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The effects of electrical stimulation on the control of muscle atrophy and strength in meniscectomy patients Baker, Robert James 1978

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THE EFFECTS OF ELECTRICAL STIMULATION ON THE CONTROL OF MUSCLE ATROPHY AND STRENGTH IN MENISCECTOMY PATIENTS by Robert James Baker B.P.E., U n i v e r s i t y of B r i t i s h Columbia, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PHYSICAL EDUCATION in THE FACULTY OF GRADUATE STUDIES i n the School of P h y s i c a l E ducation and R e c r e a t i o n We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1978 Robert James Baker, 197 8 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the requ i rement s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h Co lumb ia , I a g ree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s tudy . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i thout my w r i t t e n p e r m i s s i o n . Department o f Physical Education The U n i v e r s i t y o f B r i t i s h Co lumbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 August 15, 1 9 7 8 ABSTRACT A f t e r knee surgery, the development of l e g s t r e n g t h and s i z e t o i t s o r i g i n a l l e v e l s are important requirements i n the recovery. The major aim i n the r e h a b i l i t a t i o n of a meniscectomy i s to r e t u r n the i n j u r e d limb to i t s o r i g i n a l s i z e by a program of a c t i v e e x e r c i s e s . F a i l u r e to do t h i s may r e s u l t i n l i m i t e d a c t i v i t y and r e - i n j u r y to the knee j o i n t A program of e l e c t r i c a l s t i m u l a t i o n has been found to be e f f e c t i v e i n c o n t r o l l i n g muscle atrophy d u r i n g the time of d e n e r v a t i o n i n animals and humans ( i n animals - Schimrizk e t a 1976; Herbison e t a l , 1973, 1971; S t i l l w e l l e t a l , 1962 and Guttman and Guttman, 1942; i n humans - Osbourne, 1951 and Jackson and Seddon, 1945). At the present time no s t u d i e s have been done to determine i f e l e c t r i c a l s t i m u l a t i o n w i l l be e f f e c t i v e i n c o n t r o l l i n g muscle atrophy i n normally i n n e r v a t e d muscles d u r i n g the p e r i o d of i m m o b i l i z a t i o n . The purpose of t h i s i n v e s t i g a t i o n was to determine the e f f e c t s of a 10-12 day program of e l e c t r i c a l s t i m u l a t i o n on the c o n t r o l of muscle atrophy and s t r e n g t h l o s s d u r i n g the p e r i o d of i m m o b i l i z a t i o n . A subproblem of t h i s i n v e s t i g a t i o n was to determine the r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s . The s u b j e c t s f o r t h i s study were eighteen p a t i e n t s undergoing a meniscectomy o p e r a t i o n (mean age 22.7 y r s . ) . S ubjects were r a t e d a c c o r d i n g to s t r e n g t h per body weight and assigned to a c o n t r o l or an experimental group. The experimental group p a r t i c i p a t e d i n a f i v e s e s s i o n program of e l e c t r i c a l s t i m u l a t i o n i n a d d i t i o n to a standard physiotherapy program. The c o n t r o l group p a r t i c i p a t e d o n l y i n the standard p hysiotherapy program. The e l e c t r i c a l s t i m u l a t i o n c o n s i s t e d of f i v e s e s s i o n s each l a s t i n g ten minutes. Nin e t y muscle c o n t r a c t i o n s were made du r i n g the ten minute s e s s i o n . The s e s s i o n s were h e l d on weekdays w i t h i n a 10-12 day p e r i o d of the o p e r a t i o n . The f i r s t s e s s i o n was h e l d 48 hours a f t e r the o p e r a t i o n . In the f i r s t two s e s s i o n s the l e g was s t i m u l a t e d a t the immobilized angle and i n the remaining three s e s s i o n s the l e g was s t i m u l a t e d a t 115 degrees of e x t e n t i o n . A l l s u b j e c t s were t e s t e d one day p r i o r to the o p e r a t i o n and a t the end of the 10-12 day p e r i o d f o r t h i g h volume and maximal i s o m e t r i c l e g s t r e n g t h . The f o l l o w i n g hypotheses were t e s t e d f o r s i g n i f i c a n c e a t the .05 l e v e l . 1. The use of e l e c t r i c a l s t i m u l a t i o n i n a d d i t i o n to the standard physiotherapy program w i l l show l e s s muscle atrophy as compared to the standard physiotherapy program. 2. The use of e l e c t r i c a l s t i m u l a t i o n i n a d d i t i o n to the standard physiotherapy program w i l l m a i n t ain a higher l e v e l of o r i g i n a l i s o m e t r i c s t r e n g t h as compared to the standard physiotherapy program. 3. There i s a p o s i t i v e l i n e a r r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s . i v A n a l y s i s of v a r i a n c e r e v e a l e d t h a t hypothesis #1 i s supported a t the .01 l e v e l and hypothesis #2 i s not supported a t the .05 l e v e l of s i g n i f i c a n c e . The Pearson Product Moment C o r r e l a t i o n showed t h a t hypothesis #3 i s supported when the two groups were combined and f o r the c o n t r o l group o n l y a t the .01 l e v e l of s i g n i f i c a n c e , but not f o r the treatment group o n l y , a t the .05 l e v e l . V TABLE OF CONTENTS Page T i t l e Page i ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES v i i i ACKNOWLEDGEMENTS . .. i x Chapter 1 INTRODUCTION 1 Statement of the Problem 4 D e f i n i t i o n s 4 Hypotheses 5 D e l i m i t a t i o n s 5 L i m i t a t i o n s 6 Chapter 2 REVIEW OF LITERATURE 7 Disuse Atrophy . 7 E l e c t r i c a l S t i m u l a t i o n 15 Summary 18 Chapter 3 METHODS AND PROCEDURES 21 Subject s 21 Time and D u r a t i o n of the Study 21 T e s t s 22 Maximal Leg Strength T e s t (cable tensiometer) . . . 22 Thigh Volume 2 3 Procedures f o r the F a r a d i c S t i m u l a t i o n 24 Experimental Design 25 S t a t i s t i c a l Treatment 26 v i Page Chapter 4 RESULTS AND DISCUSSION 2 8 The e f f e c t of f a r a d i c s t i m u l a t i o n on the c o n t r o l of muscle atrophy 29 R e s u l t s : The e f f e c t of f a r a d i c s t i m u l a t i o n on the c o n t r o l of muscle s t r e n g t h 37 Hypothesis 39 D i s c u s s i o n 39 R e s u l t s : The r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s 41 Hypothesis 41 D i s c u s s i o n 42 Chapter 5 SUMMARY AND CONCLUSIONS 4 3 Con c l u s i o n s 44 Recommendations f o r F u r t h e r Study 45 BIBLIOGRAPHY . . . . . . . 46 APPENDIX A 49 APPENDIX B 61 APPENDIX C 62 v i i LIST OF TABLES Page Table 1 Experimental Design 26 Table 2 Subject Data 28 Table 3 Observed C e l l Means . 29 Table 4 The D i f f e r e n c e i n Thigh Circumference and Volume Over a 10-12 Day P e r i o d 30 Table 5 T-Test f o r the Observation of Muscle Atrophy 30 Table 6 A n a l y s i s of V a r i a n c e f o r Maximal Leg Circumference 31 Table 7 A n a l y s i s of V a r i a n c e f o r T o t a l Thigh Volume 32 Table 8 A n a l y s i s o f V a r i a n c e f o r P a r t i a l Thigh Volume 33 Table 9 Observed C e l l Means 37 Table 10 The D i f f e r e n c e i n Maximum Leg S t r e n g t h per Body Weight Over a 10-12 Day P e r i o d 38 Table 11 A n a l y s i s of V a r i a n c e f o r Str e n g t h per Body Weight 39 Table 12 C o r r e l a t i o n C o e f f i c i e n t s Between Muscle Atrophy and Str e n g t h Loss 41 V1X1 LIST OF FIGURES Page F i g u r e 1 Thigh Measurement Reference S i t e s 23 i x ACKNOWLEDGEMENTS The i n v e s t i g a t o r would l i k e t o express s i n c e r e a p p r e c i a t i o n t o the members of the committee f o r t h e i r guidance i n t h i s study and to Mrs. N. Nobbs, Mrs. L. Newman and Mrs. E. Bishop, from the physiotherapy department a t S a i n t Mary's H o s p i t a l f o r t h e i r v a l u a b l e a s s i s t a n c e throughout the study. Chapter 1 1 INTRODUCTION When a limb has been immobilized i n a c a s t or heavy bandage f o r any p e r i o d of time the muscles are s u b j e c t to a s u b s t a n t i a l l o s s i n s i z e and s t r e n g t h . There does not seem to be any r e l a t i o n s h i p between the l e n g t h of time immobilized and the amount of muscle atrophy (Davies and Sargeant, 1975; Wolf e t a l , 1971 and P a t e l e t a l , 1969). In the area of d i s u s e atrophy of the lower limb, Wolf e t a l (1971) while working wi t h knee p a t i e n t s , found there was a s u b s t a n t i a l d i f f e r e n c e i n circumference between the i n j u r e d and u n i n j u r e d t h i g h r e g a r d l e s s of whether i s o m e t r i c e x e r c i s e s were c a r r i e d out d u r i n g the p e r i o d of i m m o b i l i z a t i o n or not. Davies and Sargeant (197 5) found when st u d y i n g p a t i e n t s with lower limb f r a c t u r e s t h a t a s i g n i f i c a n t r e d u c t i o n of 16 percent i n t h i g h volume o c c u r r e d i n the i n j u r e d l e g a f t e r the removal of the c a s t . Sargeant e t a l (1977), a l s o s t u d y i n g p a t i e n t s w i t h lower limb f r a c t u r e s , found a r e d u c t i o n i n volume of 12 percent between the i n j u r e d and u n i n j u r e d limb. A s s o c i a t e d with t h i s l o s s was a r e d u c t i o n i n maximum oxygen uptake achieved i n one-leg c y c l i n g of .321/min. T h i s was a r e d u c t i o n of 17 p e r c e n t . M u l l e r and H e t t i n g e r (1953) st u y d i n g i m m o b i l i z a t i o n by c a s t i n g , found t h a t muscles l o s t up to 20 percent of t h e i r maximal s t r e n g t h w i t h i n the f i r s t week. However, D u f f i n (19 77) 2 found that the loss i n muscle strength did not necessarily relate to a similar loss i n muscle bulk. The whole muscle with disuse atrophy becomes soft and decreases i n s i z e . This decrease i n size predominantly af f e c t s the f i b e r s of medium and larger sizes and i s accompanied by a s i g n i f i c a n t loss i n strength of sustained contraction (Anderson 1971). Sargeant et a l (1977) found that both type I and II fi b e r s atrophied s i g n i f i c a n t l y a f t e r immobilization. Research by Fudema et a l (1961) on the hind limb of cats and Petal et a l (1969) on the quadriceps of humans discovered a decrease of active muscle f i b e r s and shortened contraction time accompanied by decreased amplitude of e l e c t r i c a l a c t i v i t y . Goldspink (1977) found the major reason for muscle atrophy was that during the time of immobilization and limited physical a c t i v i t y there was a decrease i n protein synthesis and an increase i n protein breakdown. Another minor reason was that during the time of decreased a c t i v i t y there was a narrowing of blood vessels and a loss of n u t r i t i o n . Wolf et a l (1971) found there was almost a complete cessation of e l e c t r i c a l a c t i v i t y during immobilization. "This lack of e l e c t r i c a l a c t i v i t y i l l u s t r a t e s the i n a b i l i