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Selective Strengthening of the VMO

 
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Selective Strengthening of the VMO - December 25, 1999 7:49:00 PM   
Randy Moore


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41% of those who answered our survey believe the VMO can be selectively strengthened. I would like to start a discussion on this topic. If you believe it can be done, how?
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Re: Selective Strengthening of the VMO - January 6, 2000 11:14:00 AM   
scriss

 

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From: Columbus, IN USA
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I have had decent success with neuromuscular stimulation specifically focusing on the VMO. I have also used biofeedback to some degree of success.

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - January 7, 2000 7:43:00 AM   
Jeff Weil

 

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Scriss,
How do you determine that you have had success?

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Re: Selective Strengthening of the VMO - January 7, 2000 8:59:00 PM   
Dana D

 

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If I remember correctly from school and my affiliations, the VMO is responsible for the achievement of terminal knee extension. My CI's on 2 of my affiliations, targeted the VMO, when using e-stim, while doing SAQ (by having the leg in slight external rotation), and with facilatory techniques (tapping...)in efforts to achieve the last degrees of knee extension.
Either it was luck or the VMO was appropriately targeted through those techniques, but in the cases I saw, our goal was achieved.

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - January 8, 2000 8:00:00 AM   
Randy Moore


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From: Columbus, OH USA
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Is anyone aware of research which demonstrates the ability to selectively recruit the VMO, vs the VL? If it cannot be selectively recruited, how can it be selectively strengthened?

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - January 13, 2000 3:15:00 PM   
jeanie5126

 

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I am currently researching the topic of patellofemoral pain in PT school. I have read through many articles which address attaining patella stability via strengthening of the VMO (assuming that the VMO is weak in comparison to the VL). There is very little evidence, however, which supports isolated strengthening of the VMO (VMO selective recruitment).
For example, Powers addresses this topic in his article entitled "Rehabilitation of Patellofemoral Joint Disorders: A Critical Review" (JOSPT, Vol 28 #5, 1998). Powers states that the most common activities used to attain VMO strengthening are quad exercises (i.e. SLR, isometric quad sets, TKE), hip add, and internal tibial rotation. Powers goes on to state that a study by Lieb & Perry demonstrated that the VMO was not capable of independent TKE & that this ROM was due to all vasti working together. Also cited, is a study by Cerny which found that out of 22 variations of quad exercises, not one resulted in greater VMO activity than VL. In respect to hip add, Powers cites numerous studies which reported no effect on VMO recruitment & a few which reported increased VMO activity relative to the VL. When addressing internal tibial rotation, Powers cites studies by Hanten & Schulthies and by Cerny which both found no evidence of greater VMO activation during resisted tibial rotation.
I am still in the process of researching this subject but have come to the conclusion that this is a very controversial topic amongst PTs (and rightly so due to the insurmountable contradictory evidence out there).

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - January 13, 2000 5:24:00 PM   
Randy Moore


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From: Columbus, OH USA
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jeanie5126,

I'm glad to see you are researching the topic. It has always interested me. My literature reviews came to the same conclusion. I reviewed several articles, including the ones you have sited, and have not found any evidence the VMO can be selectively recruited. Perhaps someone can shed some light on how it is accomplished. 41% of those who participated in our poll believe it is possible. Thanks for sharing your information!

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - January 17, 2000 1:33:00 PM   
ptdot

 

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Maybe the VMO is chronically inhibited ( which we do visually observe) and estim, positioning and proprioceptive augmentation re-educate it vs. restrengthen. The semantics may be relevant since the re-education results in increased muscle activity during daily activities, thus a stronger muscle.

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - April 22, 2000 1:56:00 AM   
bradles70

 

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I've come across some good research on this topic:

Gilleard et al (1998) The effect of patellar taping on the onset of vastus medialis oblique and vastus lateralis muscle activity in persons with patellofemoral pain. Physical Therapy 78(1):25-32

Suggesting:
1. No significant difference in angle of onset of VMO & VL between symptomatic patients ("patellofemoral dysfunction") and non-symptomatic subjects for stair ascent, descent and cycling.

2. Medial glide patella taping of non-symptomatic subjects caused a later VMO onset during stair ascent with no change during descent.

3. Medial glide patella taping of symptomatic subjects caused significantly earlier VMO onset during stair ascent & descent.

