PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (1161581)

Clipboard (0)
None

Related Articles

1.  Contribution of Hamstring Fatigue to Quadriceps Inhibition Following Lumbar Extension Exercise 
The purpose of this study was to determine the contribution of hamstrings and quadriceps fatigue to quadriceps inhibition following lumbar extension exercise. Regression models were calculated consisting of the outcome variable: quadriceps inhibition and predictor variables: change in EMG median frequency in the quadriceps and hamstrings during lumbar fatiguing exercise. Twenty-five subjects with a history of low back pain were matched by gender, height and mass to 25 healthy controls. Subjects performed two sets of fatiguing isometric lumbar extension exercise until mild (set 1) and moderate (set 2) fatigue of the lumbar paraspinals. Quadriceps and hamstring EMG median frequency were measured while subjects performed fatiguing exercise. A burst of electrical stimuli was superimposed while subjects performed an isometric maximal quadriceps contraction to estimate quadriceps inhibition after each exercise set. Results indicate the change in hamstring median frequency explained variance in quadriceps inhibition following the exercise sets in the history of low back pain group only. Change in quadriceps median frequency explained variance in quadriceps inhibition following the first exercise set in the control group only. In conclusion, persons with a history of low back pain whose quadriceps become inhibited following lumbar paraspinal exercise may be adapting to the fatigue by using their hamstring muscles more than controls.
Key PointsA neuromuscular relationship between the lumbar paraspinals and quadriceps while performing lumbar extension exercise may be influenced by hamstring muscle fatigue.QI following lumbar extension exercise in persons with a history of LBP group may involve significant contribution from the hamstring muscle group.More hamstring muscle contribution may be a necessary adaptation in the history of LBP group due to weaker and more fatigable lumbar extensors.
PMCID: PMC3818676  PMID: 24198683
Superimposed burst technique; electromyography; spectral median frequency; correlation and regression; low back pain
2.  Reduced Quadriceps Activation After Lumbar Paraspinal Fatiguing Exercise 
Journal of Athletic Training  2006;41(1):79-86.
Context: Although poor paraspinal muscle endurance has been associated with less quadriceps activation (QA) in persons with a history of low back pain, no authors have addressed the acute neuromuscular response after lumbar paraspinal fatiguing exercise.
Objective: To compare QA after lumbar paraspinal fatiguing exercise in healthy individuals and those with a history of low back pain.
Design: A 2 × 4 repeated-measures, time-series design.
Setting: Exercise and Sport Injury Laboratory.
Patients or Other Participants: Sixteen volunteers participated (9 males, 7 females; 8 controls and 8 with a history of low back pain; age = 24.1 ± 3.1 years, height = 173.4 ± 7.1 cm, mass = 72.4 ± 12.1 kg).
Intervention(s): Subjects performed 3 sets of isometric lumbar paraspinal fatiguing muscle contractions. Exercise sets continued until the desired shift in lumbar paraspinal electromyographic median power frequency was observed. Baseline QA was compared with QA after each exercise set.
Main Outcome Measure(s): An electric burst was superimposed while subjects performed a maximal quadriceps contraction. We used the central activation ratio to calculate QA = (FMVIC/[FMVIC + FBurst])* 100, where F = force and MVIC = maximal voluntary isometric contractions. Quadriceps electromyographic activity was collected at the same time as QA measurements to permit calculation of median frequency during MVIC.
Results: Average QA decreased from baseline (87.4% ± 8.2%) after the first (84.5% ± 10.5%), second (81.4% ± 11.0%), and third (78.2% ± 12.7%) fatiguing exercise sets. On average, the group with a history of low back pain showed significantly more QA than controls. No significant change in quadriceps median frequency was noted during the quadriceps MVICs.
Conclusions: The quadriceps muscle group was inhibited after lumbar paraspinal fatiguing exercise in the absence of quadriceps fatigue. This effect may be different for people with a history of low back pain compared with healthy controls.