t y of the patient to contract the muscle even to a moderate degree. The only possible cause, considering the muscle proper was not damaged and the nerve and blood supply were in t a c t , was interference with the actual performance of the muscular contraction. The nature of t h i s interference may have been caused by pain e s p e c i a l l y at the beginning, li m i t e d 3 range of the knee j o i n t caused by s w e l l i n g , and damage of the s o f t t i s s u e and the presence of the p l a s t e r c a s t . " In the c o n d i t i o n s where v o l u n t a r y c o n t r a c t i o n s are i n h i b i t e d , e l e c t r i c a l s t i m u l a t i o n has been shown to be of c o n s i d e r a b l e value ( N i c o l s 1976, S c o t t 1975). I f the a f f e r e n t nerve f i b e r s from the muscle s p i n d l e s are s t i m u l a t e d e l e c t r i c a l l y , t h i s should reduce the i n h i b i t i o n , so f a c i l i t a t i n g the t r a n s m i s s i o n of v o l u n t a r y impulses to the muscle (Scott 1975). The muscle c o n t r a c t i o n generated by the e l e c t r i c a l s t i m u l a t i o n i s the same as a v o l u n t a r y c o n t r a c t i o n , thus the same p h y s i o l o g i c a l p r o p e r t i e s of muscle c o n t r a c t i o n o c c u r s . When a muscle was e l e c t r i c a l l y s t i m u l a t e d i t has been r e p o r t e d to i n h i b i t p r o t e i n breakdown (Goldberg e t a l 1975). L i t t l e r e s e a r c h has been done i n the use of e l e c t r i c a l s t i m u l a t i o n f o r the c o n t r o l of muscle atrophy i n humans d u r i n g i m m o b i l i z a t i o n . In theory the e l e c t r i c a l s t i m u l a t i o n should c o n t r o l the f a c t o r s a s s o c i a t e d w i t h the causes of muscle atrophy, such as: muscle i n a c t i v i t y , the decrease i n p r o t e i n s y n t h e s i s and the i n c r e a s e i n p r o t e i n breakdown, c e s s a t i o n of e l e c t r i c a l impulses, and the narrowing of blood v e s s e l s . P r e v i o u s animal s t u d i e s have found e l e c t r i c a l s t i m u l a t i o n to be an e f f e c t i v e means of c o n t r o l l i n g muscle atrophy d u r i n g the p e r i o d - of d e n e r v a t i o n (Schimrizk e t a l , 1976 and Herbison e t a l , 1973). In a r e c e n t study Johnson e t a l (.1977) found e l e c t r i c a l s t i m u l a t i o n to be an e f f e c t i v e form of r e h a b i l i t a t i o n f o r c h o n d r o m a l i c i a p a t e l l a . The r e s u l t s showed an i n c r e a s e i n l e g s t r e n g t h and t h i g h g i r t h a f t e r 20 4 s e s s i o n s o f e l e c t r i c a l s t i m u l a t i o n . Johnson e t a l (1977) a l s o mentioned the use of e l e c t r i c a l s t i m u l a t i o n as a means of therapy f o r p o s t - o p e r a t i v e knee o p e r a t i o n s . Statement of the Problem The purpose of the study was to i n v e s t i g a t e the e f f e c t of an e l e c t r i c a l s t i m u l a t i o n program on the c o n t r o l of muscle atrophy and s t r e n g t h i n the quadricep muscles of meniscectomy p a t i e n t s . Subproblem To determine the r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s . D e f i n i t i o n s M e n i s c i are semilunar f i b r o c a r t i l a g e s . They l i e on the p l a t e a u s of the t i b i a and a r t i c u l a t e w i t h the fermoral. condyles. Meniscectomy i s the s u r g i c a l procedure used i n the removal of a meniscus. Muscle atrophy a c q u i r e d decrease i n the s i z e of a normally developed t i s s u e . Disuse atrophy atrophy as a r e s u l t of f o r c e d i n a c t i v i t y . E l e c t r i c a l S t i m u l a t i o n the e l e c t r i c a l s t i m u l a t i o n used i n the study was a f a r a d i c c u r r e n t . The c u r r e n t i s produced by a f a r a d i c c o i l which c o n s i s t s o f a r i s e and f a l l of u n i d i r e c t i o n a l c u r r e n t impulses. The e s s e n t i a l f e a t u r e s are t h a t the s t i m u l i with a d u r a t i o n of .1-1 m i l l i s e c o n d are repeated 50-100 times per second. Hypotheses 1. The use of e l e c t r i c a l s t i m u l a t i o n i n a d d i t i o n to the standard physiotherapy program w i l l show l e s s muscle atrophy as compared to the standard p h ysiotherapy program R a t i o n a l e : The muscular c o n t r a c t i o n s produced by the e l e c t r i c a l s t i m u l a t i o n w i l l i n h i b i t p r o t e i n breakdown and s t i m u l a t e c i r c u l a t i o n to the muscle. 2. The use of e l e c t r i c a l s t i m u l a t i o n i n a d d i t i o n to the standard physiotherapy program w i l l m a i n t a i n a higher l e v e l of o r i g i n a l i s o m e t r i c s t r e n g t h as compared to the standard p h ysiotherapy program. R a t i o n a l e : E l e c t r i c a l s t i m u l a t i o n s w i l l produce muscle c o n t r a c t i o n s of s u f f i c i e n t i n t e n s i t y t o maintain muscle s t r e n g t h . 3. There i s a p o s i t i v e l i n e a r r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s . R a t i o n a l e : Since the same p h y s i o l o g i c a l f a c t o r s are r e q u i r e d i n m a i n t a i n i n g s t r e n g t h and s i z e , these v a r i a b l e should be p o s i t i v e l y c o r r e l a t e d . D e l i m i t a t i o n s 1. Inferences from t h i s study were l i m i t e d to meniscectomy p a t i e n t s between the ages of 14 and 33. 2. The e f f e c t s of the f a r a d i c s t i m u l a t i o n program were assessed over a 10-12 day p e r i o d . L i m i t a t i o n s 1. The i n v e s t i g a t o r had no c o n t r o l of the s u b j e c t s ' a c t i v i t i e s o u t s i d e the t e s t i n g s i t u a t i o n . 2. I t was assumed t h a t s u b j e c t s p a r t i c i p a t e d i n the standard p hysiotherapy program. 3. Each s u b j e c t ' s t o l e r a n c e l e v e l to the f a r a d i c s t i m u l a t i o n was d i f f e r e n t . 4. The accuracy of the r e s u l t s were l i m i t e d by the equipment used f o r the measurement of l e g s t r e n g t h and t h i g h circumference. 5. M o t i v a t i o n to produce maximum e f f o r t c o u l d not be measured i n t h i s study. 7 Chapter 2 REVIEW OF LITERATURE A l i b r a r y search r e v e a l e d a l a c k . o f l i t e r a t u r e c oncerning the e f f e c t s of e l e c t r i c a l s t i m u l a t i o n on the c o n t r o l o f muscle atrophy and s t r e n g t h d u r i n g the p e r i o d of i m m o b i l i z a t i o n on normally i n n e r v a t e d human s k e l e t a l muscle. Two areas of r e l a t e d l i t e r a t u r e e s s e n t i a l f o r the understanding of t h i s area w i l l be examined. The two areas are: d i s u s e atrophy and e l e c t r i c a l s t i m u l a t i o n . Disuse Atrophy Research i n the area of d i s u s e atrophy on humans has been p r i m a r i l y concerned w i t h : 1) the measurement of muscle atrophy and i t s r e l a t i o n s h i p to the l e n g t h of time immobilized; 2) the e f f e c t of muscle atrophy on p h y s i c a l performance; 3) the s t r u c t u r a l changes t h a t occur to the muscle d u r i n g d i s u s e atrophy; 4) the e f f e c t i v e n e s s of v a r i o u s r e h a b i l i t a t i o n programs on muscle atrophy. The measurement of muscle atrophy has been done a n t h r o p o m e t r i c a l l y by e i t h e r a s i n g l e circumference measurement at a p o i n t of maximal ci r c u m f e r e n c e , u s u a l l y 10-15 cm. d i s t a l to the g l u t e a l furrow or by c a l c u l a t i n g t h i g h volume from the procedures mentioned i n Katch e t a l (1975) and Jones and Pearson (1969). A l l p r e v i o u s r e s e a r c h on the measurement of muscle atrophy has compared the i n j u r e d to the u n i n j u r e d limb. 8 T h i s type of a n a l y s i s assumes t h a t both limbs were the same s i z e i n i t i a l l y which i s not always the case. The presence o f atrophy a f t e r a p e r i o d of i m m o b i l i z a t i o n i s a common o b s e r v a t i o n i n the medical p r o f e s s i o n . Sargeant e t a l (.1977), Sargeant and Davies (1977), Davies and Sargeant (1975), Wolf e t a l (1971) and P a t e l e t a l (1969) have r e p o r t e d the presence of d i s u s e atrophy r e g a r d l e s s o f the l e n g t h of time immobilized. The degree of muscle atrophy d i d not appear to r e l a t e to the l e n g t h of time the i n j u r e d limb was immobilized (Davies and Sargeant, 1975; Wolf e t a l , 1 9 7 1 and P a t e l e t a l 1969). Sargeant e t a l (1977) s t u d i e d seven p a t i e n t s each who had s u f f e r e d u n i l a t e r a l l e g f r a c t u r e s and had been immobilized i n a p l a s t e r c a s t f o r a mean' p e r i o d of 131 days. Leg volume was assessed a n t h r o p o m e t r i c a l l y and an average r e d u c t i o n o f 12 percent was found, when the i n j u r e d limb was compared t o the u n i n j u r e d limb. A muscle biopsy of the vastus l a t e r a l i s was performed and the r e s u l t s showed a s u b s t a n t i a l r e d u c t i o n (.42 percent) i n c r o s s - s e c t i o n a l area o f the muscle f i b e r s sampled. From t h i s r e s u l t Sargeant e t a l (1977) i n d i c a t e d t h a t the volume measurement may have been an u n d e r e s t i m a t i o n . Sargeant and Davies (1977) s t u d i e d s i x p a t i e n t s who had s u f f e r e d u n i l a t e r a l leg. f r a c t u r e s and were immobilized f o r an average of 14 5 days. The p a t i e n t s were f i r s t measured 6 2 days a f t e r the removal of the c a s t , when t o t a l weight b e a r i n g had been reached and i t was found t h a t a r e d u c t i o n i n l e g volume of 11 percent o c c u r r e d . 