Neuromuscular Exercise Program NEMEX: Difference between revisions

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== Introduction ==
== Introduction ==
[[File:Lunge with Dumbells.png|thumb|An exercise in NEMEX]]
[[File:Lunge with Dumbells.png|thumb|An exercise in NEMEX]]
The neuromuscular exercise (NEMEX) program is aimed at improving sensorimotor control and attaining functional joint stabilization by addressing the quality of movement in all 3 movement planes.<ref name=":2">Clausen B, Holsgaard-Larsen A, Roos EM. An 8-week neuromuscular exercise program for patients with mild to moderate knee osteoarthritis: a case series drawn from a registered clinical trial. Journal of Athletic Training. 2017 Jun;52(6):592-605. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5488851/<nowiki/>(accessed 28.5.2022)</ref> It’s an evidence-based education and supervised [[Neuromuscular Adaptations to Exercise|neuromuscular]] exercise program targeting [[Hip Osteoarthritis|hip]] and [[knee Osteoarthritis]]. The GLA:D® program (Good Life with Arthritis: Denmark) is an education and exercise program developed by researchers in Denmark for people with hip or knee osteoarthritis (OA) symptoms. NEMEX a part of this program. The GLA:D program is an eight week program that includes education and exercise, based on the latest evidence in osteoarthritis research. The program is overseen by a certified GLA:D physiotherapist, with the aim to help patients manage their OA symptoms.   
The neuromuscular exercise (NEMEX) program is aimed at improving sensorimotor control and attaining functional joint stabilization by addressing the quality of movement in all three movement planes.<ref name=":2">Clausen B, Holsgaard-Larsen A, Roos EM. An 8-week neuromuscular exercise program for patients with mild to moderate knee osteoarthritis: a case series drawn from a registered clinical trial. Journal of Athletic Training. 2017 Jun;52(6):592-605. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5488851/<nowiki/>(accessed 28.5.2022)</ref> It is an evidence-based education and supervised [[Neuromuscular Adaptations to Exercise|neuromuscular]] exercise program targeting [[Hip Osteoarthritis|hip]] and [[knee Osteoarthritis]].  
 
# It is part of the GLA:D® program (Good Life with Arthritis: Denmark), an education and exercise program developed by researchers in Denmark for people with [[Hip Osteoarthritis|hip]] or [[Knee Osteoarthritis|knee osteoarthritis]] (OA) symptoms.  
# The GLA:D program is an eight week program that includes education and [[Therapeutic Exercise|exercise]], based on the latest evidence in [[osteoarthritis]] research. The program is overseen by a certified GLA:D physiotherapist, with the aim to help patients manage their OA symptoms.   


'''Key Facts'''  
'''Key Facts'''  


* Feasible in patients with severe [[Total Hip Replacement|hip]] and [[Total Knee Arthroplasty|knee joint replacement surgery]]
* Feasible in patients with severe [[Total Hip Replacement|hip]] and [[Total Knee Arthroplasty|knee joint replacement surgery]]
* Improves pain, function and [[Quality of Life|quality of life]]
* Improves function and [[Quality of Life|quality of life]]  
* Associated with reduction in use of analgesia and sick days from work<ref>Trek NEMEX Available:https://nemex.trekeducation.org/ (accessed 28.5.2022)</ref>
* Reduces pain (associated with reduction in use of analgesia) and sick leave<ref>Trek NEMEX Available:https://nemex.trekeducation.org/ (accessed 28.5.2022)</ref>
== NEMEX Program  ==
== NEMEX Program  ==
[[File:Neuromuscular reeducation step 1.jpg|thumb|Neuromuscular reeducation]]
[[File:Neuromuscular reeducation step 1.jpg|thumb|Neuromuscular reeducation]]
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# Postural control: Performing voluntary movements without losing one's posture.  
# Postural control: Performing voluntary movements without losing one's posture.  
# Strength of lower extremity
# Strength of lower extremity
# Balance
# [[Balance]]
# Functional stability of the trunk and knee.   
# Functional stability of the trunk and knee.   