PMCID: PMC1421484  PMID: 16619099
superimposed burst technique; quadriceps muscle inhibition; low back pain
3.  INFLUENCE OF PATTERNED ELECTRICAL NEUROMUSCULAR STIMULATION ON QUADRICEPS ACTIVATION IN INDIVIDUALS WITH KNEE JOINT INJURY 
Background:
Neuromuscular Electrical Stimulation is a common intervention to address muscle weakness, however presents with many limitations such as fatigue, muscle damage, and patient discomfort that may influence its effectiveness. One novel form of electrical stimulation purported to improve neuromuscular re‐education is Patterned Electrical Neuromuscular Stimulation (PENS), which is proposed to mimic muscle‐firing patterns of healthy individuals. PENS provides patterned stimulating to the agonist muscle, antagonist muscle and then agonist muscle again in an effort to replicate firing patterns.
Purpose:
The purpose of this study was to determine the effect of a single PENS treatment on knee extension torque and quadriceps activation in individuals with quadriceps inhibition.
Methods:
18 subjects (10 males and 8 females: 24.2±3.4 years, 175.3±11.8cm, 81.8±12.4kg) with a history of knee injury/pain participated in this double‐blinded randomized controlled laboratory trial. Participants demonstrated quadriceps inhibition with a central activation ratio of ≤90%. Maximal voluntary isometric contraction of the quadriceps and central activation ratio were measured before and after treatment. The treatment intervention was a 15‐minute patterned electrical stimulation applied to the quadriceps and hamstring muscles with a strong motor contraction or a sham group, who received an identical set up as the PENS group, but received a 1mA subsensory stimulation. A 2×2 (group × time) ANCOVA was used to determine differences in maximal voluntary isometric contraction and central activation ratio between groups. The maximal voluntary isometric contraction was selected as a covariate due to baseline differences.
Results:
There were no differences in change scores between pre‐ and post‐intervention for maximal voluntary isometric contraction: (PENS: 0.09±0.32Nm/kg and Sham 0.15±0.18Nm/kg, p=0.713), or central activation ratio:(PENS: ‐1.22±6.06 and Sham: 1.48±3.7, p=0.270).
Conclusions:
A single Patterned Electrical Neuromuscular Stimulation treatment did not alter quadriceps central activation ratio or maximal voluntary isometric contraction. Unlike other types of muscle stimulation, PENS did not result in a reduction of quadriceps torque.
Level of Evidence:
Level III
PMCID: PMC4275196  PMID: 25540707
Electrical stimulation; muscle inhibition; quadriceps torque
4.  Lumbopelvic Joint Manipulation and Quadriceps Activation of People With Patellofemoral Pain Syndrome 
Journal of Athletic Training  2012;47(1):24-31.
Context:
Quadriceps weakness and inhibition are impairments associated with patellofemoral pain syndrome (PFPS). Lumbopelvic joint manipulation has been shown to improve quadriceps force output and inhibition, but the duration of the effect is unknown.
Objective:
To determine whether quadriceps strength and activation are increased and maintained for 1 hour after high-grade or low-grade joint mobilization or manipulation applied at the lumbopelvic region in people with PFPS.
Design:
Randomized controlled clinical trial.
Setting:
University laboratory.
Patients or Other Participants:
Forty-eight people with PFPS (age = 24.6±8.9 years, height = 174.3 ± 11.2 cm, mass = 78.4 ± 16.8 kg) participated.
Intervention(s):
Participants were randomized to 1 of 3 groups: lumbopelvic joint manipulation (grade V), side-lying lumbar midrange flexion and extension passive range of motion (grade II) for 1 minute, or prone extension on the elbows for 3 minutes.
Main Outcome Measure(s):
Quadriceps force and activation were measured using the burst superimposition technique during a seated isometric knee extension task. A 2-way repeated-measures analysis of variance was performed to compare changes in quadriceps force and activation among groups over time (before intervention and at 0, 20, 40, and 60 minutes after intervention).
Results:
We found no differences in quadriceps force output (F5,33,101,18 = 0.65, P = .67) or central activation ratio (F4.84,92.03 = 0.38, P= .86) values among groups after intervention. When groups were pooled, we found differences across time for quadriceps force (F2.66,101.18 = 5.03, P = .004) and activation (F2.42,92.03 = 3.85, P = .02). Quadriceps force was not different at 0 minutes after intervention (t40 = 1.68, P = .10), but it decreased at 20 (t40 = 2.16, P = .04), 40 (t40 = 2.87, P = .01) and 60 (t40 = 3.04, P = .004) minutes after intervention. All groups demonstrated decreased quadriceps activation at 0 minutes after intervention (t40 = 4.17, P <.001), but subsequent measures were not different from preintervention levels (t40 range, 1.53–1.83, P >.09).
