Download Incorporating the Kneehab® XP in to Your Patellofemoral Joint Pain

®
Quadriceps Therapy System
®
Incorporating the Kneehab XP in
to Your Patellofemoral Joint Pain
Treatment Program
Kneehab is useful for addressing both early muscular activation deficits and later power
and strength development concerns with a patellofemoral joint (PFJ) rehabilitation
progression. The following program suggests ways to combine the Kneehab with a
progression of exercises to address quadriceps muscle dysfunction/weakness and
patellofemoral pain. The treatments described in this brochure may be provided with
Kneehab XP Controller Type 412 and Kneehab XP Conductive Garment Type 421.
CLINICAL SCENARIO: Acute,
Post-Surgical
Duration
Weeks 1-6, post-surgery
Recommended
Kneehab Programs
Program 3 or 4 per patient comfort*
Program 3: 20 minutes (10 sec on: 20 sec off cycle)
Program 4: 20 minutes (10 sec on: 30 sec off cycle)
Clinical goals
Manage pain
Reduce swelling
Muscle facilitation
Restore range of motion
Workout Structure
Weeks 1-3: Volitional contraction exercises done independently of Kneehab; Kneehab applied 2x
daily at sub-maximal contraction intensity levels. Patient is in supine position or sitting with legs in
a supported extended position during application of Kneehab during this stage.
Weeks 3-6: Kneehab set to full contraction intensity. Volitional exercise contractions performed
in tandem with Kneehab sessions. Isometric contraction may be performed in full knee extension
or at a fixed angle between 45-90° of knee flexion (per comfort and surgical precautions)
Week 6: Advance to strengthening phase
Workout Frequency
2 times/daily
Workout Duration
6 weeks*
Progressions
Per comfort with existing level, attainment of clinical goals
Clinical Measures
Effusion, adequate quadriceps isometric contraction, straight leg raise with no extensor lag
Precautions
Pain, effusion, PFJ surgical procedure precautions, increased lateral patellar translation observed
Do not cinch the Kneehab around the quadriceps. Full contact with conductive surface is sufficient to
ensure Multipath stimulation is optimally delivered. Avoid direct contact with incision or broken skin.
Other Considerations
Discontinue protocol if patient exhibits unresolving pain or effusion; post-operative restrictions.
Avoid Open Kinetic Chain exercises through 30-0° arc of motion.
* Workout duration may vary per patient/condition
CLINICAL SCENARIO:
Quadriceps strengthening following quadriceps
muscle dysfunction or weakness, Patellofemoral pain
Duration
8 - 12 Weeks
Recommended
Kneehab Programs
Program 1 or 2 per patient comfort*
Program 1: 20 minutes (5 sec on: 10 sec off cycle)
Program 2: 20 minutes (10 sec on: 10 sec off cycle)
Clinical goals
Restore quadriceps strength
Retard disuse atrophy
Combat loss of additional muscle volume
Workout Structure
Select 3 – 5 exercises from protocol per patient comfort and competence
Cycle through selected exercise from protocol, in tandem with Kneehab program.
Complete exercise rotations as follows:
If 3 exercises selected: 2 minutes per exercise x 3 cycles (18 minute regimen)
If 4 exercises selected: 2.5 minutes per exercise x 2 cycles (20 minute regimen)
If 5 exercises selected: 2 minutes per exercise x 2 cycles (20 minute regimen)
Workout Frequency
3 times/week (per knee symptoms and muscle soreness)
Workout Duration
8 - 12 weeks*
Progressions
Per mastery and comfort with existing level
Clinical Measures
Reported pain with stairs, circumferential thigh girth, maximum single limb squat depth and/
or hop distance
Precautions
Pain, effusion, poor technique/alignment control, PFJ surgical procedure precautions,
increased lateral patellar translation observed
Other Considerations
Discontinue protocol if patient exhibits unresolving pain or effusion; post-operative restrictions.
