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MENTAL SIMULATION STRATEGIES AS POTENTIALTOOL FOR ENHANCED
REHABILITATION OF ORTHOPAEDIC PATIENTS
Assist. Prof. Armin Paravlić, PhD
Content:
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- Background – why we need new tools for orthopaedic patients rehabilitation
- Introduction to basic theory on mental simulation strategies (MS);
- Historical overview;
- Areas of application with a focus on rehabilitation practice for orthopaedic patients;
- Overview of the literature on current use in the orthopaedic orthopaedic population;
- Is there scientific evidence for best MS practice (when, what type, and why);
- Identification of the gaps in current knowledge and suggest future research directions.
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QUICK OVERVIEW OF THE LITERATURE ON THE TOPIC
➢ 3 were literature reviews with meta-analysis
➢ 3 were experimental studies
➢ 2 were observational – diagnostic studies
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1.1. Ageing process
In patients population, e.g. following total knee arthroplasty (TKA) surgery alterations of
muscle structure and function are most likely harmful and long time lasting
Mizner et al., J Orthop Sports Phys Ther. (2005);35(7):424-36.
Paravlic et al., 2020. BJSM
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ACUTE
Long-term
Arthrogenic
inhibition
Strength
decrease
Pain
Inflamation
Impaired
mobility
Osteoarthritis
Overweight and
obesity
Cardio-vascular
diseases
Osteopenia
Disability
Musculoskeletal diseases: a burden of global society
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There is no strong
evidence of
pre-rehabilitation
practice efficiency
on measures of
muscle strength at 6
and 12 months postsurgery
periods
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There is no strong
evidence of
progressive resistance
training efficiency on
measures of muscle
strength and
functional capacity
following TKA
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Due substantially different methodologies used, there is no strong evidence of
favourable effects of NmES when compared to commonly used physical therapy
following TKA
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Alteration of central nervous system
Muscle force decreased
after UKA and the active
region of the sensorimotor
leg area also narrowed,
while the severity of pain
remained unchainged from
pre-to post surgery
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85% of quadriceps
strength loss was
explained by failure of
voluntary muscle
activation and muscle
atrophy. However, the
failure of VMA
contributed nearly twice as
musch as atrophy did.
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What we can do about it?
• Medical examination
• Functional and structural examination of injured/pathological body part
• Pre-operative management of patient
• Early rehabilitation
• Safe return to every day activities and sport: Structural and functional
examination
Specific cognitive strategies
(affecting central mechanism of movement control)
Common physiotherapy (manual therapy,cryotherapy, NmES...)
Strength training, NmES ????
Cognitive strategies (reducing anxiety, pain...)
Nutrition and supplementation aspects
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While we cannot execute a movement, what we can actually do?
Cognitive strategies
Virtual reality training
Motor imagery training
Kinesthetic
Internal
External
Rehabilitation area
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Physical Non-physical training
E
e
r
l
y
r
e
h
a
b
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1.EXPERIMENTALSTUDY
1. 1. Objectives:
• Primary goal of the research is to determine how the
MI practice intervention will influences on the
recovery of neuromuscular and locomotor function
following TKA.
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1.2. Specific goals of the research are as follows:
• To examine effects of MI practice intervention to other measured
parameters as follows:
a) maximal isometric strength of knee extensors,
b) maximal voluntary activation level
c) spatio-temporal gait parameters during different gait velocities under
single- and dual-task conditions,
d) contractile muscle parameters,
e) electromechanical efficiency index,
f) self-reported measures of lower extremity function (OKS and LEFS),
g) and pain level assessed by Visual Analogue Scale (VAS).
PRE -1 day
before TKA
POST
1 month
TKA perioperative process
7 to 12 days of hospitalization
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Trainingvariables Trainingdesign
Trainingperiod [weeks] 4
Training frequency [per week] 5
Number of sets [per training] 2-3
Number ofrepetitions [per set] 25
Number ofrepetitions [per single session] 50-70
Trainingintensity (MViC) 100
Time under tension [s] ¥
5
Durationofone trainingsession [min] 15
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2 DIAGNOSTIC STUDY I
2.1 Objectives:
• Primary goal of the research is to provide to the
Slovenian-speaking community a valid and reliable
version of Motor Imagery Questionnaire – 3 (MIQ-3),
that consists of kinaesthetic, visual and external
imagery items.