Conclusions:
Interventions directed at the lumbopelvic region did not have immediate effects on quadriceps force output or activation. Muscle fatigue might have contributed to decreased force output and activation over 1 hour of testing.
PMCID: PMC3418111  PMID: 22488227
force output; knee pain; manual therapy; muscle activation
5.  Jogging Kinematics After Lumbar Paraspinal Muscle Fatigue 
Journal of Athletic Training  2009;44(5):475-481.
Abstract
Context:
Isolated lumbar paraspinal muscle fatigue causes lower extremity and postural control deficits.
Objective:
To describe the change in body position during gait after fatiguing lumbar extension exercises in persons with recurrent episodes of low back pain compared with healthy controls.
Design:
Case-control study.
Setting:
Motion analysis laboratory.
Patients or Other Participants:
Twenty-five recreationally active participants with a history of recurrent episodes of low back pain, matched by sex, height, and mass with 25 healthy controls.
Intervention(s):
We measured 3-dimensional lower extremity and trunk kinematics before and after fatiguing isometric lumbar paraspinal exercise.
Main Outcome Measure(s):
Measurements were taken while participants jogged on a custom-built treadmill surrounded by a 10-camera motion analysis system.
Results:
Group-by-time interactions were observed for lumbar lordosis and trunk angles (P < .05). A reduced lumbar spine extension angle was noted, reflecting a loss of lordosis and an increase in trunk flexion angle, indicating increased forward trunk lean, in healthy controls after fatiguing lumbar extension exercise. In contrast, persons with a history of recurrent low back pain exhibited a slight increase in spine extension, indicating a slightly more lordotic position of the lumbar spine, and a decrease in trunk flexion angles after fatiguing exercise. Regardless of group, participants experienced, on average, greater peak hip extension after lumbar paraspinal fatigue.
Conclusions:
Small differences in response may represent a necessary adaptation used by persons with recurrent low back pain to preserve gait function by stabilizing the spine and preventing inappropriate trunk and lumbar spine positioning.
doi:10.4085/1062-6050-44.5.475
PMCID: PMC2742456  PMID: 19771285
gait analysis; spine
6.  EMG analysis of lumbar paraspinal muscles as a predictor of the risk of low-back pain 
European Spine Journal  2010;19(7):1145-1152.
Studies of EMG power spectra have established associations between low-back pain (LBP) and median frequency (MF). This 2-year prospective study investigates the association of LBP with EMG variables over time. 120 health care workers underwent paraspinal EMG measurements and assessment of back pain disability. The EMG recordings were performed under isometric trunk extension at 2/3 maximum voluntary contraction and acquired from erector spinae muscles at the level of L4/L5. 108 (90%) subjects were reviewed at a minimum 2-year follow up. 16 out of 93 subjects with no history of chronic low-back pain became worse as measured by time off work, disability, reported pain and self-assessment rating. The value of the EMG variable half-width at inception demonstrated significant association with changes in subject’s outcome measure and their own assessment of their LBP at follow up (p < 0.05). Based on self-assessment data, subjects with no history of chronic LBP with half-width of greater than 56 Hz were at threefold greater risk of developing back pain compared with the remainder of the population (p = 0.045). The value of the initial median frequency (IMF) and MF slope at inception were also associated with the subjects’ own assessment of LBP at follow up. Subjects with an IMF greater than 49 Hz were at 5.8-fold greater risk of developing back pain compared with the remainder of the population (p = 0.014). EMG variables recorded from lumbar paraspinal muscles can identify a sub group of subjects at increased risk of developing low-back pain in the future.