9 Davies and Sargeant (1975) worked with 20 p a t i e n t s again who had s u f f e r e d l e g f r a c t u r e s and had been immobilized f o r a mean p e r i o d of 117 days. The i n i t i a l t e s t s were done 2 8 days a f t e r the removal of the c a s t , a t a time when a systematic program of e x e r c i s e therapy was to s t a r t . At t h i s time the d i f f e r e n c e i n t o t a l l e g volume between the two limbs was 9 percent, but when allowance was made f o r f a t and bone volumes, the d i f f e r e n c e i n muscle volume i n c r e a s e d to 16 percent. Sargeant and Davies (1975) d i d not f i n d any r e l a t i o n s h i p between muscle atrophy and the time of i m m o b i l i z a -t i o n and suggest t h a t the a t r o p h i c response to d i s u s e i n man i s a r a p i d phenomenon o c c u r r i n g w i t h i n the f i r s t few weeks of i m m o b i l i z a t i o n . Wolf e t a l (1971) s t u d i e d d i s u s e atrophy by u s i n g 38 p a t i e n t s with v a r i o u s knee l e s i o n s r e q u i r i n g d i f f e r e n t p e r i o d s of i m m o b i l i z a t i o n i n a p l a s t e r c a s t . None of the l e s i o n s were t r e a t e d s u r g i c a l l y and the p e r i o d of i m m o b i l i z a t i o n ranged from l e s s than f i v e days to over twenty-six days. The measurement of muscle atrophy was a s i n g l e circumference measurement a t a p o i n t 15 cm. above the s u p e r i o r boarder of the p a t e l l a . R e s u l t s showed a decrease i n maximal circumference ranging from l e s s than 1.0 cm. to over 2.0 cm. The r a t e of atrophy d i d not r e l a t e to the p e r i o d of i m m o b i l i z a t i o n as two of the l a r g e s t circumference r e d u c t i o n s were found i n the s h o r t p e r i o d of i m m o b i l i z a t i o n (6-15 d a y s ) . P a t e l e t a l (1969) s t u d i e d 10 p a t i e n t s w i t h v a r i e d 10 uncomplicated limb f r a c t u r e s and the p e r i o d of i m m o b i l i z a t i o n l a s t i n g between 3.5 and 14 weeks. The r e s u l t s i n d i c a t e d t h a t the e x t e n t of atrophy v a r i e d with the type of limb immobilized. In f o u r i n s t a n c e s the immobilized limb was found to be l a r g e r than i t s mate, which was due to edema found i n the limb. The r e s u l t s i n t h i s study a l s o i n d i c a t e d t h a t there was no r e l a t i o n s h i p between the l e n g t h of time immobilized and the degree of muscle atrophy. I t i s commonly accepted t h a t i n i s o l a t e d muscle, maximal s t r e n g t h i s p r o p o r t i o n a l to the c r o s s - s e c t i o n a l area. Roughly, t h i s i s a l s o t r u e f o r muscles i n s i t u (Astrand 1976). I k a i and Fukunaga (196 8) have shown t h a t s t r e n g t h per u n i t of c r o s s s e c t i o n a l area i s about the same f o r sedentary as w e l l as t r a i n e d a d u l t s . Thus one would expect t h a t w i t h d i s u s e atrophy t h e r e would be a p r o p o r t i o n a t e decrease i n muscle s t r e n g t h . By u s i n g a v a r i e t y of p h y s i o l o g i c a l t e s t s , Sargeant e t a l (1977), Sargeant and Davies (1977), D u f f i n (1977) and M u l l e r and H e t t i n g e r (1953) found a s u b s t a n t i a l l o s s i n p h y s i c a l performance d i d accompany muscle atrophy. Sargeant e t a l (197 7) compared a group of h e a l t h y servicemen to a group of p a t i e n t s who were r e c o v e r i n g a f t e r the removal of a c a s t f o r a f r a c t u r e d lower limb. The groups were t e s t e d f o r t h i g h volume and VC>2 max.. A s p e c i a l b i c y c l e ergometer f o r one legged c y c l i n g was used i n a continuous p r o g r e s s i v e t e s t spanning the s u b j e c t s ' working c a p a c i t y from zero to maximum fou r or f i v e working s e s s i o n s each l a s t i n g f i v e 11 minutes. Maximal measurements were taken when a p l a t e a u was reached, u s i n g the same c r i t e r i o n as developed f o r two-legged t e s t s . The r e s u l t s found a 17 percent r e d u c t i o n i n VC>2 max. was achieved i n e x e r c i s e u s i n g o n l y the i n j u r e d l e g which was a s s o c i a t e d w i t h the r e d u c t i o n i n l e g volume of 12 perc e n t . Sargeant and Davies (1977) s t u d i e d s i x p a t i e n t s a f t e r the c a s t had been removed f o r a u n i l a t e r a l l e g f r a c t u r e . The procedures f o r t h i s experiment were s i m i l a r to a p r e v i o u s l y mentioned study by Sargeant e t a l (1977) except the f o r c e s e l i c i t e d by the l e g s w hile p e d a l l i n g were a l s o examined. A l s o both one legged and normal c y c l i n g were t e s t e d . The r e s u l t s showed t h a t d u r i n g e x e r c i s e u s i n g one l e g onl y the a t r o p h i e d limb produced a lower mean peak f o r c e to work r a t e , but the d i f f e r e n c e was not s i g n i f i c a n t . In normal c y c l i n g the r e l a t i o n -s h i p of mean peak f o r c e to work r a t e was s i g n i f i c a n t l y d i f f e r e n t f o r each l e g . The mean peak f o r c e was about 40 perc e n t lower i n the a t r o p h i e d compared with the normal l e g f o r a giv e n work r a t e . T h i s decrease i n mean peak f o r c e f o r a g i v e n work r a t e of 40 percent corresponded to a s i m i l a r r e d u c t i o n i n c r o s s -s e c t i o n a l f i b e r area of 40 percent. T h i s can a l s o be compared to the 12 perc e n t decrease i n l e g volume. D u f f i n (1977) surveyed f i f t y people who had p r e v i o u s l y had a meniscectomy o p e r a t i o n . The r e s u l t s i n d i c a t e d t h a t a l a r g e percentage o f the p a t i e n t s s u f f e r e d an i n i t i a l l o s s i n s i z e as w e l l as f u n c t i o n i n the quadricep muscles. A f t e r an u n d i s c l o s e d p e r i o d of time d u r i n g a c t u a l knee examinations, 12 he found t h a t muscle bulk d i d not n e c e s s a r i l y r e l a t e to muscle s t r e n g t h , as he r e p o r t e d t h a t only 18 percent of the p a t i e n t s s t i l l had a l o s s .of muscle bulk, while 38 per c e n t showed a decrease i n quadricep muscle power. M u l l e r and H e t t i n g e r (1953) r e p o r t e d experiments i n which a muscle t h a t was immobilized i n a c a s t l o s t 20 per c e n t of i t s maximal s t r e n g t h w i t h i n the f i r s t week. Many p r e v i o u s s t u d i e s have examined the s t r u c t u r a l changes t h a t occur w i t h d i s u s e atrophy. These f i n d i n g s w i l l o n l y be b r i e f l y mentioned as no p h y s i o l o g i c a l t e s t s of t h i s nature were undertaken i n t h i s study. Many s t u d i e s have i n d i c a t e d t h a t the quadricep muscles were the most a f f e c t e d group of muscles d u r i n g i m m o b i l i z a t i o n of the lower limb (Sargeant e t a l , 1977 and Wolf e t a l , 1971). The reason f o r t h i s was t h a t d u r i n g the p e r i o d of i m m o b i l i z a t i o n the quadriceps are i n a shortened s t a t e , where-as other muscles such as the hamstrings are s l i g h t l y s t r e t c h e d . Goldspink . (1977) (1976) and Goldberg (1975) mentioned muscles immobilized i n a s l i g h t l y s t r e t c h e d p o s i t i o n may even hypertrophy due to the s t r e t c h c a u s i n g an i n c r e a s e i n p r o t e i n s y n t h e s i s . Whereas i n muscles immobilized i n a shortened p o s i t i o n there i s a s u b s t a n t i a l amount of atrophy due to an i n c r e a s e i n p r o t e i n d e g r a d a t i o n . During d i s u s e atrophy both f i b e r types showed a s i g n i f i c a n t and s i m i l a r r e d u c t i o n i n the mean c r o s s s e c t i o n a l area when compared to the u n i n j u r e d limb (Sargeant e t a l , 1977 and P a t e l e t a l , 1969). The onl y other s t r u c t u r a l changes t h a t 13 o c c u r r e d to the a t r o p h i e d muscle f i b e r s themselves were t h a t there was an i n c r e a s e i n the number of n u c l e i p r e s e n t per f i b e r ( P a t e l e t a l , 1969). During d i s u s e atrophy there has a l s o been r e p o r t e d a decrease i n amplitude of e l e c t r i c a l a c t i v i t y to the muscle (Wolf e t a l , 1971). Wolf e t a l (1971) examined 38 p a t i e n t s with v a r i o u s knee l e s i o n s f o r e l e c t r i c a l a c t i v i t y t o the muscle. An EMG was given to each p a t i e n t and the r e s u l t s showed a marked decrease i n e l e c t r i c a l a c t i v i t y to the muscle from the t h i r d day of i m m o b i l i z a t i o n onwards. The r e s u l t s were s i m i l a r whether or not i s o m e t r i c e x e r c i s e s were performed d u r i n g the p e r i o d of i m m o b i l i z a t i o n . Wolf e t a l (1971) s t a t e s : "the l a c k of e l e c t r i c a l a c t i v i t y i l l u s t r a t e s the i n a b i l i t y of the p a t i e n t to c o n t r a c t the muscle even to a moderate degree. The o n l y p o s s i b l e cause c o n s i d e r i n g t h a t the muscle proper was not damaged and the nerve and blood supply were i n t a c t , was i n t e r f e r e n c e w i t h the a c t u a l performance of the muscular c o n t r a c t i o n . The nature of the i n t e r f e r e n c e may have been p a i n , e s p e c i a l l y a t the beginning, l i m i t e d range of motion of the knee j o i n t , caused by s w e l l i n g and damage to s o f t t i s s u e s and of course the presence of the p l a s t e r c a s t . " The a c t u a l causes of d i s u s e atrophy have been researched by Goldspink (1977) (1976) and Goldberg (1975). They mention t h a t d u r i n g the p e r i o d of i m m o b i l i z a t i o n and l i m i t e d a c t i v i t y there was a decrease i n p r o t e i n s y n t h e s i s and an i n c r e a s e i n p r o t e i n breakdown. They a l s o mentioned d u r i n g t h i s p e r i o d there may be a l t e r a t i o n s i n the blood supply to the muscles concerned, but these changes alone do not appear s u f f i c i e n t to e x p l a i n the events of muscle atrophy. The e f f e c t of i s o m e t r i c e x e r c i s e s d u r i n g the p e r i o d of i m m o b i l i z a t i o n on the c o n t r o l of muscle atrophy has been s t u d i e d by Wolf e t a l (1971). Wolf e t a l (1971) s t u d i e d 38 p a t i e n t s w i t h v a r i o u s knee l e s i o n s r e q u i r i n g d i f f e r e n t p e r i o d s of i m m o b i l i z a t i o n . Seventeen of these p a t i e n t s were f o l l o w e d up a f t e r the removal of the c a s t . Of these 17 p a t i e n t s , 9 performed i s o m e t r i c e x e r c i s e s of the quadriceps w i t h i n the c a s t , while the remaining 8 were immobilized, without e x e r c i s e s . The r e s u l t s i n d i c a t e d t h a t i s o m e t r i c e x e r c i s e s were b e n e f i c i a l , but d i d not e n t i r e l y c o n t r o l atrophy. Davies and Sargeant (1975) s t u d i e d the e f f e c t s of e x e r c i s e therapy on the r a t e of l e g volume i n c r e a s e a f t e r a p e r i o d of i m m o b i l i z a t i o n . The study used 16 p a t i e n t s r e c o v e r i n g from u n i l a t e r a l l e g f r a c t u r e s . The e x e r c i s e therapy l a s t e d f o r a mean p e r i o d of 50 days. The r e s u l t s showed a mean i n c r e a s e i n l e g volume of 1.2 percent per 10 day p e r i o d . The r a t e of i n c r e a s e seemed independent of the stage of r e h a b i l i t a t i o n , but the i n c r e a s e i n volume appears to be l i n e a r with time. There was a s i g n i f i c a n t n e g a t i v e a s s o c i a t i o n between the r a t e of volume i n c r e a s e and the time spent immobilized. In a more rece n t study by Davies and Sargeant (1977) they a l s o compared r e h a b i l i t a t i o n e x e r c i s e s to v a r i o u s p h y s i o l o g i c a l t e s t s . They found t h a t a f t e r a p e r i o d of r e h a b i l i t a t i o n t h e r e was a decrease i n f a t i g u e d u r i n g submaximal work, an i n c r e a s e i n p r e d i c t e d V0 9 15 