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* Allow for progression, 4 levels of difficulty are available  
* Allow for progression, 4 levels of difficulty are available  
* Progress when the physiotherapist considered that an exercise can be performed with good sensorimotor control and good quality (by visual inspection) and patients perceived that they could perform the movement with minimal exertion and with control of the movement.<ref name=":2" />
* Progress when the physiotherapist considered that an exercise can be performed with good sensorimotor control and good quality (by visual inspection) and patients perceived that they could perform the movement with minimal exertion and with control of the movement.<ref name=":2" />
* They are usually multi-joint exercises performed in functional [[Closed Chain Exercise|closed chain]] weight-bearing positions.
These exercises help to attain:
# equilibrium of loaded segments in static and dynamic situations
# postural control in situations resembling conditions of daily life and more demanding activities<ref name=":0">Ageberg E, Roos EM. [https://gladaustralia.com.au/wp-content/uploads/2018/09/Ageberg-and-Roos-2015-Neuromuscular_Exercise_as_Treatment.pdf Neuromuscular exercise as treatment of degenerative knee disease.] Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.</ref>.
These exercise programmes need to be individualized because:
# symptoms and functional limitations are heterogeneous in people with an injury or disease
# the patient’s sensorimotor function differs individually
# various factors related to the individual and the injury/disease need to be taken into account.<ref>Ageberg E, Roos EM. [https://gladaustralia.com.au/wp-content/uploads/2018/09/Ageberg-and-Roos-2015-Neuromuscular_Exercise_as_Treatment.pdf Neuromuscular exercise as treatment of degenerative knee disease.] Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.</ref>
== Viewing ==
This 3 minute video outlines the NEMEX program.{{#ev:youtube|-Xkiad0x7_I|width}}<ref>Target Physio GLA:D Hip and Knee Osteoarthritis Info Video Available:https://www.youtube.com/watch?v=-Xkiad0x7_I(accessed 28.5.2022)</ref>
This 3 minute video outlines the NEMEX program.{{#ev:youtube|-Xkiad0x7_I|width}}<ref>Target Physio GLA:D Hip and Knee Osteoarthritis Info Video Available:https://www.youtube.com/watch?v=-Xkiad0x7_I(accessed 28.5.2022)</ref>


==  The rationale for Neuromuscular Exercises  ==
==  The rationale for Neuromuscular Exercises  ==
Neuromuscular control is defined as the unconscious trained response of a [[Muscle Cells (Myocyte)|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<ref name=":1" />. Neuromuscular training programs should address several aspects of sensorimotor function and functional stabilization to improve objective function and alleviate symptoms.
Neuromuscular control is defined as the unconscious trained response of a [[Muscle Cells (Myocyte)|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<ref name=":1" />. Neuromuscular training programs should address several aspects of sensorimotor function and functional stabilization to improve objective function and alleviate symptoms.
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.


Neuromuscular exercise:
Neuromuscular exercise:
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* Addresses the quality of movement and emphasizes joint control in all three biomechanical/[[Cardinal Planes and Axes of Movement|movement planes]].<ref name=":1">Ageberg E, Link A, Roos EM. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-11-126 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.</ref>
* Addresses the quality of movement and emphasizes joint control in all three biomechanical/[[Cardinal Planes and Axes of Movement|movement planes]].<ref name=":1">Ageberg E, Link A, Roos EM. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-11-126 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.</ref>
* Has effects on functional performance, biomechanics, and muscle activation patterns of the surrounding joint musculature<ref>Clausen B. ''[https://pdfs.semanticscholar.org/f6b5/4c5d77a177ed014c07fea4fe9a010ed070a6.pdf Neuromuscular exercise as treatment for knee osteoarthritis in middle aged patients]''Neuromuscular exercise as treatment for knee osteoarthritis in middle aged patients(Doctoral dissertation), Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet).</ref>.   
* Has effects on functional performance, biomechanics, and muscle activation patterns of the surrounding joint musculature<ref>Clausen B. ''[https://pdfs.semanticscholar.org/f6b5/4c5d77a177ed014c07fea4fe9a010ed070a6.pdf Neuromuscular exercise as treatment for knee osteoarthritis in middle aged patients]''Neuromuscular exercise as treatment for knee osteoarthritis in middle aged patients(Doctoral dissertation), Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet).</ref>.   
* Coordinated neuromuscular control required during daily living and sport-specific activities.
* Address the lag in neuromuscular reaction time that results in dynamic joint instability with recurrent episodes of joint subluxation and deterioration.<ref>Risberg MA, Mørk M, Jenssen HK, Holm I. [https://www.jospt.org/doi/pdf/10.2519/jospt.2001.31.11.620 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.</ref>  
* Address the lag in neuromuscular reaction time that results in dynamic joint instability with recurrent episodes of joint subluxation and deterioration.<ref>Risberg MA, Mørk M, Jenssen HK, Holm I. [https://www.jospt.org/doi/pdf/10.2519/jospt.2001.31.11.620 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.</ref>  