doi:10.1007/s00586-010-1277-1
PMCID: PMC2900021  PMID: 20127260
EMG; Low back pain; Paraspinal muscles; Prediction; Cohort study
7.  Comparison of Active and Electrostimulated Recovery Strategies After Fatiguing Exercise 
The purpose of this study was to compare an electrostimulated to an active recovery strategy after a submaximal isometric fatiguing exercise. Nineteen healthy men completed three sessions (separated by at least 4 weeks) which included a knee extensors provocation exercise consisting of 3 sets of 25 isometric contractions. Contraction intensity level was fixed respectively at 60%, 55% and 50% of previously determined maximal voluntary contraction for the first, second and third sets. This provocation exercise was followed by either an active (AR) recovery (25 min pedaling on a cycle ergometer), an electrostimulated (ESR) recovery (25-min continuous and non-tetanic (5 Hz) stimulation of the quadriceps) or a strictly passive recovery (PR). Peak torques of knee extensors and subjective perception of muscle pain (VAS, 0-10) were evaluated before (pre-ex), immediately after the provocation exercise (post-ex), after the recovery period (post-rec), as well as 75 minutes (1h15) and one day (24h) after the exercise bout. Time course of peak torque was similar among the different recovery modes: ~ 75% of initial values at post-ex, ~ 90% at post-rec and at 1h15. At 24h, peak torque reached a level close to baseline values (PR: 99.1 ± 10.7%, AR: 105.3 ± 12.2%, ESR: 104.4 ± 10.5%). VAS muscle pain scores decreased rapidly between post-ex and post-rec (p < 0.001); there were no significant differences between the three recovery modes (p = 0.64). In conclusion, following a submaximal isometric knee extension exercise, neither electrostimulated nor active recovery strategies significantly improved the time course of muscle function recovery.
Key pointsThree sets of submaximal isometric contractions at 60%, 55% and 50% of MVC induced an early fatigue without DOMS but did not lead to exhaustion.In comparison with passive recovery, active and electrostimulated recovery did not lead to significantly higher MVC torques 24h after the exercise bout.No significant differences were demonstrated between the effects of passive, active and electrostimulated recoveries on muscle pain after repeated submaximal isometric contractions.
PMCID: PMC3761726  PMID: 24149681
Electrical stimulation; muscle recovery; isometric contraction; muscle fatigue
8.  Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain 
Annals of Rehabilitation Medicine  2013;37(1):110-117.
Objective
To compare the effects of lumbar stabilization exercises and lumbar dynamic strengthening exercises on the maximal isometric strength of the lumbar extensors, pain severity and functional disability in patients with chronic low back pain (LBP).
Methods
Patients suffering nonspecific LBP for more than 3 months were included prospectively and randomized into lumbar stabilization exercise group (n=11) or lumbar dynamic strengthening exercise group (n=10). Exercises were performed for 1 hour, twice weekly, for 8 weeks. The strength of the lumbar extensors was measured at various angles ranging from 0° to 72° at intervals of 12°, using a MedX. The visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ) were used to measure the severity of LBP and functional disability before and after the exercise.
Results
Compared with the baseline, lumbar extension strength at all angles improved significantly in both groups after 8 weeks. The improvements were significantly greater in the lumbar stabilization exercise group at 0° and 12° of lumbar flexion. VAS decreased significantly after treatment; however, the changes were not significantly different between the groups. ODQ scores improved significantly in the stabilization exercise group only.
Conclusion
Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP. However, the lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP.
doi:10.5535/arm.2013.37.1.110
PMCID: PMC3604220  PMID: 23525973
Exercise; Low back pain; Muscle strength; Abdominal muscle; Rehabilitation
9.  The Protonics Knee Brace Unloads the Quadriceps Muscles in Healthy Subjects 
Journal of Athletic Training  2004;39(1):44-49.
Objective:
The Protonics brace is a functional resistance brace designed for rehabilitative use in patients with patellofemoral pain syndrome. Our objective was to determine whether the Protonics brace altered quadriceps muscle activity or knee mechanics in healthy subjects.
Design and Setting:
We used a within-subjects design in a laboratory setting.
Subjects:
Nineteen recreationally active college students (10 females, 9 males; age = 22.6 ± 2.8 years; height = 172 ± 9.0 cm, mass = 69.7 ± 12.5 kg) with no history of patellofemoral pain syndrome.
Measurements:
A standard-length Protonics brace was fit to each subject's leg. Surface electromyography of the vastus medialis obliquus, vastus lateralis, and rectus femoris muscles was recorded during a lateral step-down exercise. Lower extremity kinematics and ground reaction force were assessed during stair descent. Subjects performed both tasks under 4 conditions: no brace and brace with low, medium, and high resistance. Electromyography values were normalized to a maximum voluntary isometric contraction. The brace moment was determined by passive testing in an isokinetic dynamometer. Changes in the subject's muscular knee-extension moment were determined by subtracting the extension moment provided by the brace from the total knee-extension moment calculated from motion and force data using an inverse dynamics approach.