max. and a small i n c r e a s e i n mechanical e f f i c i e n c y . E l e c t r i c a l S t i m u l a t i o n The m a j o r i t y of the r e s e a r c h done d e a l i n g w i t h the e f f e c t of e l e c t r i c a l s t i m u l a t i o n on the c o n t r o l of muscle atrophy or s t r e n g t h development have d e a l t w i t h e i t h e r animal s t u d i e s or on denervated muscles i n humans. I t should be mentioned t h a t f a r a d i c s t i m u l a t i o n i s not used f o r denervated muscles as the i n t e n s i t y of c u r r e n t r e q u i r e d to produce a c o n t r a c t i o n with an amplitude l a s t i n g f o r 1 m i l l i s e c o n d i s u s u a l l y too g r e a t to be t o l e r a b l e " f o r treatment purposes (Sc o t t 1975). F a r a d i c s t i m u l a t i o n i s developed from a f a r a d i c c o i l and has two e s s e n t i a l f e a t u r e s : the s t i m u l i must l a s t f o r a d u r a t i o n of .1-1 m i l l i s e c o n d and be repeated 50-100 times per second. Current of t h i s type can s t i m u l a t e the motor nerves and the muscle i t s e l f w ith s u f f i c i e n t c u r r e n t to e l i c i t a muscle c o n t r a c t i o n . Because the s t i m u l i are repeated 50-100 times per second, the c o n t r a c t i o n i s t e t a n i c . I f t h i s type of c o n t r a c t i o n i s maintained f o r any p e r i o d of time, muscle f a t i g u e i s produced, so the c u r r e n t i s u s u a l l y surged or i n t e r r u p t e d to a l l o w f o r muscle r e l a x a t i o n . When the c u r r e n t i s surged the c o n t r a c t i o n i n c r e a s e s and decreases i n s t r e n g t h , s i m i l a r to a v o l u n t a r y c o n t r a c t i o n ( S c o t t 1975, S t i l l w e l l 1967). The muscle c o n t r a c t i o n produced by t h i s type of c u r r e n t has been found to be s i m i l a r to a v o l u n t a r y c o n t r a c t i o n ( S c o t t 1975). 16 There has been l i t t l e i n f o r m a t i o n gathered t o suspect t h a t muscle power can i n c r e a s e by e l e c t r i c a l s t i m u l a t i o n ( N i c o l s 1976, S t i l l w e l l 1967). T h i s i s because the d i s c o m f o r t of the s t i m u l i i s such t h a t a c o n t r a c t i o n produced i s r a r e l y more than 30 percent o f a maximal c o n t r a c t i o n ( N i c o l s 19 76). The importance of f a r a d i c s t i m u l a t i o n comes i n t o p l a y when a p a t i e n t f i n d s i t d i f f i c u l t to produce a muscle c o n t r a c t i o n . T h i s i s e v i d e n t when a c o n t r a c t i o n i s i n h i b i t e d by p a i n from a r e c e n t i n j u r y . S c o t t (1975) s p e c i f i c a l l y mentioned the use of f a r a d i c s t i m u l a t i o n i n e s t a b l i s h i n g a v o l u n t a r y c o n t r a c t i o n a f t e r a meniscectomy o p e r a t i o n . As mentioned when d e a l i n g with d i s u s e atrophy, i f a muscle i s i n a c t i v e f o r any p e r i o d of time r e g a r d l e s s of the reason,muscle atrophy would occur. F a r a d i c s t i m u l a t i o n should be an e f f e c t i v e means of c o n t r o l l i n g atrophy, as a c o n t r a c t i o n of o n l y 20 percent of maximum i s r e q u i r e d to c o n t r o l muscle s t r e n g t h and volume. Many s t u d i e s have shown t h a t e l e c t r i c a l s t i m u l a t i o n decreased the degree of muscle atrophy d u r i n g the p e r i o d of i m m o b i l i z a t i o n or d e n e r v a t i o n i n animals (Schimrizk e t a l , 1976; Herbison e t a l , 1973, 1971; S t i l l w e l l e t a l , 1962 and Guttman and Guttman, 1942) and i n humans (Osbourne,. 1951 and Jackson and Seddon, 1945). Schimrizk e t a l (1976), Herbison e t a l (1973) (1971) and S t i l l w e l l e t a l (1962) a l l worked wi t h denervated r a t muscle and found t h a t e l e c t r i c a l s t i m u l a t i o n aided i n c o n t r o l l i n g muscle atrophy. Guttman and Guttman (1942) s t u d i e d the l e g of denervated r a b b i t muscle. The r e s u l t s i n d i c a t e d t h a t i n each case the s t i m u l a t e d limb showed l e s s atrophy as compared to the c o n t r o l limb. Osbourne (1951) n o t i c e d a decrease i n atrophy i n humans wit h l e s i o n s of p e r i p h e r a l nerves a f t e r being t r e a t e d w i t h e l e c t r i c a l s t i m u l a t i o n . Jackson and Seddon (1945) s t u d i e d p a t i e n t s with d e n e r v a t i o n of muscles to the hand and found t h a t e l e c t r i c a l s t i m u l a t i o n c o n t r o l l e d muscle atrophy d u r i n g the f i r s t 100 days of d e n e r v a t i o n . Other s t u d i e s have shown t h a t e l e c t r i c a l s t i m u l a t i o n was b e n e f i c i a l i n i n c r e a s i n g muscle s i z e and s t r e n g t h d u r i n g r e h a b i l i t a t i o n (Johnson e t a l , 1977; Peckham e t a l , 1976 and Osbourne, 1951). Johnson e t a l (1977) s t u d i e d f i f t y p a t i e n t s s u f f e r i n g chondromalacia p a t e l l a , each p a t i e n t was measured f o r l e g s t r e n g t h and t h i g h g i r t h i n i t i a l l y and a f t e r twenty s e s s i o n s of f a r a d i c s t i m u l a t i o n . The treatment c o n s i s t e d of ten maximum t e t a n i c c o n t r a c t i o n s w i t h a 50 second r e s t p e r i o d between each. The c o n t r a c t i o n s were i s o m e t r i c i n nature with the knee a t 5 degrees of f l e x i o n . The r e s u l t s showed a 25.3 p e r c e n t i n c r e a s e i n quadricep s t r e n g t h i n the m i l d chondromalacia group and a 36.2 percent i n c r e a s e i n the severe chondromalacia group. There was a l s o a s i m i l a r i n c r e a s e i n t h i g h g i r t h of 4.3 p e r c e n t i n the m i l d group and 6.8 p e r c e n t i n the severe group. Johnson e t a l (1977) concluded t h a t f a r a d i c s i m u l a t i o n i s an e f f e c t i v e form of therapy f o r chondromalacia p a t e l l a and has i t s g r e a t e s t b e n e f i t i n the i n i t i a l stages, to combat the l o s s of v o l u n t a r y c o n t r o l of quadricep c o n t r a c t i o n . 18 Peckham e t a l (1976) s t u d i e d the e f f e c t s of e l e c t r i c a l s t i m u l a t i o n on s t r e n g t h i n q u a d r i p l e g i c p a t i e n t s . An i n t r a -muscular e l e c t r o d e was p l a n t e d w i t h i n the muscle nerves which s t i m u l a t e d the muscle at 50 percent of i t s maximal f o r c e . The c o n t r a c t i o n was p r i m a r i l y by e x c i t a t i o n of i n t r a m u s c u l a r nerves and i t was estimated t h a t o n l y 5 percent of the muscular f o r c e was from d i r e c t muscle s t i m u l a t i o n . The c u r r e n t was surged with the s t i m u l a t i o n and the r e s t p e r i o d being 2.5 seconds each. The c o n t r a c t i o n was i s o m e t r i c . w i t h the hands pl a c e d i n r e s t i n g pan s p l i n t s . The muscles of the hand were s t i m u l a t e d two to t h r e e hours a day f o r 30 weeks. The r e s u l t s showed a s i g n i f i c a n t i n c r e a s e i n s t r e n g t h , which was apparent even a f t e r the f i r s t f o u r weeks. Osbourne e t a l (1950) s t u d i e d p a t i e n t s w i t h p o l i o m y e l i -t i s and used a s i n u s o i d a l wave. The r e s u l t s showed a s i g n i f i c a n t i n c r e a s e i n the circumference of the s t i m u l a t e d limb. Summary In summary of the l i t e r a t u r e reviewed, atrophy was found to occur a f t e r a p e r i o d of i m m o b i l i z a t i o n (Sargeant e t a l , 1977; Sargeant and Davies, 1977; Davies and Sargeant, 1975; Wolf e t a l , 1971 and P a t e l e t a l , 1969). The degree of muscle atrophy d i d not seem to r e l a t e to the l e n g t h of time the i n j u r e d limb was immobilized (Davies and Sargeant, 197 5; Wolf e t a l , 1971 and P a t e l et a l , 1969). There was a p o s i t i v e r e l a t i o n s h i p r e p o r t e d between 19 muscle atrophy and the decrease i n p h y s i c a l performance (Sargeant e t a l 1977; Sargeant and Davies, 1977; D u f f i n , 1977 and M u l l e r and H e t t i n g e r , 1953). The s t r u c t u r a l changes t h a t o c c u r r e d w i t h d i s u s e atrophy were: both muscle f i b e r types showed a s i g n i f i c a n t and s i m i l a r decrease i n c r o s s - s e c t i o n a l area when compared to the u n i n j u r e d limb (Sargeant e t a l , 1977; and P a t e l e t a l , 1969) . The o n l y other s t r u c t u r a l change t h a t o c c u r r e d to the a t r o p h i e d muscle f i b e r s was an i n c r e a s e i n the number of n u c l e i ( P a t e l e t a l , 1969) . Wolf e t a l (1971) a l s o r e p o r t e d a decrease i n e l e c t r i c a l impulses to the muscle. The cause of d i s u s e atrophy occurs d u r i n g the p e r i o d of i m m o b i l i z a t i o n when ther e i s a decrease i n p r o t e i n s y n t h e s i s and an i n c r e a s e i n the breakdown of p r o t e i n . A f t e r a p e r i o d of r e h a b i l i t a t i o n there.was an i n c r e a s e i n muscle s i z e which a l s o r e l a t e s to a s i m i l a r i n c r e a s e i n p h y s i c a l performance (Davies and Sargeant, 1977, 1975). Wolf e t a l (1971) showed t h a t i s o m e t r i c e x e r c i s e s c a r r i e d out d u r i n g the p e r i o d of i m m o b i l i z a t i o n i n a c a s t were b e n e f i c i a l , but d i d not f u l l y c o n t r o l muscle atrophy. E l e c t r i c a l s t i m u l a t i o n has been found to be important i n the c o n t r o l of muscle atrophy d u r i n g the p e r i o d of i m m o b i l i -z a t i o n (Schimrizk e t a l , 1976; Osbourne, 1951; Jackson and Seddon, 1945 and Guttman and Guttman, 1942). E l e c t r i c a l s t i m u l a t i o n has a l s o been e f f e c t i v e as a form of therapy i n r e s t o r i n g muscle s i z e and s t r e n g t h of the i n j u r e d limb d u r i n g 20 r e h a b i l i t a t i o n (Johnson e t a l , 1977; Peckham e t a l , 1976 and Osbourne, 1951) . F a r a d i c s t i m u l a t i o n has been s a i d to be most b e n e f i c i a l i n the i n i t i a l treatment of chondromolacia to combat the l o s t v o l u n t a r y c o n t r o l of quadricep c o n t r a c t i o n . T h i s may have another s p e c i f i c a p p l i c a t i o n to the post o p e r a t i v e p a t i e n t having undergone knee surgery (Johnson e t a l , 1977). 