Neuromuscular Exercise Program

Original Editor - PARIVESH KUMAR

Top Contributors - PARIVESH KUMAR, Kim Jackson and Rachael Lowe  

Introduction

The Neuromuscular exercise topic has been chosen from the ‘Good Life with osteoArthritis in Denmark’ (GLA:D™) program. It’s an evidence-based education and supervised neuromuscular exercise targeting Hip and Knee Osteoarthritis. The program focuses on Neuromuscular exercises along with patient education.

The rationale for Neuromuscular Exercises

Neuromuscular control is defined as the unconscious trained response of a muscle to a signal regarding dynamic joint stability. The movements of the lower extremity, including the knee joint, are controlled through this system, which needs to provide the correct messaging for purposeful movement. Neuromuscular training programs should address several aspects of sensorimotor function and functional stabilization to improve objective function and alleviate symptoms.

The neuromuscular training method that is described is based on biomechanical and neuromuscular principles and aims to improve sensorimotor control and achieve compensatory functional stability. Unlike conventional strength training, neuromuscular exercise addresses the quality of movement and emphasizes joint control in all three biomechanical/movement planes.[1]

Neuromuscular exercise has effects on functional performance, biomechanics, and muscle activation patterns of the surrounding joint musculature[2]. Simply restoring mechanical restraints is not enough for the functional recovery of a joint because the coordinated neuromuscular controlling mechanism required during daily living and sport-specific activities would be neglected.

Rehabilitation programs cannot alter mechanical joint instability but may affect neuromuscular control and dynamic joint stability. A lag in the neuromuscular reaction time can result in dynamic joint instability with recurrent episodes of joint subluxation and deterioration. Therefore, both mechanical stability and neuromuscular control are probably important for long-term functional outcome, and both aspects must be considered in the design of a neuromuscular rehabilitation program.[3]

Sensorimotor control or neuromuscular control is the ability to produce controlled movement through coordinated muscle activity. Functional stability or dynamic stability is the ability of the joint to remain stable during physical activity.

Mechanisms for Sensorimotor Deficiency[4] 

Impairments are present at different levels of the sensorimotor system,  from sensory input through integration and processing of information in the central nervous system to motor output to perform voluntary movements and maintain postural control. It has been suggested that sensorimotor dysfunction also may play a role in the development and progression of degenerative joint disease.

Neural inhibition caused by factors such as pain, swelling, inflammation, joint laxity, and damage to sensory receptors in the joint prevents the muscle to be activated fully likely through altered excitability of spinal and supraspinal pathways.[5]

Sensorimotor deficiencies also were found in the noninjured leg compared with controls possibly because of factors such as physical inactivity after the injury, inherently poor function, and/or disturbed sensory feedback from the injured joint with an inhibitory effect of muscle activation also on the noninjured side.

Principles of Neuromuscular Exercises[4]

Neuromuscular training programs are found effective in improving function and reducing symptoms in people with knee issues[6].

Neuromuscular exercises in lower extremities would involve multiple joints and muscle groups performed in functional weight-bearing positions. Emphasis is on the quality and efficiency of movement, as well as the alignment of the trunk and lower limb joints.

To improve sensorimotor control, exercises are performed mainly in closed kinetic chains in different positions (e.g., lying, sitting, standing) with the intention to obtain low, evenly distributed articular surface pressure by muscular coactivation. Several aspects of sensorimotor function, such as strength, coordination, balance, and proprioception, are included in the Neuromuscular exercises, but focus can be, for example, balance in one exercise and strength in another.

The goal is to obtain equilibrium of loaded segments in static and dynamic situations and acquire postural control in situations resembling conditions of daily life and more demanding activities. Emphasis is put on the efficiency and quality of movements of each exercise.

The training is individualized because symptoms and functional limitations are heterogeneous in people with an injury or disease. The level of training and progression is guided by the patient’s sensorimotor function, taking into account various factors related to the individual and the injury/disease.[7]

Resources

References

  1. Ageberg E, Link A, Roos EM. Feasibility of neuromuscular training in patients with severe hip or knee OA: the individualized goal-based NEMEX-TJR training program. BMC musculoskeletal disorders. 2010 Dec;11(1):126.
  2. Clausen B. Neuromuscular exercise as treatment for knee osteoarthritis in middle aged patients(Doctoral dissertation, Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet).
  3. Risberg MA, Mørk M, Jenssen HK, Holm I. Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. Journal of Orthopaedic & Sports Physical Therapy. 2001 Nov;31(11):620-31.
  4. 4.0 4.1 Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.
  5. Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. InSeminars in arthritis and rheumatism 2010 Dec 1 (Vol. 40, No. 3, pp. 250-266). WB Saunders.
  6. Zech A, Hubscher M, Vogt L, Banzer W, Hansel F, Pfeifer K. Neuromuscular training for rehabilitation of sports injuries: a systematic review. Med Sci Sports Exerc. 2009 Oct 1;41(10):1831-41.
  7. Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.