Results:
Vastus medialis obliquus activity in the brace at the low- and medium-resistance settings was significantly lower than that measured without the brace. Vastus lateralis activity while wearing the brace at medium resistance was significantly less than in the absence of the brace. Regardless of brace setting, vastus medialis obliquus and vastus lateralis activity in the descending phase of the exercise was less than during the ascending phase. A significant interaction was noted between brace setting and phase of the step-down exercise for rectus femoris activity. Significantly less activity was seen in the descending phase than in the ascending phase. Post hoc testing indicated that, in the descending phase, less activity was demonstrated with the brace at the medium and high settings than at the low setting. Muscle activity at the high setting and activity at low resistance were also significantly less than when the brace was not worn in the ascending phase. Knee flexion and extension moment during stair descent were significantly less at the higher resistance settings.
Conclusions:
Wearing the Protonics brace at moderate or high resistance during the lateral step-down exercise produced less quadriceps activity compared with not wearing the brace. The knee extensor mechanism was unloaded when the brace was worn during stair descent. These findings indicate that the Protonics brace may unload the quadriceps and therefore decrease the load on the patellofemoral joint.
PMCID: PMC385261  PMID: 15085211
patellofemoral pain; knee; unloading
10.  Quadriceps Fatigue Alters Human Muscle Performance during a Novel Weight Bearing Task 
Limited information is currently available regarding muscle synergistic patterns and triggered reflex responses during dynamic weight bearing activities in the presence of muscle fatigue.
Purpose
The purpose of this study was to examine the effects of quadriceps muscle fatigue on patterns of muscle activation and performance in response to sudden, unexpected perturbations during a weight-bearing task.
Methods
Motion of the knee was measured as subjects were asked to track a visual target as accurately as possible while performing a resisted single leg squat task. Random perturbations were delivered in 20% of the trials by unexpectedly releasing the resistance during the flexion phase of the exercise. Absolute and constant errors were calculated to evaluate target tracking performance. Quadriceps and hamstring muscle activity was recorded during both perturbed and unperturbed trials. Twelve healthy females were tested before and after completing a repetitive submaximal eccentric quadriceps fatigue protocol. A second group of 12 females served as controls. Unexpected perturbations elicited long latency responses characterized by facilitation of the quadriceps and inhibition of the hamstrings.
Results
Muscle fatigue increased the amplitude of the long latency response in vastus lateralis by 4.3% maximum voluntary isometric contraction (p=.004). Changes in tracking error occurred in response to perturbations after fatigue in spite of significantly increased quadriceps muscle activity, especially during the extension phase of the exercise.
Conclusion
Quadriceps muscle fatigue alters the patterns of coordinated muscle activity and may render subjects less able to cope with unexpected perturbations during weight bearing tasks.
doi:10.1249/MSS.0b013e3181d85527
PMCID: PMC2924940  PMID: 20164810
long latency responses; muscle activation; perturbation; eccentric exercise
11.  Effect of Differing Intensities of Fatiguing Dynamic Contractions on Contralateral Homologous Muscle Performance 
The purpose of this study was to investigate different intensities of unilateral fatiguing dynamic quadriceps contractions on non-exercised, contralateral quadriceps performance. In a randomized crossover study design with 12 recreationally trained male (1.78 ± 0.05 m, 84.5 ± 7.6 kg, 30.0 ± 8.5 yrs) participants, maximal voluntary contraction (MVC) force, force developed in the first 100 ms (F100), and electromyography of the non-exercised contralateral knee extensors were measured before and after fatiguing protocols performed by ipsilateral knee extensors. Non-exercised knee extensors’ endurance was also measured post-intervention. The fatigue protocols consisted of four sets of dynamic knee extensions each to task failure with 40% and 70% MVC on separate days. Both the 40% (p = 0.009, Effect Size [ES] = 0.72) and 70% (p = 0.001, ES = 2.03) conditions exhibited 23.7% and 34.6% decreases in F100 respectively with the non-exercised contralateral knee extensors. A significant time effect (p = 0.002) demonstrated that both the 40% (and 70% (conditions exhibited 4.4% (ES = 0.29) and 7.1% (ES = 0.53) force decreases from pre- to post-intervention, respectively. However, the condition * time interaction only showed a trend (p = 0.09) with moderate (40%: ES = 0.62) to large (70%: ES = 0.82) effect sizes for decreased contralateral limb force compared with control session. The 40% (p = 0.09, ES = 0.65) and 70% (p = 0.07, ES = 0.79) protocols had a tendency to induce greater contralateral force variation during sustained submaximal isometric contraction compared with control. In conclusion, this study highlighted that unilateral lower limb fatigue induced by low intensity as well as high intensity dynamic knee extensions provided some evidence of crossover fatigue with the contralateral non-exercised limb.