21 Chapter 3 METHODS AND PROCEDURES Subjects A l l s u b j e c t s i n the study were p a t i e n t s undergoing a meniscectomy o p e r a t i o n a t S a i n t Mary's H o s p i t a l i n New Westminister, B r i t i s h Columbia. Eighteen s u b j e c t s aged 14 to 33 (mean age 22.7 + 5.5 years) p a r t i c i p a t e d i n the experiment. There was onl y one female i n v o l v e d i n the experiment and she was a member of the c o n t r o l group. The s u b j e c t s were r a t e d a c c o r d i n g t o i n i t i a l s t r e n g t h per body weight and assigned i n t o a c o n t r o l or a treatment group. The purpose of t h i s i n i t i a l measurement was to balance the two groups f o r s t r e n g t h per body weight. Time and D u r a t i o n o f the Study Due t o the nature of the study and the a v a i l a b i l i t y of s u b j e c t s the experiment was c a r r i e d out on an i n d i v i d u a l b a s i s . The study took p l a c e between November 197 7 and A p r i l 1978. A l l s u b j e c t s were t e s t e d twice; a p r e - t e s t one day p r i o r to the o p e r a t i o n and a post t e s t 10 to 12 days a f t e r the o p e r a t i o n . The experimental group p a r t i c i p a t e d i n a standard p h y s i o t h e r a p y program as w e l l as a program of e l e c t r i c a l s t i m u l a t i o n . The c o n t r o l group p a r t i c i p a t e d o n l y i n the r e g u l a r p h ysiotherapy program. The experimental group e s t a b l i s h e d time s l o t s with the p h y s i o t h e r a p i s t f o r f i v e s e s s i o n s . The f i r s t s e s s i o n was two days a f t e r the o p e r a t i o n , the remaining f o u r treatments were on week days w i t h i n 10-12 days of the o p e r a t i o n . Personnel The same r e g i s t e r e d p h y s i o t h e r a p i s t administered a l l the f a r a d i c s t i m u l a t i o n . T e s t s Two t e s t i n g s e s s i o n s were h e l d : p r e - t e s t , one day p r i o r to the meniscectomy o p e r a t i o n and a p o s t - t e s t , 10-12 days a f t e r the o p e r a t i o n . A l l s u b j e c t s were measured on both l e g s f o r maximal i s o m e t r i c s t r e n g t h and t h i g h volume. Subjec t s were weighed and t h e i r age taken a t the p r e - t e s t i n g stage. P r i o r to each s e s s i o n v e r b a l i n s t r u c t i o n s were gi v e n to f a m i l i a r i z e the s u b j e c t s w i t h the t e s t i n g procedures. Maximal Leg.Strength T e s t (cable tensiometer) The s u b j e c t s a t on the end of the t a b l e w i t h h i s hands gr a s p i n g the t a b l e s i d e s a t the h i p s . The knee p o s i t i o n was a t 115 degrees of e x t e n s i o n . The r e g u l a t i o n s t r a p was p l a c e d around the l e g midway between the knee and the ankle j o i n t s . The p u l l i n g assembly was attached to a hook secured under the physiotherapy t a b l e . Cable l e n g t h was a d j u s t a b l e to account f o r d i f f e r e n c e s i n l e g s i z e (Clarke and Monroe 1970). The maximal r e a d i n g taken by the c a b l e tensiometer was recorded. Measurements were taken on both l e g s twice and the average f o r each l e g recorded. The f o r c e was recorded i n pounds per body weight. Thigh Volume The s u b j e c t stood e r e c t w i t h the f e e t s l i g h t l y a p a r t . Three circumference measurements were used ( F i g . 1 ) : the g l u t e a l furrow i n the h o r i z o n t a l plane, a p o i n t 10 centimeters d i s t a l to the g l u t e a l furrow and a p o i n t 80 percent d i s t a l between the g l u t e a l furrow and the s u p e r i o r head of the p a t e l l a . A l l s i t e s f o r circumference measurements were f i r s t marked with a f i n e p o i n t f e l t pen. The readings were made with the Pre s t o n tape a p p l i e d p e r p e n d i c u l a r t o the long a x i s of the bone. Research by Katch e t a l (1975) i n d i c a t e d t h a t such procedures r e s u l t i n an i n t e r - t r i a l r e l i a b i l i t y c o e f f i c i e n t of r = .94 to r = .99, with a standard e r r o r f o r a s i n g l e measurement of no l a r g e r than .13 cm. In a d d i t i o n to the circumference measure-ments, the h e i g h t s between adjacent s i t e s were taken. Each s e t of measurements were taken on both l e g s twice and the average f o r each l e g recorded. Volume was c a l c u l a t e d from the average score and recorded i n c u b i c c e n t i m e t e r s . P a r t i a l Thigh V o l . (1-2) T o t a l Thigh V o l . (1-3) Circumference 1 Circumference 2 Circumference 3 F i g u r e 1: Thigh Measurement Reference S i t e s . Circumference 1 - g l u t e a l furrow, Circumference 2 - 1 0 cm. d i s t a l t o the g l u t e a l furrow and Circumference 3 - a p o i n t 80 percent d i s t a l between the g l u t e a l furrow and the s u p e r i o r head of the p a t e l l a 24 Procedures f o r the F a r a d i c S t i m u l a t i o n The areas where the e l e c t r o d e s were to be p l a c e d were f i r s t washed w i t h soap and water, then d r i e d . Two e l e c t r o d e s were used: the anode was p l a c e d c e n t r a l l y over the proximal end of the quadriceps and the cathode was p l a c e d c e n t r a l l y across the d i s t a l end of the quadriceps. The areas were marked f o r f u t u r e r e f e r e n c e . The e l e c t r o d e s were 2 i n . x 4 i n . aluminum p l a t e s which were wrapped i n a f a c e c l o t h moistened i n a s a l t s o l u t i o n . Each e l e c t r o d e was then covered by a l e a t h e r c l o t h and secured to the l e g by an a d j u s t a b l e rubber s t r a p . The s a l t s o l u t i o n used to moisten the f a c e c l o t h was made up by mixing two tablespoons of s a l t i n two cups of warm water. The s a l t s o l u t i o n was used to a i d i n the t r a n s m i s s i o n of e l e c t r i c a l impulses t o the l e g . The s t i m u l a t i o n g i v e n was a surged c u r r e n t to s t i m u l a t e a normal v o l u n t a r y c o n t r a c t i o n and to g i v e the muscles time to r e l a x between c o n t r a c t i o n s . The d u r a t i o n of s t i m u l a t i o n was three seconds w i t h a three second r e s t p e r i o d . The f i r s t minute of the s e s s i o n was used to a c c l i m a t i z e the p a t i e n t to the s t i m u l a t i o n . In the remaining nine minutes the s t i m u l a t i o n was s e t a t the predetermined l e v e l and a t o t a l of n i n e t y c o n t r a c t i o n s were gi v e n . Ninety c o n t r a c t i o n s i s s a i d to be the minimum number of c o n t r a c t i o n s f o r an e f f e c t i v e treatment (Sco t t 1975). On the day of the p r e - t e s t s e s s i o n the p a t i e n t was hooked up and a maximal t o l e r a n c e l e v e l was determined. The maximal t o l e r a n c e l e v e l was used f o r each of the f i v e s e s s i o n s . The f i r s t s e s s i o n took p l a c e two days a f t e r the o p e r a t i o n . The remaining f o u r s e s s i o n s were h e l d on weekdays w i t h i n the 10-12 day p e r i o d . In a l l f i v e s e s s i o n s the heavy bandage was lowered below the knee and the e l e c t r o d e s hooked up i n the manner p r e v i o u s l y mentioned. In the f i r s t two s e s s i o n s the l e g was p l a c e d a t the immobilized angle and padding was p l a c e d under the knee and the lower l e g was secured to stop any movement a t the j o i n t d u r i n g the time of s t i m u l a t i o n . In the remaining three s e s s i o n s the l e g was secured a t 115 degrees of e x t e n s i o n . I t was to be noted t h a t a l l the muscular c o n t r a c t i o n s were i s o m e t r i c i n nature, thus there was no j o i n t movement du r i n g the p e r i o d of s t i m u l a t i o n . T h i s was to minimize any problem t h a t may occur to the knee j o i n t i f any u n c o n t r o l l e d movement was to occur. Experimental Design T h i s study used a' 2.x 2 f a c t o r i a l d e sign w i t h repeated measures on the second f a c t o r . The dependent v a r i a b l e s were l e g s t r e n g t h per body weight, t h i g h c i r c u m f e r e n c e , p a r t i a l t h i g h volume and t o t a l t h i g h volume. The independent v a r i a b l e s were groups, i n i t i a l s t r e n g t h and treatments. 26 Table 1  Experimental Design Groups Pre Post C o n t r o l S 1 9 Experimental S 10 18 S t a t i s t i c a l Treatment T - t e s t s were i n i t i a l l y used to determine i f there was a l o s s i n t h i g h volume i n e i t h e r group between the pre and post t e s t s . Four 2 x 2 ANOVAS wit h repeated measures on the second f a c t o r were used to t e s t hypotheses 1 and 2. Each hypothesis was t e s t e d a t an alpha l e v e l of .05. The ANOVAS were c a l c u l a t e d on the p r e - t e s t and p o s t - t e s t data on the i n j u r e d limb u s i n g the UBC BMD:P2V (Halm, 1974) computer program. The Pearson Product Moment C o r r e l a t i o n was used to determine the magnitude of the l i n e a r r e l a t i o n s h i p between the l o s s i n t h i g h volume and the l o s s i n s t r e n g t h per body weight. The c o r r e l a t i o n was c a l c u l a t e d on the d i f f e r e n c e between the 27 p r e - t e s t and p o s t - t e s t data u s i n g the program UBC SIMCORT (Le, 1974). The c o r r e l a t i o n c o e f f i c i e n t s o b tained were t e s t e d a t the .05 l e v e l of s i g n i f i c a n c e to determine i f they were s i g n i f i c a n t l y d i f f e r e n t from zero. 28 Chapter 4 RESULTS AND DISCUSSION Eighte e n s u b j e c t s v o l u n t e e r e d to take p a r t i n the study and were p r e - t e s t e d f o r maximal i s o m e t r i c l e g s t r e n g t h and t h i g h volume. One s u b j e c t from the experimental group was unable to be measured f o r l e g s t r e n g t h due to h i s l a t e admittance to the h o s p i t a l . T h e r e f o r e o n l y e i g h t s t r e n g t h measurements were recorded f o r the experimental group. Subject data i s summarized i n Table 2. Table 2  Subject Data Group Age (yrs.) Weight (lb.) X S.D. X S.D. C o n t r o l 22.4 6.9 160 31.3 Experimental 24.9 3.3 16 8.3 21.2 E S C 22.7 5.5 164.2 27.1 The r e s u l t s of t h i s i n v e s t i g a t i o n and the d i s c u s s i o n of the r e s u l t s are d i v i d e d i n t o s e c t i o n s r e l a t i n g to the hypotheses. The f i r s t two s e c t i o n s d e a l with the e f f e c t of f a r a d i c s t i m u l a t i o n on the c o n t r o l of muscle atrophy and then 29 on the maintainance of s t r e n g t h . The t h i r d s e c t i o n d e a l s with the r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s . The e f f e c t of f a r a d i c s t i m u l a t i o n on the  c o n t r o l of muscle atrophy The f o l l o w i n g r e s u l t s p e r t a i n to a major problem of t h i s i n v e s t i g a t i o n : to study the e f f e c t s of a 10-12 day treatment program i n v o l v i n g f a r a d i c s t i m u l a t i o n on the c o n t r o l of muscle atrophy. Muscle atrophy was determined i n three ways: maximum t h i g h c ircumference, p a r t i a l t h i g h volume and t o t a l t h i g h volume. P a r t i a l t h i g h volume was i n c l u d e d because s w e l l i n g was present to a degree i n some p a t i e n t s , which s l i g h t l y a f f e c t e d the t o t a l t h i g h volume measurements. The observed means f o r the experimental and c o n t r o l groups f o r maximal