====Mechanisms for Sensorimotor Deficiency ====
====Mechanisms for Sensorimotor Deficiency ====
Impairments are present at different levels of the sensorimotor system,  from [[Sensation|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<ref name=":0">Ageberg E, Roos EM. [https://gladaustralia.com.au/wp-content/uploads/2018/09/Ageberg-and-Roos-2015-Neuromuscular_Exercise_as_Treatment.pdf Neuromuscular exercise as treatment of degenerative knee disease.] Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.</ref>.
Sensorimotor dysfunctions may play a role in the development and progression of degenerative joint disease<ref name=":0" />.


Neural inhibition caused by factors such as [[Pain Behaviours|pain]], swelling, [[Inflammation Acute and Chronic|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.<ref>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.</ref>
Impairments are present at different levels of the sensorimotor system from:  


Sensorimotor deficiencies also were found in the non-injured 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 non-injured side.
# [[Sensation|Sensory]] input, integration and processing of information in the central nervous system
 
# Motor output (vital to perform voluntary movements and maintain postural control)
====Principles of Neuromuscular Exercises ====
# Neural inhibition (caused by factors such as [[Pain Behaviours|pain]], swelling, [[Inflammation Acute and Chronic|inflammation]], joint laxity, damage to sensory receptors in the joint) prevent the muscles to be activated fully likely through altered excitability of spinal and supraspinal pathways.<ref>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.</ref>
Neuromuscular training programs are found effective in improving function and reducing symptoms in people with knee issues<ref>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.</ref>. Neuromuscular exercises in lower extremities emphasise on the quality and efficiency of movement, and the alignment of trunk and joints. They are usually multi-joint exercises performed in functional weight-bearing positions.
# Sensorimotor deficiencies are also found in the non-injured leg, possibly due to 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 non-injured side.
 
Exercises performed in [[Closed Chain Exercise|closed kinetic chains]] in different positions (e.g., lying, sitting, standing) help in improving the sensorimotor control, and obtaining a low, evenly distributed articular surface pressure by muscular coactivation. 
 
These exercises help to attain:
 
# equilibrium of loaded segments in static and dynamic situations
# postural control in situations resembling conditions of daily life and more demanding activities<ref name=":0" />.
 
 
These exercise programmes need to be individualized because:
 
# symptoms and functional limitations are heterogeneous in people with an injury or disease
# the patient’s sensorimotor function differs individually
# various factors related to the individual and the injury/disease need to be taken into account.<ref>Ageberg E, Roos EM. [https://gladaustralia.com.au/wp-content/uploads/2018/09/Ageberg-and-Roos-2015-Neuromuscular_Exercise_as_Treatment.pdf Neuromuscular exercise as treatment of degenerative knee disease.] Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.</ref>


== Conclusion ==
== Conclusion ==

Revision as of 02:49, 24 November 2022

Original Editor - PARIVESH KUMAR

Top Contributors - PARIVESH KUMAR, Lucinda hampton, Kim Jackson, Rucha Gadgil, Rachael Lowe and Aminat Abolade  

Introduction[edit | edit source]

An exercise in NEMEX

The neuromuscular exercise (NEMEX) program is aimed at improving sensorimotor control and attaining functional joint stabilization by addressing the quality of movement in all three movement planes.[1] It is an evidence-based education and supervised neuromuscular exercise program targeting hip and knee Osteoarthritis.

  1. It is part of the GLA:D® program (Good Life with Arthritis: Denmark), an education and exercise program developed by researchers in Denmark for people with hip or knee osteoarthritis (OA) symptoms.
  2. The GLA:D program is an eight week program that includes education and exercise, based on the latest evidence in osteoarthritis research. The program is overseen by a certified GLA:D physiotherapist, with the aim to help patients manage their OA symptoms.

