadriceps MVC of the affected knee was reduced by 30%. The VL thickness of the affected knee was 10% smaller than that of the unaffected knee. VL activity seen on EMG did not differ between knees, but RF, VM and BF activity was greater in the unaffected than affected knee. Neuromuscular efficiency was higher (26%) in the unaffected knee. Knee position sense was reduced by 33% in the affected knee. Conclusion: Quadriceps weakness associated with knee osteoarthritis seems to be related to changes in muscle rather than pennation angle and changes in fascicule length. [Copyright &y& Elsevier]

Abstract: Objective: To develop clinical practice guidelines concerning individual and group exercise therapy for knee and/or hip osteoarthritis (OA). Method: We used the SOFMER (French Physical Medicine and Rehabilitation Society) methodology, combining systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, to develop the guidelines. Results: Physical exercises are proposed for knee and hip OA. The benefit of individual exercises is low to moderate for pain, strength and ability to walk. The effectiveness is not maintained over time if the individual exercise program is not continued. The benefit of group exercise is also low to moderate for pain, strength, balance and ability to walk. There is no evidence of the superiority of one modality over the other (individual or group). Conclusion: More randomised controlled trials with good methodology are needed to compare the effectiveness of individual versus group exercise therapy for knee and hip OA. [Copyright &y& Elsevier]

Abstract: The objective of our study was to determine whether waist circumference (WC) is a more reliable indicator than body mass index (BMI) of the presence of knee osteoarthritis in obese subjects. Patients and Methods: We performed an observational study of obese patients with no other risk factors for knee osteoarthritis. For each patient, we evaluated BMI, WC, duration of obesity and knee pain. Two groups were identified: “asymptomatic patients” (AG), without knee pain, and “symptomatic patients” (SG). For the SG, we measured pain intensity (visual analog scale [VAS], 0-100 mm) and functional repercussions (using the Lequesne and WOMAC indexes). Patients with knee pain underwent standard radiographic procedures to search for signs of osteoarthritis, and the SG was divided into two subgroups: with radiological signs of osteoarthritis (SG-1) and without radiological signs of osteoarthritis (SG-2). The AG and SG groups and SG-1 and SG-2 groups were compared for age, sex, and duration of obesity. Comparisons of BMI, WC, and function involved the Student''s t-test. Results: We recruited 56 patients for the study (82.5% females; mean obesity duration (13±6.5 years; mean age 43.21±9.58 years). The mean BMI was 39.6±7.23 kg/m2 and mean WC was 113±14.3 cm. We found 33 patients (59%) with knee pain. Independent of age, sex, duration of obesity and BMI, the SG showed more significant WC (117.27±14.71 cm vs. 107±11.75 cm for the AG, P 0.01). In the same group and independent of the already mentioned factors, the patients with radiological signs of osteoarthritis showed significant WC [122±15.57 cm (SG-1) vs. 108±6.88 cm (SG-2) (P 0.01)]. Moreover, the VAS score of pain at rest and during effort and the WOMAC and Lequesne scores were 16±25.7 mm, 75±18.3 mm, 12.3±8.92 and 11.5±5.44 (SG-1) and 7±18.4 mm, 70±19.2 mm, 5.7±3.05, and 6.9±3.79 (SG-2), respectively. The difference between SG-1 and SG-2 was significant only for the WOMAC (P =0.015) and Lequesne (P =0.026) scores. Conclusion: Independent of BMI, WC appears to be a factor associated with the presence of knee pain and osteoarthritis in obese patients. Furthermore, a high WC is associated with significant functional repercussion. [Copyright &y& Elsevier]