t h i g h c i r c u m f e r e n c e , p a r t i a l t h i g h volume and t o t a l t h i g h volume are presented i n Table 3. The d i f f e r e n c e scores between the pre and p o s t - t e s t p e r i o d f o r each dependent v a r i a b l e i s the measure of muscle atrophy. The measurements of muscle atrophy are shown i n Table 4. Table 3 Observed C e l l Means Group Dependent V a r i a b l e s Pre Post C o n t r o l Max. Thigh Circumference 50.8 cm. 4 8.5 cm T o t a l Thigh Volume 4316.20cm 3 4053.7 cm 3 P a r t i a l Thigh Volume 2320.31cm 3 2133.22cm 3 Experimental Max. Thigh Circumference 51.8 cm 50.9 cm T o t a l Thigh Volume 4299.4 cm 3 4226.0 cm 3 P a r t i a l Thigh Volume 2330.77cm 3 2239.82cm 3 30 Table 4 The D i f f e r e n c e i n Thigh Circumference  and Volume Over a 10-12 Day P e r i o d Dependent V a r i a b l e Group Mean Maximum Thigh Circumference P a r t i a l Thigh Volume T o t a l Thigh Volume C o n t r o l Experimental C o n t r o l Experimental C o n t r o l Experimental 2.3 cm. .9 cm. 187.09cm" 91.0 cm" 262.5 cm" 7 3.5 cm" 4.5 1.7 8.1 3.7 6.1 1.8 A t - t e s t was performed and the r e s u l t s i n Table 5 i n d i c a t e t h a t muscle atrophy o c c u r r e d i n both the c o n t r o l and experimental groups. Table 5 T-T.ests f o r the Observation of Muscle Atrophy Group df C a l c u l a t e d t P C o n t r o l 8 4.567 .01 Experimental 8 3.176 .01 31 Tables 6, 7 and 8 summarized the a n a l y s i s of v a r i a n c e f o r the three dependent v a r i a b l e s used to measure muscle atrophy. The a n a l y s i s of v a r i a n c e found t h a t the experimental group showed s i g n i f i c a n t l y l e s s muscle atrophy as compared to the c o n t r o l group. Table 6 A n a l y s i s of V a r i a n c e f o r  Maximal Leg Circumference Source Groups Subjects w i t h i n Groups T r i a l s Groups by T r i a l s S u b j e c t s w i t h i n Groups by T r i a l s df 1 16 1 1 16 Mean Square 25.67 63.25 22.72 4.14 .24 F .40 94.32 17.16 533 000 001 32 Table 7 A n a l y s i s of Va r i a n c e  f o r T o t a l Thigh Volume Source df Groups 1 Subject s w i t h i n 16 Groups T r i a l s 1 Groups by 1 T r i a l s S u b j e c t s w i t h i n 16 Groups by T r i a l s Mean Square 39968.0 2513349.0 288673.31 62574.69 4759.09 F 01590 60.66 13.15 P .901 .000 .002 33 Table 8 A n a l y s i s of Va r i a n c e  f o r P a r t i a l Thigh Volume Source df Groups 1 Subject s w i t h i n 16 Groups T r i a l s 1 Groups by 1 T r i a l s S u b j e c t s w i t h i n 16 Groups by T r i a l s Mean Square 30831.0 534985.87 173930.625 20798.395 1097.41 F 058 158.49 18.95 P .813 . 000 .000 Hypothesis: The use of e l e c t r i c a l s t i m u l a t i o n i n a d d i t i o n to the standard physiotherapy program w i l l show l e s s muscle atrophy as compared to the standard physiotherapy program. T h i s h ypothesis was accepted s i n c e a s i g n i f i c a n t d i f f e r e n c e was found between the groups on the measurements of muscle atrophy a t the .01 l e v e l of s i g n i f i c a n c e . D i s c u s s i o n The r e s u l t s i n Table 4 i n d i c a t e d a mean r e d u c t i o n i n maximum t h i g h circumference of 2.3 cm. f o r the c o n t r o l group over the 10-12 day p e r i o d . T h i s r e s u l t i s s i m i l a r to p r e v i o u s 34 r e s e a r c h by Wolf e t a l (19 71) f o r a s i m i l a r time p e r i o d w i t h a non-exercise group. Wolf e t a l (1971) used a p o i n t f o r circumference measurement s l i g h t l y lower on the t h i g h , thus a s m a l l e r measurement. The c o n t r o l group showed a mean r e d u c t i o n i n t o t a l t h i g h volume of 6.1 percent. Numerous s t u d i e s by Sargeant e t a l (1977), Sargeant and Davies (1977) and Davies and Sargeant (1975) have shown a decrease i n t h i g h volume ranging from 9 - 1 6 percent a f t e r a p e r i o d of i m m o b i l i z a t i o n of 53 -213 days. The r e s u l t s from these s t u d i e s are d i f f i c u l t to compare to the present study due to the l a r g e . d i f f e r e n c e i n the p e r i o d s of i m m o b i l i z a t i o n . The r e s u l t s from the p r e s e n t study r e i n f o r c e a suggestion by Davies and Sargeant (1975) t h a t the a t r o p h i c response to d i s u s e i n man i s a r a p i d phenomenon o c c u r r i n g w i t h i n the f i r s t few weeks of i m m o b i l i z a t i o n . The r e s u l t s from the present study showed t h a t a program of f a r a d i c s t i m u l a t i o n was an e f f e c t i v e means of therapy i n c o n t r o l l i n g muscle atrophy. A h i g h l y s i g n i f i c a n t d i f f e r e n c e was found (P «C .002) i n the c o n t r o l of atrophy between the experimental and c o n t r o l groups. The r e s u l t s agreed with numerous animal and human s t u d i e s t h a t e l e c t r i c a l s t i m u l a t i o n was an e f f e c t i v e means of c o n t r o l l i n g muscle atrophy d u r i n g the p e r i o d of d e n e r v a t i o n or i m m o b i l i z a t i o n (animal s t u d i e s - Schimizk e t a l , 1976; Herbison e t a l , 1973, 1971; S t i l l w e l l e t a l , 1962; and Guttman and Guttman, 1942. Human s t u d i e s - Osbourne, 1951; and Jackson and Seddon, 1945). The r e s u l t s i n Table 4 showed an average decrease i n circumference o f .9 cm. T h i s r e s u l t showed a s l i g h t improvement as compared to the i s o m e t r i c e x e r c i s e group i n Wolf e t a l (19 71) study of 1.0 - 1.5 cm. The i n v e s t i g a t o r f e e l s t h i s r e s u l t would be more s u b s t a n t i a l i f the measurements i n both s t u d i e s had been taken a t the same p o i n t . The program of f a r a d i c s t i m u l a t i o n was very e f f e c t i v e but d i d not c o n t r o l muscle atrophy t o t a l l y as t h e r e was a mean r e d u c t i o n of 1.8 p e r c e n t p r e s e n t i n the experimental group. The i n v e s t i g a t o r f e e l s some of the reasons f o r t h i s r e d u c t i o n can be e x p l a i n e d by the l i m i t a t i o n s of the study: the f i r s t treatment had to be administered 4 8 hours a f t e r the o p e r a t i o n and a c e r t a i n degree of atrophy a l r e a d y o c c u r r e d by t h i s time. A l s o t h e r e may have been a s l i g h t amount o f atrophy i n the hamstring muscles which were not s t i m u l a t e d ; though the ham-s t r i n g s were immobilized i n a s l i g h t l y s t r e t c h e d p o s i t i o n and Goldspink (1977) has mentioned s t r e t c h i n h i b i t s muscle atrophy. The e f f e c t i v e n e s s of such a program as f a r a d i c s t i m u l a t i o n d u r i n g the time of i m m o b i l i z a t i o n can be i l l u s t r a t e d by a p p l y i n g i n f o r m a t i o n gathered from Sargeant and Davies (1975) to the r e s u l t s of t h i s study. Sargeant and Davies (1975) s t a t e : "The r a t e of i n c r e a s e i n l e g muscle volume as a percentage of the i n i t i a l p r e -r e h a b i l i t a t i o n measurement, the mean r a t e of improvement of the i n j u r e d l e g i s 1.2 p e r c e n t per 10 days. T h i s r a t e tends to be l a r g e l y independent of the stage of r e h a b i l i t a t i o n and the i n c r e a s e i n volume appears to be l i n e a r with time." 36 The f o l l o w i n g example i s an e s t i m a t i o n of the approximate time r e q u i r e d a f t e r the removal of the bandage, f o r the p a t i e n t s of t h i s study to re c o v e r t o t a l l y i n terms of r e s t o r i n g the i n j u r e d l e g to i t s o r i g i n a l volume. The e s t i m a t i o n assumes t h a t both groups p a r t i c i p a t e i n the same post i m m o b i l i z a t i o n r e h a b i l i t a t i o n program, thus the d i f f e r e n c e i n r e c o v e r y time i s a d i r e c t r e s u l t of the type of program used d u r i n g the p e r i o d of i m m o b i l i z a t i o n . There were no measurements taken i n t h i s study t o v e r i f y these e s t i m a t i o n s . The r e s u l t s i n Table 4 showed a mean r e d u c t i o n i n t h i g h volume of 6.1 per c e n t f o r the c o n t r o l group and 1.8 p e r c e n t r e d u c t i o n f o r the experimental group. When a p p l y i n g the i n f o r m a t i o n by Sargeant and Davies (1975) to these r e s u l t s , i t would take approximately 3.4 times as long f o r the c o n t r o l group to recover as compared to the experimental group. The time f o r recover y i n the c o n t r o l group would be a mean p e r i o d o f 51 days as compared to a mean p e r i o d of 15 days f o r the experimental group. The r e s u l t s f o r the e s t i m a t i o n of the c o n t r o l group were found t o be s i m i l a r to i n f o r m a t i o n gathered by Leonard (1975) when e v a l u a t i n g two post meniscec-tomy regimes. Leonard (19 75) found f o r the two r e h a b i l i t a t i o n programs a mean of 52 days o f f work o c c u r r e d . One of the regimes mentioned was very s i m i l a r to the procedures used i n t h i s study. A l o n g i t u d i n a l study of t h i s nature should be undertaken to determine i f a program of e l e c t r i c a l s t i m u l a t i o n d u r i n g i m m o b i l i z a t i o n w i l l l e s s e n the r e c o v e r y time a f t e r the removal of the bandage. R e s u l t s : The e f f e c t of f a r a d i c s t i m u l a t i o n on the c o n t r o l  of muscle s t r e n g t h . The f o l l o w i n g r e s u l t s a l s o p e r t a i n to a major problem of t h i s i n v e s t i g a t i o n : to study the e f f e c t s of a 10-12 day treatment program i n v o l v i n g f a r a d i c s t i m u l a t i o n on the c o n t r o l of i s o m e t r i c s t r e n g t h . The observed c e l l means f o r the experimental and c o n t r o l groups f o r s t r e n g t h per body weight are presented i n Table 9. Table 9 Observed C e l l Means (Units) Groups Strength/body wt. ( l b / l b ) Pre Post C o n t r o l .62 .35 Experimental .88 .68 The r e s u l t s i n Table 10 showed t h a t both the c o n t r o l and experimental groups l o s t a l a r g e percentage of t h e i r o r i g i n a l maximal i s o m e t r i c s t r e n g t h , 4 3.5 p e r c e n t and 25.3 p e r c e n t r e s p e c t i v e l y . The same percentage r e d u c t i o n s were found when a n a l y z i n g the a b s o l u t e s t r e n g t h v a l u e s f o r each 38 group (Appendix A). Though the r e s u l t s i n d i c a t e d t h a t the experimental group maintained a higher percentage of t h e i r o r i g i n a l i s o m e t r i c s t r e n g t h , an a n a l y s i s of v a r i a n c e (Table 11) f a i l e d to show t h a t t h i s d i f f e r e n c e was s i g n i f i c a n t a t a .05 l e v e l of s i g n i f i c a n c e . Table 10 The D i f f e r e n c e i n Maximum Leg Strength  per Body Weight Over a 10-12 Day P e r i o d Dependent V a r i a b l e Group Mean Strength per Body Weight C o n t r o l .27 l b / l b 43.5% Experimental .20 l b / l b 25.3% Table 11 A n a l y s i s of Va r i a n c e f o r Str e n g t h per Body Weight Source df Mean Square F P Groups 1 .75601 13.79123 .002 Subject s w i t h i n Groups 15 .05482 T r i a l s 1 .46337 67.04060 .000 Groups by T r i a l s 1 .00973 1.40743 . 