The authors concluded that since tape has an effect in the absence of pain, that its effects musn't be rlated to the reduction of pain, and therefore by mechanical changes to the joint (congruence) or neuromuscular facilitation (proprioception, cutaneous feedback etc.)

Thought it was interesting stuff.
Brad Stevens
half-way through a Masters.

------------------

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - April 22, 2000 11:11:00 AM   
Andrew M. Ball, MS, PT

 

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WAY TO GO BRAD!!! I love it when people back up their statements with research!!!!

You may find the Watson study interesting as well.

In the clinic, the McConnell technique is often preached in the treatment of patellofemoral pain, but the inter-rater reliability of measuring patellofemoral tracking and displacement is not much better than Craniosacral therapy (Watson, 1999). Well okay, maybe a smidge better.

Respectfully Submitted,
Drew

REFERENCES:

Watson CJ. et al. Reliability of McConnell's classification of patellar orientation in symptomatic and asymptomatic subjects. JOSPT 29(7):378-85; discussion 386-93 1999 Jul.


------------------
Andrew M. Ball, MS, PT
MBA/PhD Candidate

(in reply to Randy Moore)
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Re: Selective Strengthening of the VMO - April 26, 2000 11:06:00 PM   
jeffmcv

 

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Am J Sports Med 1995 Jul-Aug;23(4):465-71
Patellar taping was not effective in maintaining medial glide after exercise

In school they were telling us that the effect of taping is more proprioceptively than on actual alteration of the patella's tracking

Med Sci Sports Exerc 1993 Sep;25(9):989-92
Taping decreased perceived pain but did not alter the tracking of the patella.

Jeff
Research provided with nods to Andrew Ball
:-)

(in reply to Randy Moore)
Post #: 11
Re: Selective Strengthening of the VMO - May 25, 2000 12:44:00 AM   
bradles70

 

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From: Gosford, NSW, Australia
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Randy, Jeff, SJ, Drew and co-PFJ thinkers,

Researchers agree with Randy's findings so far, namely that VMO cannot be selectively strengthened by altering tibiofemoral or patellofemoral position during exercise (incl taping it seems).

I guess we must keep in mind however, that to truly measure muscle output we need direct measures of torque (whether isokinetic or not) to compare. To date, research has relied on EMG to measure muscle output mainly due its (comparative) ease of use.

While some work does show linear and non-linear relationships of rectified EMG signals to tension (See Winter 1990 for an excellent review) other components of muscle force cannot be accounted for - namely length-tension, agonist assistance and antagonist resistance.

So far then, we can summarise that no evidence exists that we can selectively improve VMO EMG activity BUT what remains unproven is whether we can alter VMO force/torque output by modifying length-tension and competing forces in the control of the patella.

McConnell (1986) discusses the importance of addressing any tight lateral structures and in this context it would be easy to appreciate the effect on VMO length-tension, not just gross bony congruence.

Don't give up on VMO yet!
Brad Stevens
nearly 3/4 through Masters

Refs
McConnell J (1986) The Management of Chondromalacia Patellae: A Long-term Solution. Australian Journal of Physiotherapy 32(4):215-223

Winter DA (1990) Biomechanics & Motor Control of Human Movement. Wiley Interscience. Canada.



[This message has been edited by bradles70 (edited May 24, 2000).]

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Re: Selective Strengthening of the VMO - May 25, 2000 9:06:00 AM   
Randy Moore


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From: Columbus, OH USA
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Bradles70,

Great point. A group of 4 other students and I conducted a research project which delt with the linear relationship between EMG and torque. The project started out as an attempt to find the true MVIC position for the glut max and hamstrings. However, when we started testing people for the pilot we found a directly inverse relationship between force and EMG. After extensive review of the literature we found the relationship to be very poorly supported with weak studies. The actual research involved 50 subjects 25 M, 25 F, college aged, and we found a completely inverse relationship between EMG output and torque in the glut max, in 100% of the subjects. We have assumed with many studies for years that a linear relationship exsists. How many studies have been used to guide clinical treatment that assumed this relationship, which may not exsist?

The abstract can be found in JOSPT Jan. 1999 page A-43 (PL130)

Randy

[This message has been edited by Randy J Moore (edited May 25, 2000).]

[This message has been edited by Randy J Moore (edited May 25, 2000).]

(in reply to Randy Moore)
Post #: 13
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