Avoid Open Kinetic Chain exercises through 30-0° arc of motion.
* Workout duration may vary per patient/condition
Incorporating Kneehab for quadriceps strengthening
+ The patient performs a volitional quadriceps contraction in tandem with the stimulated contraction from the Kneehab.
+ Kneehab is set at an intensity that elicits a good contraction but does not provoke patellofemoral symptoms.
+ Volitional contractions are performed during each exercise as the patient cycles through their exercise array.
Therapeutic Exercises
Exercises vary by angle of knee flexion and weight-bearing status for maximal patellofemoral joint comfort
and maximal functional carry-over of the program.
KNEEHAB QUADRICEPS STRENGTHENING EXERCISE PROGRESSION
LEVEL 1
Open Kinetic Chain
Extension (A)
Open Kinetic
Chain Flexion (B)
Closed Kinetic
Chain Extension (C)
Closed Kinetic Chain
Flexion: Squat (D)
Closed Kinetic Chain
Flexion: Step (E)
Isometric contraction
at 0° knee flexion with
Kneehab ”on” cycle;
relax during “off” cycle
Isometric contraction,
bilateral stance
Isometric press (against
belt) at fixed knee
flexion angle
Shallow squat hold ()50°)
Press up into squat hold
from high stool/counter
with Kneehab “on” cycle,
sit to rest with “off”
Leg Press: Press & hold
against weight in a
shallow squat position
with “on” cycle, relax
during “off” cycle
2-4” step, anterior or
lateral weight shift:
Isometric shift & hold
with “on” cycle, shift
weight off limb during
“off” cycle
* Knee flexion angle (45-90°)
per comfort
* Shift direction per comfort
LEVEL 2
Isometric contraction
maintained + straight
leg raise during
Kneehab “on” cycle;
relax with “off” cycle
Concentric press
through deep flexion
(90° A45°)
Concentric TKE w/
resistance band
Progress amount of
weight maintained over
involved limb
Concentric press up
through shallow squat
()50°)
(Using high stool /
counter or leg press)
Shift + step-up
(Anterior or Lateral)
Concentrically press up
step with “on” cycle
Step back down to start
position with “off” cycle
LEVEL 3
Add ankle weight for
straight leg raise**
(complete exercise
same as previously)
Increased resistance
(concentric) or intensity
of push (isometric)
Isometric contraction in
single limb stance at 0°
knee flexion (return to
2 legs with “off” cycle)
Deeper squat starting
depth OR
Add weight or band
resistance to shallow
squats**
(IsometricAConcentric)
Shift + hold at higher
step OR
Add weight or band
resistance at same step
height** (isometric or
concentric exercise)
* Selection per comfort
* Selection per comfort
LEVEL 4
* Selection per comfort
Isometric contraction
in single limb stance at
fixed angle (10-30° knee
flexion); return to 2 legs
with “off” cycle
Progress to 1 leg squat or
leg press (Use opposite
leg or hand support for
gradual progression to 1
leg squat)
Use clinical judgment when advancing patients
to these exercises, i.e. symptoms
** Add weight or band resistance under the supervision of a clinician
OPEN KINETIC CHAIN EXTENSION (A)
Quadriceps Isometric Contraction – LEVEL 1
Straighten the leg completely (toes pointing up). Contract the quadriceps and hold the
contraction for the duration of a single Kneehab contraction. Release and repeat.
Quadriceps Isometric + Straight leg raise – LEVEL 2
Contract the quadriceps with the Kneehab contraction to lock the knee in full extension,
then lift and lower the leg, maintaining full knee extension throughout the motion.
Release and repeat.
Quadriceps Isometric + Weighted straight leg raise – LEVEL 3
Perform the straight leg exercise as instructed prior, with the addition of ankle weight resistance.
Start at a comfortable amount of weight and gradually progress per strength.