254 Subject s w i t h i n Groups by T r i a l s 15 .00691 Hypothesis; The use of e l e c t r i c a l s t i m u l a t i o n i n a d d i t i o n to the standard physiotherapy program w i l l m a i n t a i n a hig h e r l e v e l of o r i g i n a l i s o m e t r i c s t r e n g t h as compared to the standard physiotherapy program. T h i s hypothesis was not supported as a s i g n i f i c a n t d i f f e r e n c e was not found between groups i n s t r e n g t h per body weight a t the .05 l e v e l of s i g n i f i c a n c e . D i s c u s s i o n The r e s u l t s showed a s u b s t a n t i a l r e d u c t i o n i n s t r e n g t h o c c u r r e d i n both the c o n t r o l and experimental^groups. There was a mean r e d u c t i o n of 43.5 percent and 25.3 percent r e s p e c t i v e l y . T h i s r e s u l t was s i g n i f i c a n t l y h i g h e r than the 20 percent 40 reduction i n the f i r s t week found by Muller and Hettinger (.1953) . The treatment group showed a higher maintainance of o r i g i n a l isometric strength as compared to the control group, but t h i s difference was found not to be s i g n i f i c a n t . Though the res u l t s were not s i g n i f i c a n t , the investigator f e e l s there i s a trend toward th i s higher maintainance of strength i n the experimental group. The reason why the res u l t s did not indicate t h i s may be p a r t i a l l y explained by the many problems encountered administering the strength t e s t s . Many precautions were taken by the investigator to l i m i t these problems. The patients had a short period to warm up before the maximal contraction, took place. An explanation of the procedures were given stressing the safety of t h i s type of contraction as there i s no j o i n t movement. Also isometric exercises were done throughout the period of immobilization i n both groups. Three types of problems appeared to be encountered that limited the measurement of muscle strength. The problems were the following: psychological, physiological and mechanical. The psychological problems were associated with the fear of using or r e i n j u r i n g the injured limb. The main physiological factor was that the i n d i v i d u a l was unable to contract the muscle to i t s maximum, due to swelling i n the knee j o i n t . Swelling was e s p e c i a l l y noticeable i n the members of the treatment group (Appendix A). The mechanical problem i s i n the nature of the equipment used for the measurement of strength. 41 R e s u l t s ; The r e l a t i o n s h i p between muscle atrophy  and s t r e n g t h l o s s . The f o l l o w i n g r e s u l t s p e r t a i n to the subproblem of t h i s i n v e s t i g a t i o n : to determine i f there i s a r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s . The c o r r e l a t i o n c o e f f i c i e n t s f o r the r e s u l t s are presented i n Table 12. Table 12 C o r r e l a t i o n C o e f f i c i e n t s Between  Muscle Atrophy and S t r e n g t h Loss Group r C o n t r o l .81* Experimental .31 C o n t r o l & .67* Experimental * S i g n i f i c a n t a t the .01 l e v e l H ypothesis: The t h i r d hypothesis s t a t e s t h a t t h e r e i s a p o s i t i v e r e l a t i o n s h i p between muscle atrophy and s t r e n g t h l o s s . T h i s h y pothesis was p a r t i a l l y supported as a s i g n i f i c a n t c o r r e l a t i o n was found i n the t o t a l group and the c o n t r o l group, but not i n the experimental group. The c o r r e l a t i o n s i n Table 12 i n d i c a t e t h a t muscle atrophy i s s i g n i f i c a n t l y r e l a t e d t o s t r e n g t h l o s s . The experimental group i s the o n l y group where the c o r r e l a t i o n i s not s i g n i f i c a n t . The c o e f f i c i e n t s of d e t e r m i n a t i o n are .45 f o r the combination of the c o n t r o l and experimental group groups, .66 f o r the c o n t r o l group and o n l y .1 f o r the e x p e r i -mental group. T h i s i n d i c a t e s 45 percent ( c o n t r o l and e x p e r i -mental) , 66 percent ( c o n t r o l ) and 10 percent (experimental) of the v a r i a n c e of the one v a r i a b l e i s p r e d i c t a b l e from the v a r i a n c e of the other v a r i a b l e , w i t h 55 percent (experimental and c o n t r o l ) , 34 p e r c e n t ( c o n t r o l ) and 90 percent (experimental) of the v a r i a n c e being unexplained. The h i g h c o r r e l a t i o n agrees w i t h the theory by Atrand (1976) t h a t muscle s t r e n g t h i s p r o p o r t i o n a l to the c r o s s -s e c t i o n a l area. The r e s u l t s d i s a g r e e w i t h the f i n d i n g s by D u f f i n (1977) who found when st u d y i n g meniscectomy p a t i e n t s t h a t the l o s s i n s t r e n g t h d i d not n e c e s s a r i l y r e l a t e to a s i m i l a r l o s s i n s i z e . The reasons f o r D u f f i n ' s f i n d i n g s may be e x p l a i n e d by the p s y c h o l o g i c a l and p h y s i o l o g i c a l problems t h a t were encountered i n t h i s study. The r e s u l t s i n Table 12 showed a low c o r r e l a t i o n f o r the experimental group. T h i s low c o r r e l a t i o n r e i n f o r c e s the suggestion t h a t c e r t a i n problems appeared to be encountered t h a t l i m i t e d the measurement of muscle s t r e n g t h . The problems the p a t i e n t s had e l i c i t i n g a maximal f o r c e were mentioned e a r l i e r i n t h i s study. 43 Chapter 5 SUMMARY AND CONCLUSIONS A f t e r knee surgery, the development of l e g streng t h and s i z e to o r i g i n a l l e v e l s are important requirements i n the recovery. The major aim i n the r e h a b i l i t a t i o n of a meniscectomy i s to r e t u r n the i n j u r e d limb to i t s o r i g i n a l s i z e by a program of a c t i v e e x e r c i s e s . F a i l u r e to do t h i s may r e s u l t i n l i m i t e d a c t i v i t y and r e - i n j u r y to the knee j o i n t . A program of e l e c t r i c a l s t i m u l a t i o n has been found to be e f f e c t i v e i n c o n t r o l l i n g muscle atrophy during the time of denervation i n animals and humans. At the present time no stu d i e s have been done to determine i f e l e c t r i c a l s t i m u l a t i o n w i l l be e f f e c t i v e i n c o n t r o l l i n g muscle atrophy i n normally innervated muscles during a period of i m m o b i l i z a t i o n . I f t h i s was found to be the case, i t may r e s u l t i n a shor t e r recovery p e r i o d . The purpose of t h i s i n v e s t i g a t i o n was to study the e f f e c t s of a 10-12 day program of f a r a d i c s t i m u l a t i o n on the c o n t r o l of muscle atrophy and streng t h i n meniscectomy p a t i e n t s . A subproblem of the i n v e s t i g a t i o n was to determine the r e l a t i o n s h i p between muscle atrophy and strength l o s s . Eighteen subjects volunteered to take p a r t i n t h i s study. A l l subjects were p a t i e n t s undergoing a meniscectomy operation at Sa i n t Mary's H o s p i t a l i n New Westminister, B r i t i s h Columbia. The subjects were ra t e d according to streng t h and assigned i n t o a c o n t r o l or experimental group. A balance of s t r e n g t h per body weight was performed to e q u a l i z e the two groups and the r e s u l t s shown i n Table 10 and Appendix A. A s i g n i f i c a n t amount of atrophy was found to occur d u r i n g the 10-12 day p e r i o d of i m m o b i l i z a t i o n . The r e s u l t s i n Table 4 i n d i c a t e d a mean r e d u c t i o n i n t h i g h volume of 6.1 percent o c c u r r e d i n the c o n t r o l group. Although a degree of muscle atrophy o c c u r r e d to the members of the experimental group (1.8% r e d u c t i o n i n t h i g h volume), i t was found to be s i g n i f i c a n t l y l e s s than i n the c o n t r o l group (Table 6, 7, and 8). The r e s u l t s f a i l e d to f i n d t h a t the program of f a r a d i c s t i m u l a t i o n was e f f e c t i v e i n c o n t r o l l i n g muscle s t r e n g t h d u r i n g the p e r i o d of i m m o b i l i z a t i o n (Table 11). The r e s u l t s i n Table 12 showed a l i n e a r r e l a t i o n s h i p e x i s t s between muscle atrophy and s t r e n g t h l o s s , when the two groups were combined and f o r the c o n t r o l group o n l y , but not the experimental group. Co n c l u s i o n s The f o l l o w i n g c o n c l u s i o n can be reached: 1. A s i g n i f i c a n t degree of atrophy occurs to the quadricep muscles d u r i n g the 10-12 day p e r i o d of i m m o b i l i z a t i o n f o r a meniscectomy. 2. A f i v e s e s s i o n program of f a r a d i c s t i m u l a t i o n was e f f e c t i v e i n c o n t r o l l i n g d i s u s e atrophy. 3. A f i v e s e s s i o n program of f a r a d i c s t i m u l a t i o n was found not to be e f f e c t i v e i n c o n t r o l l i n g muscle s t r e n g t h . 4. There i s a p o s i t i v e c o r r e l a t i o n between muscle atrophy and l o s s i n s t r e n g t h . Recommendations f o r F u r t h e r Study 1. Though the degree of muscle atrophy was s i g n i f i c a n t l y lower i n the experimental group as compared to the c o n t r o l group, a c e r t a i n degree of muscle atrophy was s t i l l p r e s e n t . F u r t h e r i n v e s t i g a t i o n i s needed to determine i f muscle atrophy can be t o t a l l y c o n t r o l l e d . 2. The r e s u l t s f a i l e d to i n d i c a t e a s i g n i f i c a n t d i f f e r e n c e i n the maintainance of quadricep s t r e n g t h between the two groups. Before the second hypothesis of t h i s study i s d i s r e g a r d e d , i t should be r e t e s t e d u s i n g a more e f f e c t i v e p i e c e of equipment, such as a cybex machine. The t e s t i n g s e s s i o n should be a d m i n i s t e r e d a few days a f t e r the removal of the bandage to a l l o w the p a t i e n t to r e g a i n confidence i n the i n j u r e d limb. 3. The same type of study should be undertaken i n v o l v i n g p a t i e n t s w i t h n o n - s u r g i c a l ligament damage, where i m m o b i l i z a t i o n i s f o r a longer p e r i o d of time. 4. A l o n g i t u d i n a l study should be done to determine i f the program of f a r a d i c s t i m u l a t i o n d u r i n g i m m o b i l i z a t i o n i s e f f e c t i v e i n d e c r e a s i n g the p e r i o d of r e c o v e r y . 46 BIBLIOGRAPHY Anderson, W.A.D. 1971. Pathology. S t . L o u i s : C.V. Mosby Company. Astrand, P. and K. Rodahl. Textbook of Work P h y s i o l o g y . 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Electromyography of E x p e r i m e n t a l l y Immobilized S k e l e t a l Muscle i n C a t s . Amer. J . P h y s i o l . 