Abstract: Objective: A review of the literature to investigate physical training in rehabilitation programs before and after hip and knee arthroplasty. Methods: We performed a literature search of the MedLINE and Cochrane databases since 1966 to 2006 using 8 keywords for articles of literature reviews or randomized controlled trials investigating physical training before and after hip and knee arthroplasty. Results and Discussion: The search resulted in 14 articles: 2 reviews of the literature and 7 articles of studies concerning total hip arthroplasty and 5 knee arthroplasty. Results were difficult to analyze because of the low number of patients included, a high number of dropouts, no matched control populations, different physical training protocols, and the use of functional scores or inadequate parameters. We found no randomized controlled trial concerning physical training after knee arthroplasty. Conclusion: Physical training does not seem benefit patients before hip or knee arthroplasty. However, the training may have benefit immediately after, and particularly well after, total hip arthroplasty. [Copyright &y& Elsevier]

Abstract: Objective: To develop clinical practice guidelines concerning predictive criteria for transfer of patients to a rehabilitation ward after hip and knee total arthroplasty. Method: The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating a systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, was used. Results: From systematic literature review and collection of French professional practice, we cannot distinguish the patients undergoing THA and TKA who can transfer to a rehabilitation ward. For both types of patients, the main criteria determining transfer are demographic criteria such as older age or female sex; psychosocial and environmental criteria such as living alone, feeling unable to return home directly (pre-operative education could modify this criterion); and surgeon advice based on the pre and post-operative clinical and functional status. Conclusion: Studies with good methodological quality are urgently needed to evaluate the use of predictive tools such as the RAPT, separating THA and TKA, and using as parameters of assessment functional status and handicap reduction. [Copyright &y& Elsevier]

Abstract: Objective: We aimed to assess the isokinetic profile of the flexor and extensor muscles of the knee within a population of rugby players. Methods and Population: This was a descriptive study. The rugby players underwent bilateral isokinetic assessment of knee flexion and extension on a CON-TREX MJ isokinetic dynamometer functioning at four angular frequencies — 90, 120, 180 and 240°/s — in a concentric manner. The isokinetic parameters were peak torque, mean power, and mean work in relation to weight and femoral bicep: quadriceps ratio. The population included 16 “Federal 1” (semi-professional) rugby players with mean age 25 years (range 20–33 years). The players were divided into two groups: “forward” players (props, hookers, second line, third line) and “back” players (scrum, inside, center, wing, tail). Results: The values of the isokinetic parameters did not reveal use of a preferred limb. Consequently, peak torque and mean power were higher in forward players than back players, whereas back players showed a higher relative power throughout the isokinetic test. Conclusion: Among rugby players, forward and back players showed differences in several isokinetic parameters. Accurate knowledge of the equilibrium between the knee''s effector muscles is important for stability of the joint, to not only minimize articular accidents but also pinpoint force imbalances, thereby preventing muscular lesions during the sports season. [Copyright &y& Elsevier]

Abstract: Objective: To study the effect of cycling or running retraining between 4 and 6 months after patients underwent anterior cruciate ligament reconstruction with hamstring grafting (Semitendinosus-Gracilis) compared with that in patients who had the same surgery but were untrained. Method: Patients who had undergone surgery for an anterior cruciate ligament reconstruction by the same surgeon who used hamstring grafting were included if they were free of knee pain 4 months after the surgery. After giving consent, patients were randomized to receive controlled retraining (cycling or running 3 times a week) or not. The effect of retraining was measured by the evolution of the knee isokinetic peak torque at 60°/s and 180°/s 6 months after surgery. Results: Fifteen patients were retrained with cycling (GI), 17 with running (GII) and 15 patients did not retrain (GIII). Before retraining, the 3 groups had the same peak torque deficit, measured at an angular speed of 60°/s and 180°/s, for knee extensors (GI: 33±11% and 27±8%; GII: 30±13% and 24±10%; GIII: 31±15% and 24±13%, respectively) and knee flexors (GI: 26±11% and 20±13%; GII: 20±14% and 17±13%; GIII: 19±15% and 14±15%, respectively). After retraining, progress measured at 60°/s of knee extensors and flexors on the operated knees was 18±9% and 16±10% for GI, 16±9% and 11±11% for GII and 12±15% and 8±12 for GIII, respectively. Progress measured at 180°/s followed the same evolution. After comparison of the 3 groups, any significant difference was put in relief according to the type of retraining. Conclusion: Retraining after anterior cruciate ligament reconstruction is necessary for patients to practice their previous sport. In our study, aerobic cycling or running between 4 and 6 months after surgery did not improve peak torque in the operated knee extensors and flexors. However, these 2 types of retraining are well-tolerated. [Copyright &y& Elsevier]