OPEN KINETIC CHAIN FLEXION (B)
Isometric Contraction – LEVEL 1
Secure a strap around the ankle to hold the knee at a fixed angle of flexion between 90°
to 45° (per comfort). Press into the strap to create an isometric contraction and hold for
the duration of the Kneehab contraction. Release and repeat.
Concentric Contraction – LEVEL 2
Secure an elastic band around the ankle with the knee flexed to approximately
90°. As the Kneehab contraction comes on, press the knee into a slightly more
extended position (no higher than 45°). Release and repeat.
CLOSED KINETIC CHAIN EXTENSION (C) - Stance Progression
Isometric Contraction (Bilateral Stance) – LEVEL 1
Contract the quadriceps while standing with your weight evenly distributed.
Hold the contraction for the duration of a single Kneehab contraction.
Release and repeat.
Concentric Contraction (Bilateral Stance) – LEVEL 2
With an exercise band placed behind the knee, bend the knee to a 20° angle
(a) and slowly straighten it while contracting the quadriceps (b). Perform in
tandem with the Kneehab contraction. Release and repeat.
Isometric Contraction (Single limb stance) – LEVEL 3**
Shift weight onto one leg (keeping the knee straight) and contract the
quadriceps in tandem with the Kneehab contraction (use balance support
as needed) (a). Release and transition back to 2 legs, then repeat with the
next contraction cycle (b).
** For safety, patients should perform single leg stance exercises with
a chair or support surface close by in the event of loss of balance.
Isometric Contraction (Single limb stance in slight flexion) – LEVEL 4**
Shift weight onto one leg (with the knee in a slight bend) and contract the
quadriceps in tandem with the Kneehab contraction (use balance support
as needed). Release and transition back to 2 legs, then repeat with the
next contraction cycle.
** For safety, patients should perform single leg stance exercises with
a chair or support surface close by in the event of loss of balance.
(a)
(b)
(a)
(b)
CLOSED KINETIC CHAIN: SQUAT (D)
Squat Hold – LEVEL 1
Start in a seated position with both feet on the ground (a). When the Kneehab
contraction initiates, slowly press up with both legs and hold a squat position
at a comfortable angle of knee flexion (< 50°) (b). Maintain this shallow squat
hold for the duration of the contraction. When the Kneehab contraction
is completed, sit back down to rest. Repeat the squat holds with the
contraction cycles.
(a)
(b)
Concentric Squat Press-Up – LEVEL 2
Start in a seated position with both feet on the ground (a). When the
Kneehab contraction initiates, slowly press up with both legs through the
rising phase of the squat motion until arriving in full upright stance (b). When
the Kneehab contraction releases, lower back down to a seated position to
rest. Repeat the squat press-ups with each contraction.
(a)
(b)
Intermediate Squat Progressions – LEVEL 3
Progress the 2-legged squat activity by either*:
(a) Performing a hold or press-up from a deeper squat starting position
(b) Adding weight or band resistance with the hold or the press-up activity
* Choose the progression that is best tolerated per symptoms and control.
Single-Leg Squat – LEVEL 4
Start in a seated position with 1 foot on the ground. When the Kneehab contraction
initiates, press up with 1 leg and either:
(a)
(b)
(a). Hold a single leg squat position for the duration of the Kneehab contraction
(b). Press through the rising phase of the squat motion until arriving in full upright stance
When the Kneehab contraction releases, lower back down to a seated position
to rest (c). Repeat the squat holds or press-ups with each contraction.
* Tip-toe support from the opposite limb or hand support may be used to help
transition safely and comfortably into single leg squatting. (see photo)
(c)
Add external weight (dumbbell) to squatting position
Progress to a deeper starting squat position
CLOSED KINETIC CHAIN: STEP (E)
Anterior weight shift onto step - LEVEL 1
Start with the involved leg up on a small step placed slightly to the front (a). When
the Kneehab contraction initiates, slowly shift a comfortable amount of weight
forward onto the step, leaning forward at the trunk and bending at the knee and hip
(b). Hold this position for the duration of the contraction. Shift body weight back
to the opposite limb (leaving the involved foot up on the step) to rest. Repeat the
weight shift & hold with each contraction cycle.