200:963-967. Goldberg, A.L., J.D. E t t i n g e r , D.F. Goldspink, and C. J a b l e c k i . 1975. Mechanisms of work-induced hypertrophy of s k e l e t a l muscle. Medicine and Science i n Sport.7:248-261. Goldspink, D.F. 1976. The e f f e c t s of d e n e r v a t i o n on p r o t e i n t u r nover of r a t s k e l e t a l muscle. Biochem. J . 156: 71-80. Goldspink, D.F. 1977. The I n f l u e n c e of I m m o b i l i z a t i o n and s t r e t c h on P r o t e i n Turnover of Rat S k e l e t a l Muscle. J . P h y s i o l . 264:267-282 Guttman, E. and L. Guttman. 1942. E f f e c t of E l e c t r o t h e r a p y on Denervated Muscle i n Rabbits. The Lancet. 1:169-170. Herbison, G.J., C. Tang and T. Reyes. 1971. E f f e c t of E l e c t r i c a l S t i m u l a t i o n on Denervated Rat Muscle. Arch Phys Med  R e h a b i l . 52:516-522. 47 Herbison, G.J., C. Tang, and E.E. Gordon. 1973. E l e c t r i c a l S t i m u l a t i o n of R Rat Muscle. Arch. Phys. Med, and R e h a b i l . 54:156-160. I k a i , M. and T. Fukunaga. 196 8. C a l c u l a t i o n of Muscle S t r e n g t h per U n i t C r o s s - s e c t i o n a l Area o f Human Muscle by Means of U l t r a s o n i c Measurement. I n t . Z. anyew. P h y s i o l . e r n s c h l . A r b e i t s p h y s i o l . 26:26. Jackson, E.C.S. and H.J. Seddon. 1945. I n f l u e n c e of G a l v a n i c S t i m u l a t i o n on Atrophy R e s u l t i n g from Denervation. B r i t . Med. J . 2:285. Johnson, D.H., P. Thurston and P.J. A s h c r o f t . 1977. The Russian technique of faradism i n the treatment of chondomalacia p a t e l l a e . Physiotherapy Canada. 29:266-268. Jones, P.R.M. and J . Pearson. 1969. Anthropometric d e t e r m i n a t i o n of l e g f a t and muscle p l u s bone volumes i n young male and female a d u l t s . J o u r n a l of P h y s i o l o g y . 204:65-66P. Katch, V. and A. Weltman. 1975. P r e d i c t a b i l i t y of Body Volume i n L i v i n g S u b j e c t s . Human Biology.47:203-218. Leonard, M.A. 1975. An E v a l u a t i o n of Two Post-meniscectomy Regimes. Physiotherapy. 61:110-111. M u l l e r , E.A. and T. H e t t i n g e r . 1953. Uber U n l e r s c h i e d e der T r a i n i n g S y i s c h w i n d i g k e i t a t r o p h i e r t e r und normaler Muskeln. A r b e i l s p h y s i o l . 15:223. N i c o l s , P.J.R. 1976. R e h a b i l i t a t i o n Medicine. Toronto: Butterworths and Co. L t d . Osbourne, S.S. and A.J. Kosman e t a l . 1950. A n t e r i o r P o l i o m y e l i t i s : E a r l y and Late E l e c t r i c a l S t i m u l a t i o n of A f f e c t e d Muscles. B r i t . J . Phys. Med. 13:97. Osbourne, S.L. 1951. R e t a r d a t i o n of Atrophy i n Man by E l e c t r i c a l S t i m u l a t i o n of Muscles. Arch. Phys. Med. 32:523. P a t e l , A.N., A Razzak, and D.K. Dastur. 1969. Disuse Atrophy of Human S k e l e t a l Muscle. Arch. N e u r o l . 20:413-421. Peckham, P.H., J.T. Mortimer and E.B. M a r s o l a i s . 1976. A l t e r a t i o n i n the Force and F a l i g a b i l i t y of S k e l e t a l Muscle i n Q u a d r i p l e g i c Humans F o l l o w i n g E x e r c i s e Induced by Chronic E l e c t r i c a l S t i m u l a t i o n . C l i n . Ofthbp. 114:326-33. 48 Sargeant, A . J . and C.T.M. Davies. 1977. The e f f e c t o f d i s u s e muscular atrophy on the f o r c e s generated i n dynamic e x e r c i s e . C l i n i c a l Science arid M o l e c u l a r Medicine. 53:183-188. Sargeant, A . J . , C.T.M. Davies, R.H.T. Edwards, C.Maunder and A. Young. 1977. F u n c t i o n a l and s t r u c t u r a l changes a f t e r d i s u s e of human muscle. C l i n i c a l Science and Mole c u l a r Medicine-52:337-342. Schimrizk, K., J . McLaughlin, and W. Gruninger. 1976. The E f f e c t of E l e c t r i c a l S t i m u l a t i o n on the E x p e r i m e n t a l l y Denervated Rat Muscle. Scarid. J . Rehab. Med. 9:55-60. S c o t t , P.M. 1975. C l a y t o n ' s E l e c t r o t h e r a p y and A c t i n o t h e r a p y . London: B a i l l x e r e T i n d a l l . S t i l l w e l l , G.K. and K.G. Wakim. 1962. E f f e c t o f V a r y i n g I n t e r v a l Between Sessions of S t i m u l a t i o n of E l e c t r i c a l S t i m u l a t i o n of Denervated Rat Muscle. Arch. Phys. Med. Rehab. 43:95-9 8. S t i l l w e l l , K.G. 1967. C l i n i c a l E l e c t r i c a l S t i m u l a t i o n . T h e r a p e u t i c E l e c t r i c i t y and U l t r a v i o l e t R a d i a t i o n . Ed. L i g h t , S~. New Haven, C o n n e c t i c u t . P. 105-155. Wolf, E., A. Mogora, and B. Gonen. 1971. Disuse Atrophy of the Quadriceps Muscle. ETe'ctroiriypgraphy.11:479-490. 48a APPENDIX A 49 C o n t r o l Group Str e n g t h Subject # Age Wt. I n j u r e d U n i n j u r e d (yr) (lb) ( l b ) ( l b / (lb) ( l b / body body weight) weight) 1 16 145 95 .66 100 .69 2 26 185 143 .77 170 92 3 18 132 43 . 33 68 .52 4 14 120 70 .58 70 .58 5 30 125 55 .44 60 .48 6 33 175 43 .25 106 .61 7 28 170 153 .9 153 .9 8 17 220 180 . 82 180 . 82 9 20 168 137 .82 160 .95 X 22.4 160 102.1 .62 118.6 .72 S.D. 6.9 31.3 47.8 .04 47.7 .04 50 Post T e s t C o n t r o l Subject # I n j u r e d U n i n j u r e d (lb) ( l b / l b ) (lb) ( l b / l b ) 1 63 .43 95 .66 2 103 .56 170 .92 3 30 .23 68 .52 4 43 . 36 70 . 58 5 25 .2 60 .48 6 27 .15 120 . 69 7 85 .5 153 . 9 8 55 .25 173 .79 9 80 .48 160 .95 X S.D. 56. 8 26.9 ,35 14 118.8 46.7 72 19 51 D i f f e r e n c e i n Strength  C o n t r o l Group Subject # Injured (lb) ( l b / l b ) 1 32 .23 2 40 .21 3 13 .10 4 27 .22 5 30 .24 6 16 .10 7 68 .4 8 125 .57 9 57 .34 X 41.3 .27 S.D. 35 .15 52 Experimental Group Strength Subject # Age Wt I n j u r e d U n i n j u r e d (yr.) (lb) (lb) ( l b / l b ) (lb) ( l b / l b ) 10 23 145 133 .92 160 1.10 11 30 155 110 .71 143 .93 12 21 220 130 .68 150 .68 13 25 160 170 1.06 170 1.06 14 23 165 170 1.03 195 1.22 15 24 165 16 30 175 153 . 87 147 . 86 17 26 170 160 .94 160 .94 18 22 160 137 . 86 150 .94 X 24.9 168.3 147.9 .79 159.4 .86 S.D. 3.3 21.2 20.5 .17 15.6 .25 53 Post T e s t  Experimental S t r e n g t h Subject # I n j u r e d U n i n j u r e d (lb) ( l b / l b ) (lb) ( l b / l b ) 10 100 .69 160 1.10 11 85 .55 143 .93 12 85 . 39 127 .58 13 143 .89 173 1.0 8 14 127 .77 195 1.2 2 15 16 110 .63 147 . 86 17 143 .84 160 .94 18 113 .71 150 .94 X 113. 3 .68 156.9 .96 S.D. 23.1 .16 15.2 .19 54 D i f f e r e n c e i n S t r e n g t h  Experimental Subject # I n j u r e d (lb) ( l b / l b ) 10 33 .23 11 25 .16 12 65 .29 13 27 .17 14 43 .26 15 16 43 .24 17 17 .10 18 24 .15 X 34.6 .2 S.D. 15.5 .06 55 I n d i v i d u a l Raw Scores  Pre T e s t  C o n t r o l Group Subject # Circumference Measurements Volume 1 (cm) 2 (cm) 3 (cm) 1-3(cm? 1-2(cm? 1 54.2 48.2 38.4 3896.1 2099.8 2 60.0 54.5 42.0 4809.2 2658.9 3 50.5 46.2 35.1 3444.0 1894.8 4 46.0 44.4 34.8 2956.7 1655.0 5 54.5 46.3 36.0 3550.1 2062.1 6 55.3 51.4 40.7 4736.4 2306.5 7 53.6 49.7 38.5 3976.7 2116.9 8 71.0 64.1 50.6 7164.1 3699.3 9 56.4 52.2 39.4 4312.4 2389.5 X 55.7 50.8 39.5 4316.2 2320.3 S.D. 6.0 6.4 4.8 1225.7 591.8 Post Test 56 Control Group Subject # Circumference Measurements Volume 1 (cm) 2 (cm) 3 (cm) 1-3 (cm? 1-2 (cm)3 1 51.4 46.3 37.6 359.3.0 1934.7 2 58.1 53.0 40.9 4529.1 2501.3 3 48.1 44.8 35.2 3285.9 1748.4 4 43.8 40.8 33.5 2704.8 1484.1 5 51.6 44.7 35.8 3301.1 1881.1 6 53.3 48.8 42.0 4653.6 2112.3 7 50.1 46.2 37.0 3554.3 1879.0 8 69.0 61.7 49.4 6790.4 3462.8 9 53.8 50.3 39.4 4071.2 2195.3 X 53.2 48.5 39.0 4053.7 2133.2 S.D. 7.1 6.1 2.0 1199.6 575.0 57 The D i f f e r e n c e i n Circumference and  Volume Over a 10 - 12 Day P e r i o d C o n t r o l Group Subject # Circumference Measurements ; Volume 1 (cm) 2 (cm) 3 (cm) 1-3(cm? 1-2(cm? 1 2.8 1.9 .8 303.1 165.1 2 1.9 1.5 1.1 280.1 157.6 3 2.4 1.4 - .1 158.1 146.4 4 2.2 3.6 1.3 251.9 170.9 5 2.9 1.6 .2 249. 0 181.0 6 2.0 2.6 -1.3 82.8 194.2 7 3.5 3.5 1.5 422.4 237. 9 8 2.0 2.4 1.2 373.7 236. 5 9 2.6 1.9 0 241.2 194.2 X 2.5 2.3 .52 262.5 187.09 S - D - .53 .83 .64 102.4 37.5 58 Pre T e s t  Experimental Group Subject # Circumference Measurements Volume 1 (cm) 2 (cm) 3 (cm) 1-3 (cm? 1-2 (cm)3 10 54.8 49.6 37.3 3863.0 2209.0 11 49.9 48.4 37.1 3773.7 1956.9 12 65.8 64.3 46.1 6831.5 3427.7 13 51.6 48.8 39.9 3661.8 2041.8 14 58.4 53.2 42.9 4653.8 2523.9 15 52.1 48.9 38.1 3567.6 2066.4 16 53.1 49.1 38.4 3935.6 2124.5 17 52.2 48.5 39.6 4010.5 2054.4 18 57.4 55.3 41.0 4397.5 2572.3 X 55.0 51.8 40.0 4299.4 2330.77 S.D. 4.9 5.3 2.9 1010.7 464.46 Post T e s t 59 Experimental Group Subject # Circumference Measurements Volume 1 (cm) 2. (cm) 3 (cm) 1-3(cmf 1-2(cmf IP 53.5 49.1 38.0 3803.6 2133.0 11 49.0 47. 8 37.0 3684.8 1897.6 12 64.8 6 3.0 47.0 6811.3 3207.6 13 51.2 48.3 39.5 3598.4 2005.4 14 57.0 52. 3 43.0 4529.4 2420.7 15 51.4 47.6 39.0 3577.2 1985.7 16 51.6 • 47.1 37.4 3714.5 1985.9 17 51.6 48.1 39.4 3998.7 2013.7 18 56.7 54.6 40.8 4315.8 2408.8 X 54.1 50.9 40.1 4226.7 2239.82 S.D. 4.8 4.2 3.2 1036.1 419.13 60 The D i f f e r e n c e i n Circumference arid  Volume Over a 10 - 12 Day P e r i o d Experimental Group Subject # Circumference Measurements Volume 1 (cm) 2 (cm) 3 (cm) 1-3(cm? 1-2(cm? 10 1.3 .5 -.7 59.4 76.0 11 .9 .6 -.1 88.9 59.3 12 1.0 1.3 -.9 20.2 220.1 13 .4 .5 -.4 63.4 36.4 14 1.4 .9 -.1 124.4 103.2 15 .7 1.3 -.9 -9.6 80.9 16 1.5 2.0 1.0 221.1 138.6 17 .6 .4 -.2 11.8 40.7 18 .7 .7 .2 81.8 63.5 X .9 .9 0 73.5 91.0 S.D. .39 .53 45.9 57.8 6 0 a APPENDIX B 61 Sample C a l c u l a t i o n f o r Volume Circumference 1 Circumference 2 Circumference 3 P a r t i a l Thigh Vol, (1-2) T o t a l Thigh V o l . (1-3) Subject # Circumference (cm) 1 2 3 54.2 48.2 38.4 Heights (cm) 1-3 1-2 22.4 10 VOL = 1/3 h (a1 + a 2 + aia2^ h = h e i g h t a = area r e w r i t t e n as VOL = h/12 C 2 + C 2 + C 1 C 2 h = h e i < ? h t c = circumference s u b j e c t 1 = 22.4 (54.2) 2 + (38.4) 2 + (54.2:38.4) 37.68 VOL = 3896.1 61a APPENDIX C 62 The f o l l o w i n g program i s an example of a standard physiotherapy program f o r the post o p e r a t i v e care of a meniscectomy p a t i e n t . Day of Operation - I s o m e t r i c Quadriceps muscle c o n t r a c t i o n s and s t r a i g h t l e g r a i s e s i f the p a t i e n t i s a b l e . Day One - S t r a i g h t l e g r a i s e s . Walking with the use of c r u t c h e s a l l o w i n g p a r t i a l weight b e a r i n g on the i n j u r e d l e g . Day Two - S t r a i g h t l e g r a i s e s . Walking with the use of c r u t c h e s , g r a d u a l l y i n c r e a s i n g to f u l l weight b e a r i n g . Day Three - S t a i r c l i m b i n g w i t h the c r u t c h e s . E x e r c i s e s a l l o w i n g a s m a l l degree of f l e x i o n , as f a r as the Robert Watson Jones p r e s s u r e bandage w i l l a l low. Discharge from the h o s p i t a l , with i n s t r u c t i o n s to continue the program throughout the p e r i o d of i m m o b i l i z a t i o n . 

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