Key PointsThere was a pattern of crossover fatigue effects with significant impairments in F100, near significant, moderate to large magnitude decrements in MVC force and moderate magnitude increases in submaximal force variability in the contralateral knee extensors.Although both contraction intensities resulted in significant and near significant F100 and force decrements respectively, higher intensity (70%) fatiguing contractions manifested moderate to large magnitude effects (force and F100 respectively) compared to small to moderate magnitude effects (F100 and force respectively) for the lower intensity (40%) fatiguing contractions.
PMCID: PMC4234954  PMID: 25435777
Central fatigue; peripheral fatigue; maximal voluntary contraction; dynamic contractions; electromyography
12.  Neuromuscular Fatigue During a Modified Biering-Sørensen Test in Subjects with and Without Low Back Pain 
Studies employing modified Biering-Sørenson tests have reported that low back endurance is related to the potential for developing low back pain. Understanding the manner in which spinal musculature fatigues in people with and without LBP is necessary to gain insight into the sensitivity of the modified Biering-Sørenson test to differentiate back health. Twenty male volunteers were divided into a LBP group of subjects with current subacute or a history of LBP that limited their activity (n = 10) and a control group (n = 10). The median frequency of the fast Fourier transform was calculated from bilateral surface electromyography (EMG) of the upper lumbar erector spinae (ULES), lower lumbar erector spinae (LLES) and biceps femoris while maintaining a prescribed modified Biering-Sørensen test position and exerting isometric forces equivalent to 100, 120, 140 and 160% of the estimated mass of the head-arms-trunk (HAT) segment. Time to failure was also investigated across the percentages of HAT. Fatigue time decreased with increasing load and differences between groups increased as load increased, however these differences were not significant. Significant differences in the EMG median frequency between groups occurred in the right biceps femoris (p ≤ 0.05) with significant pairwise differences occurring at 140% for the left biceps femoris and at 160% for the right biceps femoris. There were significant pairwise differences at 120% for average EMG of the right biceps femoris and at 140% for the right ULES, and right and left biceps femoris (p ≤ 0.05). The modified Biering-Sørensen test as usually performed at 100% HAT is not sufficient to demonstrate significant differences between controls and subjects with varying degrees of mild back disability based on the Oswestry classification.
Key pointsThe results do not wholly support the modified Biering-Sørensen test utilizing resistance of 100% HAT to discern differences in fatigue in subjects with mild low back pain.A greater activation of the biceps femoris by low back pain individuals probably contributed to the lack of significant differences in back fatigue times.The possibility exists that subjects with more sophisticated strategies could yield higher fatigue times despite inferior neuromuscular fatigue and the existence of low back pain.
PMCID: PMC3794498  PMID: 24149491
Endurance; electromyography; median frequency; back muscles; healthy subjects
13.  Low frequency fatigue in human quadriceps is fatigue dependent and not task dependent 
It is well accepted that a low intensity/long duration isometric contraction induces more low frequency fatigue (LFF) compared to a high-intensity/short-duration contraction. However, previous reports examined the intensity/duration of the contraction but did not control the level of fatigue when concluding fatigue is task dependent. The purpose of this study was to determine whether a long duration/low intensity fatiguing contraction would induce greater LFF than a short duration/high-intensity contraction when the quadriceps muscle was fatigued to similar levels. Eighteen healthy male subjects performed quadriceps contractions sustained at 35% and 65% of maximal voluntary contraction (MVC) on separate days, until the tasks induced a similar amount of fatigue (force generating capacity = 45% MVC). Double pulse torque to single pulse torque ratio (D/S ratio) was obtained before, immediately and 5 min after fatigue along with the electromyographic (EMG) signal from vastus medialis (VM) and rectus femoris (RF). The D/S ratio significantly (p < 0.05) increased by 8.7 ± 8.5% (mean ± SD) and 10.2 ± 9.2% after 35% and 65% tasks, respectively, and remained elevated 5 min into recovery; however, there was no significant difference in ratio between the two sessions immediately or 5 min post-fatigue (p > 0.05) even though the endurance time for the 35% fatigue task (124 ± 39.68 s) was significantly longer (p = 0.05) than that of the 65% task (63 ± 17.73 s). EMG amplitude and median power frequency (MPF) analysis also did not reveal any significant differences between these two sessions after fatigue. These findings indicate that LFF fatigue is fatigue dependent as well as task intensity/duration dependent. These findings assist us in understanding task dependency and muscle fatigue.