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2.1.1 Specific goals of the research:
• To examine psychometric properties of Slovenian version of MIQ-3
such as:
a) Internal consistency
b) Test-retest reliability
c) Construct validity
• To examine differences in imagery ability scores for kinesthetic and
visual ([internal and external]) scales considering participants
characteristics such as age, gender and sport participation
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3 DIAGNOSTIC STUDY II
3.1 Objectives:
• Primary goal of this research was to provide to the
Slovenian-speaking community a valid and reliable version
of Oxford Knee Score (OKS) and Lower Extremity
Functional Score (LEFS) questionnaires
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3.1.1 Specific goals of the research:
• To examine psychometric properties of Slovenian
version of OKS and LEFS such as:
a) Internal consistency
b)Test-retest reliability
Construct validity
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QUICK OVERVIEW OF THE RESULTS
LIST OF PUBLICATIONS
➢ 3 were literature reviews with meta-analysis
➢ 3 were experimental studies
➢ 2 were observational – diagnostic studies
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RESULTS:
- 13 articles
- 370 participants
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Objectives
Study design
➢The aim of this study was to investigate the maximal voluntary strength
(MVS), voluntary muscle activation (VMA), and the cross-sectional
area (CSA) of the muscle, up to 33 months after the TKA
➢A systematic review of the literature with meta-analysis;
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➢10 studies were included with a total of 289 patients involved
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Objectives
Methods
➢ The aim of this study was to provide to the Slovenian-speaking
community a valid and reliable version of Motor Imagery Questionnaire
– 3 (MIQ-3)
➢Diagnostic study
➢ Both absolute and relative test-retest repeatability; construct validity
and internal consistency of the KI, IMI and EMI items of the
Slovenian version of MIQ-3 in 86 healthy adult subjects.
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Questions/purposes
➢ We cross-culturally adapted Oxford Knee Score (OKS) and Lower
Extremity Functional Scale (LEFS) questionnaires to the Slovenianspeaking
community;
➢ We evaluated OKS and LEFS psychometric characteristics.
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Characteristic Whole sample (n = 123) Patients (n = 78) Control (n = 45) p value
Sex (men/women) 55/68 41/37 14/31
Age of participants 66.07 ± 7.25 66.19 ± 7.94 65.87 ± 5.93 .797
Education (number)
Elementary school 66 44 22 NA
High school 41 26 15 NA
University 16 9 7 NA
Body mass index 28.15 ± 7.76 31.27 ± 4.66 22.75 ± 9.05 <.001
Performance tests
Timed-up to go test 8.02 ± 3.94 9.72 ± 3.85 4.75 ±.85 <.001
Sit-to Stand test 12.60 ± 7.45 8.35 ± 3.79 20.78 ± 5.72 <.001
Knee pain
Affected leg 38.54 ± 30.93 59.23 ± 15.81 1.00 ± 6.11 <.001
Unaffected leg 4.88 ± 12.31 6.92 ± 13.87 1.16 ± 7.63 0.004
Questionnaires
OKS-Slo 29.89 ± 12.82 21.21 ± 6.40 44.96 ± 4.25 <.001
LEFS-Slo 44.80 ± 23.47 28.27 ± 8.65 73.44 ± 8.56 <.001
LEFS-Slo Lower Extremity Functional Scale (Slovenian version); OKS-Slo Oxford Knee Score
(Slovenian version); p-value – the level of significance assessed by student t-test between Patients and
Control group only; NA – not applicable
Table 1. Demographic characteristics of participants.Data were presented as
Means ± Standard deviations [SD] for all participants assessed in Time 1.
Variable Time 1 Time 2* PANOVA CV (%) MDC SEM ICC (95% CI)
Cronbach's
alpha
Oxford Knee Score
Whole sample (n = 121) 29.66 ± 12.79 29.38 ± 12.79 0.095 1.92 2.50 points 0.90 0.99 (0.99-1.00) 0.995
Patients (n = 78) 21. 21 ± 6.40 20.88 ± 6.22 0.201 2.77 3.06 points 1.11 0.97 (0.95-0.98) 0.969
Control (n = 43) 45.00 ± 4.34 44.79 ± 4.41 0.130 0.5 1.23 points 0.45 0.99 (0.98-0.99) 0.990
Lower Extremity Functional Score
Whole sample (n = 121) 44.36 ± 23.41 44.01 ± 22.93 0.382 5.13 6.08 points 2.20 0.99 (0.99 – 0.99) 0.991
Patients (n = 78) 28.27 ± 8.65 27.94 ± 6.92 0.580 7.44 7.73 points 2.80 0.87 (0.80-0.92) 0.871
Control (n = 43) 73.53 ± 8.75 73.16 ± 8.04 0.146 1.1 2.69 points 0.97 0.99 (0.97-0.99) 0.990
PANOVA – P-value of repeated measures analysis of variance; CV – within-subject coefficient of variation; MDC – minimal detectable change;
SEM – standard error of estimate; ICC (95% CI) – intra-class correlation coefficient with 95% confidence intervals; * 43 subjects in total were
assessed at Time 2 in control group.