(a)
(b)
(a)
(b)
* Be watchful for proper body position
* Increase amount of weight shifted and height of step as tolerated.
* Monitor the amount of weight shifted with each repetition by using
a bathroom scale securely placed on top of the step
Lateral weight shift onto step - LEVEL 1
Start with the involved leg up on a small step placed slightly to the side (a). When
the Kneehab contraction initiates, slowly shift a comfortable amount of weight over
onto the step, sitting back slightly into the hip and bending at the knee slightly (b).
Hold this position for the duration of the contraction. Shift body weight back to the
opposite limb (leaving the involved foot up on the step) to rest. Repeat the weight
shift & hold with each contraction cycle.
* Be watchful for proper body position
* Increase amount of weight shifted and height of step as tolerated (b).
* Monitor the amount of weight shifted with each repetition by using
a bathroom scale securely placed on top of the step
Anterior step up – LEVEL 2
Start with the involved leg up on a small step placed slightly to the front (a). When
the Kneehab contraction initiates, shift weight over onto the step and slowly press
up the height of the step (b-c). When the Kneehab contraction releases, lower back
down the step to the starting position. Repeat the step-ups with each contraction.
(a)
(b)
(c)
* Be watchful for proper body position
* Gradually increase height of step or add band or dumbbell resistance
to increase challenge, per symptoms and control
Increase step height and external load (dumbbell) as tolerated
Lateral step up – LEVEL 2
Start with the involved leg up on a small step placed slightly to the side (a). When
the Kneehab contraction initiates, shift weight over onto the step and slowly press
up the height of the step (b-c). When the Kneehab contraction releases, lower back
down the step to the starting position. Repeat the step-ups with each contraction.
* Be watchful for proper body position
* Gradually increase height of step or add band or dumbbell resistance
to increase challenge, per symptoms and control
(a)
(b)
(c)
CLOSED KINETIC CHAIN: STEP (E)
CONTINUED
Step Exercise Progressions – LEVEL 3
Progress the step exercise per symptoms and control in any of the following ways:
1. Use a higher step with either holds or step-ups
2. Use external load/resistance (dumbbell, resistance band) with either holds or press-up
Useful clinical tools:
1. Bathroom scales can be useful for observing symmetrical weight bearing with the
2 legged squatting activities and observing the amount of weight shifted with the
step & hold activities. (see photos)
2. If full body weight squatting or stepping is not tolerated due to pain or weakness,
consider the following strategies:
a. Have the patient use hand support at a sturdy counter or overhead bar to offload weight from the limb(s)
b. Have the patient use a leg press machine at a comfortable knee flexion angle
with a comfortable load (isometric or concentric presses)
c. Have the patient perform a “home leg press” by lying supine on the floor and
pressing into an exercise ball that is secured in a corner (see photo)
Key points to consider with quadriceps
muscle training for patellofemoral conditions
Patellofemoral joint (PFJ) pain can be aggravated via joint stress, < 30° knee angle positions in non-weight
bearing settings and deeper knee angle positions in weight-bearing settings.
+ Non-weight bearing exercises where the knee is flexed at a < 30° position should be avoided
+ Preferred knee angles for non-weight bearing exercises are 45° to 90°
+ Non-weight bearing strengthening exercises in deeper angles of knee flexion may be less stressful to the
patellofemoral cartilage due to increased contact area
+ There is less lateral movement of the patella when the knee is flexed at a deeper angle. An exception to this
is where there is a known cartilage defect within the joint.
+ Weight-bearing strengthening exercises create less PFJ stress at < 50° of knee flexion
+ Weight-bearing strengthening exercises, where the knee is flexed at a greater degree, increases PFJ stress
and should only be initiated based on the patient’s individual progress and continued symptom control.