doi:10.1016/j.jelekin.2006.09.010
PMCID: PMC2963071  PMID: 17157533
Task dependency; Equivalent fatigue; Double/single ratio; Excitation–contraction coupling; Electrical stimulation
14.  Quadriceps Function After Exercise in Patients with Anterior Cruciate Ligament–Reconstructed Knees Wearing Knee Braces 
Journal of Athletic Training  2011;46(6):615-620.
Context:
Knee braces and neoprene sleeves are commonly worn by people with anterior cruciate ligament reconstructions (ACLRs) during athletic activity. How knee braces and sleeves affect muscle activation in people with ACLRs is unclear.
Purpose:
To determine the effects of knee braces and neoprene knee sleeves on the quadriceps central activation ratio (CAR) before and after aerobic exercise in people with ACLRs.
Design:
Crossover study.
Patients or Other Participants:
Fourteen people with a history of ACLR (9 women, 5 men: age = 23.61 ± 4.44 years, height = 174.09 ± 9.82 cm, mass = 75.35 ± 17.48 kg, months since ACLR = 40.62 ± 20.41).
Intervention(s):
During each of 3 sessions, participants performed a standardized aerobic exercise protocol on a treadmill. The independent variables were condition (brace, sleeve, or control) and time (baseline, pre-exercise with brace, postexercise with brace, postexercise without brace).
Main Outcome Measure(s):
Normalized torque measured during a maximal voluntary isometric contraction (TMVIC) and CAR were measured by a blinded assessor using the superimposed burst technique. The CAR was expressed as a percentage of full muscle activation. The quadriceps CAR and TMVIC were measured 4 times during each session: baseline, pre-exercise with brace, postexercise with brace, and postexercise without brace.
Results:
Immediately after the application of the knee brace, TMVIC decreased (P = .01), but no differences between bracing conditions were observed. We noted reduced TMVIC and CAR (P < .001) after exercise, both with and without the brace. No differences were seen between bracing conditions after aerobic exercise.
Conclusions:
The decrease in TMVIC immediately after brace application was not accompanied by differences between bracing conditions. Wearing a knee brace or neoprene sleeve did not seem to affect the deterioration of quadriceps function after aerobic exercise.
PMCID: PMC3418938  PMID: 22488186
neuromuscular function; aerobic exercise; central activation ratio
15.  Effect of eccentric exercise-induced muscle damage on electromyographyic activity of quadriceps in untrained healthy females 
Background: The aim of this study was to investigate muscle damage indicators and electromyography activities of quadriceps muscles at 25° of hip flexion in untrained healthy females after an eccentric exercise induced muscle fiber damage.
Methods: A total of 14 healthy females participated in this pre-experimental study. The subjects performed maximal eccentric quadriceps contractions at 25˚ of hip flexion. Maximum voluntary extensor isometric and concentric moments, angle of maximum moment for concentric contractions, perceived pain intensity, and pain pressure threshold were examined before, immediately, 48 hours, 120 hours and 14 days after eccentric exercise. Additionally, electromyography of three parts of quadriceps muscle, knee flexion range of motion and thigh circumference were measured before and after eccentric exercise.
Results: Significant reductions in maximum isometric moment and maximum concentric moment were observed at angular velocity of 60˚ per sec immediately after eccentric exercise (p<0.05). Both maximum isometric moment and maximum concentric moment recovered to the baseline 48 hours after eccentric exercise. Increased pain intensity and decreased knee joint range of motion manifested 48 hours after eccentric exercise. Pain pressure threshold for the quadriceps was higher 14 days after exercise as compared to 48 and 120 hours (p<0.05). No significant changes observed in electromyography and thigh circumference (p>0.05).