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Table 3. Between Time 1 and Time 2 reliability analysis of the Oxford Knee Score and Lower Extremity
Functional Score scales
Variables
Age of
subjects
BMI TUG STS VASsym VASasym OKS LEFS
Age of subjects 1.000 .047 .356** -.151 .104 -.018 -.083 -.094
BMI .047 1.000 .319**
-.420**
.500**
.098 -.490**
-.507**
TUG .356**
.319**
1.000 -.729**
.677**
.164 -.679**
VASas
ym
-.692**
STS -.151 -.420**
-.729**
1.000 -.802**
-.145 .790**
.815**
VASsym .104 .500**
.677**
-.802**
1.000 .241**
-.923**
-.915
VASasym -.018 .098 .164 -.145 .241*
1.000 -.231*
-.233*
OKS -.083 -.490**
-.679**
.790**
-.923**
-.231*
1.000 .968**
LEFS -.094 -.507**
-.692**
.815**
-.915**
-.233*
.968**
1.000
BMI Body Mass Index, TUG Timed-up to go test, STS Sit-to-Stand test, OKS Oxford Knee Score, LEFS
Lower Extremity Functional Scale
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Table 2. Correlation between Oxford Knee Score and Lower Extremity Functional Scale questionnaires with
other domains assessed at Time 1 (n = 123 subjects)
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Conclusions
➢ The OKS-Slo and LEFS-Slo validation process conducted in the current study
showed that both translated versions preserved very well the main
characteristics of reliability and validity observed in the original versions.
➢ Thus, our findings show that both the OKS and LEFS could be translated into
the Slovenian language without losing the psychometric characteristics of the
original questionnaire versions. Therefore, we can state that the Slovenian
version of both questionnaires is feasible, valid, and reliable for use among the
older adult population diagnosed with knee OA.
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PRE -1 day
before TKA
POST
1 month
TKA perioperative process
7 to 12 days of hospitalization
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Trainingvariables Trainingdesign
Trainingperiod [weeks] 4
Training frequency [per week] 5
Number of sets [per training] 2-3
Number ofrepetitions [per set] 25
Number ofrepetitions [per single session] 50-70
Trainingintensity (MViC) 100
Time under tension [s] ¥
5
Durationofone trainingsession [min] 15
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Objectives
➢This study explored whether the addition of motor imagery to routine
physical therapy reduces the deterioration of quadriceps muscle strength
and voluntary activation (VA) as well as other variables related to motor
performance in patients after total knee arthroplasty (TKA).
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Conclusions
➢ In summary, to our knowledge, this is the first study analysing the effects of MI
practice on voluntary activation of the quadriceps muscle and self-reported
measure of physical function in patients who underwent TKA surgery.
➢ The addition of MI practice to routine physical therapy initiated within 48 hours
after TKA preserved the pre-operative level of voluntary activation of the
quadriceps muscle and attenuated both objective and subjective measures of
physical function at one month after TKA.
➢ However, the performance of the non-operated leg was not altered, suggesting
that MI practice did not exert any statistically significant effect on the
contralateral limb for the variables considered in this investigation.
➢ MI practice might be a suitable adjunct therapeutic tool to common
rehabilitation practice for TKA patients in the early postoperative period.
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General conclusions
Objective I
• Primary goal of the intervention study was to determine how the MI
practice intervention will influences on the recovery of neuromuscular
and locomotor function following TKA. In brief, we concluded that:
i) MI practice positively effects maximal isometric strength of knee extensors;
ii) MI practice positively effects maximal voluntary activation level of mm. quadriceps;
iii) MI practice positively effects Spatio-temporal gait parameters during different gait
velocities under single- and dual-task conditions;
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iv) MI practice does not have effect on contractile parameters of
muscles that surrounds knee joint;
v) MI practice does not have effect on electromechanical efficiency
index of gastrocnemius muscle;
vi) MI practice positively effects self-reported measures of lower
extremity function (OKS and LEFS);
vii) MI practice does not have effect on pain level assessed by Visual
Analogue Scale (VAS).
...continuing of Objective 1
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Objective II
• Primary goal of the diagnostic study I, was to provide to the Slovenian-speaking
community a valid and reliable version of Motor Imagery Questionnaire – 3
[MIQ-3], that consists of kinaesthetic, visual and external imagery items. The
main hypothesis related to this study was confirmed, showing that the Slovenian
translation of the MIQ-3 is culturally and linguistically equivalent to the original
English version. The results of this study support the use of the MIQ-3 as a
reliable and valid motor imagery ability assessment instrument in the Slovenianspeaking
population.
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Objective III
• Primary goal of Diagnostic study II was to provide to the Slovenianspeaking
community a valid and reliable version of Oxford Knee Score
(OKS) and Lower Extremity Functional Scale (LEFS) questionnaires. The
main hypothesis related to this study was confirmed, showing that the
Slovenian version of both questionnaires is culturally and linguistically
equivalent to the original English version. It is feasible, valid and reliable
to be used in clinical studies including older adults’ population in
Slovenia.
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CONTRIBUTION TO SCIENCE AND EXPECTED RESULTS
➢ Improved post-surgery rehabilitation process of TKA patients;
➢ Add a new knowledge about MIp application in a field of
rehabilitation of TKA patients;
➢ Two questionnaires were validated and cross-culturally adapted
to Slovenian language speaking community. These new tools will
enable all practitioners and scientist from the field to successfully
conduct and evaluate the results of their practices and/or
research;
➢ Potential application to other similar pathologies and muscle
disuse situations
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