Key Facts

NEMEX Program[edit | edit source]

Neuromuscular reeducation

In brief the NEMEX program comprise 11 exercises (predominantly performed in a closed kinetic chain) focusing on the following components:

  1. Correct functional performance and alignment ie being with the knee is lining up over the second toe without tending to fall in medially during knee flexion.
  2. Postural control: Performing voluntary movements without losing one's posture.
  3. Strength of lower extremity
  4. Balance
  5. Functional stability of the trunk and knee.

The exercises

  • Are performed with each leg but focus on the affected leg.
  • Allow for progression, 4 levels of difficulty are available
  • Progress when the physiotherapist considered that an exercise can be performed with good sensorimotor control and good quality (by visual inspection) and patients perceived that they could perform the movement with minimal exertion and with control of the movement.[1]
  • They are usually multi-joint exercises performed in functional closed chain weight-bearing positions.

These exercises help to attain:

  1. equilibrium of loaded segments in static and dynamic situations
  2. postural control in situations resembling conditions of daily life and more demanding activities[3].

These exercise programmes need to be individualized because:

  1. symptoms and functional limitations are heterogeneous in people with an injury or disease
  2. the patient’s sensorimotor function differs individually
  3. various factors related to the individual and the injury/disease need to be taken into account.[4]

Viewing[edit | edit source]

This 3 minute video outlines the NEMEX program.

[5]

The rationale for Neuromuscular Exercises[edit | edit source]

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[6]. Neuromuscular training programs should address several aspects of sensorimotor function and functional stabilization to improve objective function and alleviate symptoms.

Neuromuscular exercise:

  • Addresses the quality of movement and emphasizes joint control in all three biomechanical/movement planes.[6]
  • Has effects on functional performance, biomechanics, and muscle activation patterns of the surrounding joint musculature[7].
  • Address the lag in neuromuscular reaction time that results in dynamic joint instability with recurrent episodes of joint subluxation and deterioration.[8]

Mechanisms for Sensorimotor Deficiency[edit | edit source]

Sensorimotor dysfunctions may play a role in the development and progression of degenerative joint disease[3].

Impairments are present at different levels of the sensorimotor system from:

  1. Sensory input, integration and processing of information in the central nervous system
  2. Motor output (vital to perform voluntary movements and maintain postural control)
  3. Neural inhibition (caused by factors such as pain, swelling, inflammation, joint laxity, damage to sensory receptors in the joint) prevent the muscles to be activated fully likely through altered excitability of spinal and supraspinal pathways.[9]
  4. Sensorimotor deficiencies are also found in the non-injured leg, possibly due to 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 non-injured side.

Conclusion[edit | edit source]

There is evidence underlining the positive effects of Neuromuscular exercises in lower limb impairments, when given in conjunction with structured education. The quality of life, physical function and ADLs improved over a period of time when this exercise protocol was followed. However, its effect on pain still needs to be investigated further.[10]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Clausen B, Holsgaard-Larsen A, Roos EM. An 8-week neuromuscular exercise program for patients with mild to moderate knee osteoarthritis: a case series drawn from a registered clinical trial. Journal of Athletic Training. 2017 Jun;52(6):592-605. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5488851/(accessed 28.5.2022)
  2. ↑ Trek NEMEX Available:https://nemex.trekeducation.org/ (accessed 28.5.2022)
  3. ↑ 3.0 3.1 Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.
  4. ↑ 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. ↑ Target Physio GLA:D Hip and Knee Osteoarthritis Info Video Available:https://www.youtube.com/watch?v=-Xkiad0x7_I(accessed 28.5.2022)
  6. ↑ 6.0 6.1 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.
  7. ↑ Clausen B. Neuromuscular exercise as treatment for knee osteoarthritis in middle aged patientsNeuromuscular exercise as treatment for knee osteoarthritis in middle aged patients(Doctoral dissertation), Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet).
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Health Quality Ontario. Structured Education and Neuromuscular Exercise Program for Hip and/or Knee Osteoarthritis: A Health Technology Assessment. Ont Health Technol Assess Ser. 2018 Nov 2;18(8):1-110. PMID: 30443280; PMCID: PMC6235070.
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