Patellar Instability
+ Improved quadriceps muscle function may improve patellar stability
+ The patella demonstrates increased lateral movement through the arc of motion near full knee extension
(30°-0°) in non-weight bearing situations. Exercise in such a manner should be avoided.
+ Non-weight bearing strengthening exercises utilizing deeper knee angles demonstrate reduced lateral
movement of the patella. 45° to 90° of motion is considered a safe range for quadriceps strengthening.
- An exception would be with a known cartilage defect or surgical precaution.
+ These deeper angle/non-weight bearing exercises are also less stressful to the patellofemoral cartilage,
except when there is a known cartilage defect within the joint
Kneehab Program Selection
Kneehab XP delivers 9 programs total — 6 Multipath NMES programs and 3 TENS programs. Programs not
specifically referenced in this brochure can be utilized in an individual program, e.g. Program 9 TENS for pain
relief, as determined by the clinician.
Program
Program Description
Frequency
(Seconds)
(Hz)
1 – Ramp Up
5 – Contraction Time
0.5 – Ramp Down
10 – Relaxation Time
50Hz
1 – Ramp Up
10 – Contraction Time
0.5 – Ramp Down
10 – Relaxation Time
50Hz
1 – Ramp Up
10 – Contraction Time
0.5 – Ramp Down
20 – Relaxation Time
50Hz
1 – Ramp Up
10 – Contraction Time
0.5 – Ramp Down
30 – Relaxation Time
50Hz
1 – Ramp Up
5 – Contraction Time
0.5 – Ramp Down
5 – Relaxation Time
35Hz
(Multipath)
1 – Ramp Up
10 – Contraction Time
0.5 – Ramp Down
50 – Relaxation Time
70Hz
P7
Continuous
stimulation time
99Hz
Continuous
stimulation time
4Hz
Continuous
stimulation time
125Hz
P1
(Multipath)
P2
(Multipath)
P3
(Multipath)
P4
(Multipath)
P5
(Multipath)
P6
(TENS)
P8
(TENS)
P9
(TENS)
Kneehab XP indications for use:
+ Early post-surgical quadriceps strengthening and improved post-surgical knee stability secondary to
quadriceps strengthening
+ Muscle re-education of the quadriceps
+ Maintain or increase range of motion of the knee joint
+ Prevent or slow disuse atrophy in the quadriceps
+ Increase local blood circulation
+ Symptomatic relief and management of chronic, intractable pain
+ Management of intractable pain and relief of pain associated with arthritis
+ Adjunctive treatment in the management of acute, post-surgical or post-traumatic pain
+ Adjunctive therapy in reducing the level of pain and symptoms associated with osteoarthritis of the knee
About us:
40 years of innovation and advanced patient care
neurotech® is a division of Bio-Medical Research (BMR) Ltd., a worldwide leader providing
innovative devices for pain relief and rehabilitation health. Since the 1960s, we have worked
with health care professionals and patients to design and develop pain management and
rehabilitative devices that are effective and deliver on promised results. Through extensive
research and clinical trials, we are committed to developing medical innovations for muscle
disorders, incontinence, post-stroke rehabilitation, pain management and more. Our easy
to use, clinically proven products help patients worldwide embrace life to the fullest.
Scan to view tutorial
videos of the exercises
contained in this brochure.
For more information about the Neurotech Kneehab® XP:
Contact your distributor or visit us at www.neurotech.us and click the “Contact Us” tab.
This device is by prescription only.
®
Designed by & Manufactured for:
Neurotech
A Division of Bio-Medical Research Ltd.
PO Box 5179
Hoboken, NJ 07030
866-453-0578
www.neurotech.us
U.S. Patent Number 6,944,503
Part No: 2441-3302
Copyright © 2013 Bio-Medical Research Ltd. All rights reserved.
Rev.:
1
neurotech® is a trademark of Bio-Medical Research Ltd.
Issued:
8/13