Neuromuscular Exercise Program NEMEX: Difference between revisions

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</div>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, aerobic program, and patient education.
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== Introduction ==
[[File:Lunge with Dumbells.png|thumb|An exercise in NEMEX]]
The neuromuscular exercise ([https://nemex.trekeducation.org/ NEMEX]) program is aimed at improving sensorimotor control and attaining functional joint stabilization by addressing the quality of movement in all three movement planes. In patients with mild to severe pain with activity, the NEMEX is program feasible. The jumping activities however were deemed not feasible in 2017 clinical trial.<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>


==  The rationale for Neuromuscular Exercises  ==
* It is part of the [https://www.glaid.dk/english.html 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.
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 GLA:D program is an eight week program that includes education and [[Therapeutic Exercise|exercise]]. The program is overseen by a certified GLA:D physiotherapist, with the aim to help patients manage their OA 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.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2896351/ 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.]</ref>
'''Key Facts'''


Neuromuscular exercise 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|(Doctoral dissertation]], Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet).</ref>. 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.
* Feasible in patients with severe [[Total Hip Replacement|hip]] and [[Total Knee Arthroplasty|knee joint replacement surgery]]
* Improves function and [[Quality of Life|quality of life]]
* 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  ==
[[File:Neuromuscular reeducation step 1.jpg|thumb|Neuromuscular reeducation]]
In brief the NEMEX program comprise 11 exercises (predominantly performed in a closed kinetic chain) focusing on the following components:


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.<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>  
# 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.
# Postural control: Performing voluntary movements without losing one's posture.  
# Strength of lower extremity
# [[Balance]]
# Functional stability of the trunk and knee.   


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. 
The exercises


==== '''Mechanisms for Sensorimotor Deficiency'''<ref name=":0">[https://gladaustralia.com.au/wp-content/uploads/2018/09/Ageberg-and-Roos-2015-Neuromuscular_Exercise_as_Treatment.pdf Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews]. 2015 Jan 1;43(1):14-22.</ref>  ====
* Are performed with each leg but focus on the affected leg.
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.
* 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" />
* They are usually multi-joint exercises performed in functional [[Closed Chain Exercise|closed chain]] weight-bearing positions.
This 3 minute video outlines the NEMEX program. In summary


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.<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>
* Training occurs groups, with an experienced physical therapist supervising
* Consists of three parts: warming up, a circuit program, and cooling down
* Training session are 60 minutes long.
* The movement quality in each exercise is important, with an appropriate position of the joints in relation to each other, i.e., with the hip, knee and foot well aligned.<ref>Glad Australia NEMEX-TJR training program Available:https://gladaustralia.com.au/wp-content/uploads/2018/09/Ageberg-et-al-Appendix-Feasibility-NEMEX-TJR-2010.pdf (accessed 26.11.2022)</ref>
{{#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>


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.
==  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.
==== '''Principles of Neuromuscular Exercises'''<ref name=":0" /> ====
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 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.
Neuromuscular exercise:


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.
* 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>. 
* 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>


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 efficiency and quality of movements of each exercise.
====Mechanisms for Sensorimotor Deficiency ====
Sensorimotor dysfunctions 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>.


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.<ref>Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.[https://journals.lww.com/acsm-essr/Fulltext/2015/01000/Neuromuscular_Exercise_as_Treatment_of.5.aspx]</ref>
Impairments are present at different levels of the sensorimotor system from:  


== Resources ==
# [[Sensation|Sensory]] input, integration and processing of information in the central nervous system
* https://www.glaid.dk/english.html
# Motor output (vital to perform voluntary movements and maintain postural control)
* https://gladaustralia.com.au/
# 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>
* http://nemex.trekeducation.org/
# 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.


== References  ==
== References  ==


<references />
<references />
[[Category:Exercise Therapy]]
[[Category:Rehabilitation Protocols]]
[[Category:Rehabilitation]]
[[Category:Knee - Conditions]]
[[Category:Knee - Interventions]]
[[Category:Hip - Conditions]]
[[Category:Hip - Interventions]]

Latest revision as of 02:27, 26 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. In patients with mild to severe pain with activity, the NEMEX is program feasible. The jumping activities however were deemed not feasible in 2017 clinical trial.[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.
  • The GLA:D program is an eight week program that includes education and exercise. 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.

This 3 minute video outlines the NEMEX program. In summary

  • Training occurs groups, with an experienced physical therapist supervising
  • Consists of three parts: warming up, a circuit program, and cooling down
  • Training session are 60 minutes long.
  • The movement quality in each exercise is important, with an appropriate position of the joints in relation to each other, i.e., with the hip, knee and foot well aligned.[3]

[4]

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[5]. 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.[5]
  • Has effects on functional performance, biomechanics, and muscle activation patterns of the surrounding joint musculature[6].
  • Address the lag in neuromuscular reaction time that results in dynamic joint instability with recurrent episodes of joint subluxation and deterioration.[7]

Mechanisms for Sensorimotor Deficiency[edit | edit source]

Sensorimotor dysfunctions may play a role in the development and progression of degenerative joint disease[8].

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.

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. ↑ Glad Australia NEMEX-TJR training program Available:https://gladaustralia.com.au/wp-content/uploads/2018/09/Ageberg-et-al-Appendix-Feasibility-NEMEX-TJR-2010.pdf (accessed 26.11.2022)
  4. ↑ Target Physio GLA:D Hip and Knee Osteoarthritis Info Video Available:https://www.youtube.com/watch?v=-Xkiad0x7_I(accessed 28.5.2022)
  5. ↑ 5.0 5.1 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.
  6. ↑ 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).
  7. ↑ 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.
  8. ↑ Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.
  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.
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