Abstract: Objective. – To evaluate of the effective use of gait orthosis in patients with spinal cord injuries. Patients and methods. – A total of 43 patients with complete paraplegia, level T3 to L1, who had a gait orthosis (hip-knee-ankle-foot orthosis, reciprocating gait orthosis, hybrid orthosis and functional electrical stimulation) answered a telephone questionnaire. Results. – Orthotic gait use was discontinued in 65% of patients who used the orthosis twice a week for 15 to 60 minutes. Two-thirds of the patients were able to fit the orthosis independently, 60% for standing and 25% for walking. The main reasons for discontinuing use were psychological reasons in 30% of patients, the lack of functional use and the necessity for human help or supervision. Conclusion. – Presently available devices do not allow functional and independent use of gait orthoses. Their use is limited to physical training, and the only demonstrated physiological benefits are the effects of functional electrical stimulation on cardiovascular status. Prescription for gait orthosis appears justified only if requested by a motivated and well-informed patient or if it appears a useful step in the acceptation of the loss of the gait. [Copyright &y& Elsevier]

Abstract: Introduction. – Ilizarov’s external fixator indications are classically used in children to lengthen the lower limbs. This technique is used for adults to gradually correct articular limitations, especially in the knee, ankle and foot. Method and results. – We report a case of a 53-year-old patient with distal microangiopathy of the lower limbs leading to amputation of the toes and a bilateral, direct, irreducible, isolated equine feature? from the back foot to 0/50/60°? on retraction of the Achilles tendon. The aim of patient management was to regain walking ability. Because of vascular and cutaneous fragility, the classical surgical treatment was contra-indicated. Progressive reduction by Ilizarov’s external fixator was tried. Dorsal inflection was obtained by twice-daily screwing until a radiological angle of 90° was obtained between the tibia and talus. At ten weeks post-surgery, the dorsal voluntary inflection ankle amplitude was symmetrical to 0/10/60°. The patient walked with orthopaedic shoes compensating for the few degrees of residual equine. Discussion. – Correction of adult equine without osseous deformation by Ilizarov’s external fixator should be considered when conventional surgery is contra-indicated. [Copyright &y& Elsevier]

Abstract: Objective. – To evaluate the contribution of isokinetic methods of shoulder strength measurement and training. Method. – A Medline search of English and French publications, including referenced articles, allowed us to analyse non-indexed publications. Eighty-seven articles were retained for analysis. Results. – The isokinetic evaluation of the shoulder is valid. Although reproducibility of shoulder evaluation is inferior to that of the knee, it is nevertheless satisfactory when a rigorous test method is used. Normal values for the rotators, abductors–adductors, and extensors–flexors depend on diverse parameters such as age, gender, fat mass, and the type and intensity of physical activity. The agonist to antagonist ratio is particularly informative in pathological conditions. The ratio is modified in cases of impingement syndrome and shoulder instability, and this modification appears to be a cause rather than a consequence of pathologic features. The ratio generally remains modified post-surgery, and normalization must be a major focus of post-surgery rehabilitation. Conclusion. – Isokinetic measurement, particularly disturbances in the agonist–antagonist balance, is a reference method for evaluating shoulder muscle strength and detecting deficits in specific muscle groups seen in certain shoulder abnormalities. Such measurement is a valuable tool for orienting rehabilitation towards the deficient muscle groups, complements classical techniques of muscle strengthening, and is an accurate means for following the rehabilitation progress. [Copyright &y& Elsevier]