Disinhibitory interventions and voluntary quadriceps activation: a systematic review.
OBJECTIVE
To determine the effects of various therapeutic interventions on increasing voluntary quadriceps muscle activation.


BACKGROUND
Decreased voluntary quadriceps activation is commonly associated with knee injury. Recently, research has focused on developing specific disinhibitory interventions to improve voluntary quadriceps activation; yet, it remains unknown which interventions are most effective in promoting this improvement.


METHODS
We searched Web of Science from January 1, 1965 through September 27, 2012, using the key words quadriceps activation and transcutaneous electrical nerve stimulation, transcranial magnetic stimulation, cryotherapy, focal joint cooling, joint mobilization, joint mobilisation, joint manipulation, manual therapy, and neuromuscular electrical stimulation.


METHODS
Studies evaluating the effect of disinhibitory interventions on volitional quadriceps activation were used in our review. Standardized effect sizes (Cohen d) and 95% confidence intervals (CIs) were calculated from voluntary quadriceps activation means and standard deviations measured at baseline and at all available postintervention time points from each study.


RESULTS
Ten studies were grouped into 5 categories based on intervention type: manual therapy (4 studies), transcutaneous electrical nerve stimulation (2 studies), cryotherapy (2 studies), neuromuscular electrical stimulation (2 studies), and transcranial magnetic stimulation (1 study). Transcutaneous electrical nerve stimulation demonstrated the strongest immediate effects (d = 1.03; 95% CI = 0.06, 1.92) and long-term effects (d = 1.93; 95% CI = 0.91, 2.83). Cryotherapy (d = 0.76; 95% CI = -0.13, 1.59) and transcranial magnetic stimulation (d = 0.54; 95% CI = -0.33, 1.37) had moderate immediate effects in improving voluntary quadriceps activation, whereas manual therapy (d = 0.38; 95% CI = -0.35, 1.09) elicited only weak immediate effects. Neuromuscular electrical stimulation produced weak negative to strong positive effects (range of d values = -0.50 to 1.87) over a period of 3 weeks to 6 months.


CONCLUSIONS
Transcutaneous electrical nerve stimulation demonstrated the strongest and most consistent effects in increasing voluntary quadriceps activation and may be the best disinhibitory intervention for improving the same.
Musculoskeletal Health and Movement Science Laboratory, Department of Kinesiology, University of Toledo, OH. Mr Harkey and Dr Pietrosimone are now at the Neuromuscular Research Laboratory, Department of Exercise and Sports Science, University of North Carolina at Chapel Hill.
Matthew S
MS
Harkey
Phillip A
PA
Gribble
Brian G
BG
Pietrosimone
D065767:Activation, Metabolic; D017679:Cryotherapy; D006801:Humans; D007718:Knee Injuries / Q000503:physiopathology* / Q000534:rehabilitation*; D026201:Musculoskeletal Manipulations; D052097:Quadriceps Muscle / Q000502:physiology*; D013995:Time; D050781:Transcranial Magnetic Stimulation; D004561:Transcutaneous Electric Nerve Stimulation
arthrogenic muscle inhibition; disinhibitory modalities; knee