Conclusion: Eccentric exercise performed at 25˚ of hip flexion resulted in muscle fiber injuries within the quadriceps muscle. However, electromyography of quadriceps muscle was not significantly different than the baseline. The result indicates that hip joint position may modify the effect of eccentric exercise on muscle activation.
PMCID: PMC4322328
Muscles; electromyography; hip; muscle soreness; exercise
16.  Eccentric exercise and delayed onset muscle soreness of the quadriceps induce adjustments in agonist–antagonist activity, which are dependent on the motor task 
This study investigates the effects of eccentric exercise and delayed onset muscle soreness (DOMS) of the quadriceps on agonist–antagonist activity during a range of motor tasks. Ten healthy volunteers (age, mean ± SD, 24.9 ± 3.2 years) performed maximum voluntary contractions (MVC) and explosive isometric contractions of the knee extensors followed by isometric contractions at 2.5, 5, 10, 15, 20, and 30% MVC at baseline, immediately after and 24 h after eccentric exercise of the quadriceps. During each task, force of the knee extensors and surface EMG of the vasti and hamstrings muscles were recorded concurrently. Rate of force development (RFD) was computed from the explosive isometric contraction, and the coefficient of variation of the force (CoV) signal was estimated from the submaximal contractions. Twenty-four hours after exercise, the subjects rated their perceived pain intensity as 4.1 ± 1.2 (score out of 10). The maximum RFD and MVC of the knee extensors was reduced immediately post- and 24 h after eccentric exercise compared to baseline (average across both time points: 19.1 ± 17.1% and 11.9 ± 9.8% lower, respectively, P < 0.05). The CoV for force during the submaximal contractions was greater immediately after eccentric exercise (up to 66% higher than baseline, P < 0.001) and remained higher 24 h post-exercise during the presence of DOMS (P < 0.01). For the explosive and MVC tasks, the EMG amplitude of the vasti muscles decreased immediately after exercise and was accompanied by increased antagonist EMG for the explosive contraction only. On the contrary, reduced force steadiness was accompanied by a general increase in EMG amplitude of the vasti muscles and was accompanied by increased antagonist activity, but only at higher force levels (>15% MVC). This study shows that eccentric exercise and subsequent DOMS of the quadriceps reduce the maximal force, rate of force development and force steadiness of the knee extensors, and is accompanied by different adjustments of agonist and antagonist muscle activities.
doi:10.1007/s00221-011-2942-2
PMCID: PMC3262141  PMID: 22094715
Delayed onset muscle soreness; Eccentric exercise; Muscle damage
17.  Central and peripheral quadriceps fatigue in congestive heart failure☆ 
International Journal of Cardiology  2013;167(6):2594-2599.
Aims
The clinical syndrome of heart failure includes exercise limitation that is not directly linked to measures of cardiac function. Quadriceps fatigability may be an important component of this and this may arise from peripheral or central factors.
Methods and results
We studied 10 men with CHF and 10 healthy age-matched controls. Compared with a rest condition, 10 min after incremental maximal cycle exercise, twitch quadriceps force in response to supramaximal magnetic femoral nerve stimulation fell in both groups (CHF 14.1% ± 18.1%, p = 0.037; Control: 20.8 ± 11.0%, p < 0.001; no significant difference between groups). There was no significant change in quadriceps maximum voluntary contraction voluntary force. The difference in the motor evoked potential (MEP) response to transcranial magnetic stimulation of the motor cortex between rest and exercise conditions at 10 min, normalised to the peripheral action potential, also fell significantly in both groups (CHF: 27.3 ± 38.7%, p = 0.037; Control: 41.1 ± 47.7%, p = 0.024). However, the fall in MEP was sustained for a longer period in controls than in patients (p = 0.048).
Conclusions
The quadriceps is more susceptible to fatigue, with a similar fall in TwQ occurring in CHF patients at lower levels of exercise. This is associated with no change in voluntary activation but a lesser degree of depression of quadriceps motor evoked potential.
doi:10.1016/j.ijcard.2012.06.064
PMCID: PMC3776927  PMID: 22795722
Brain; Exercise; Muscles; Transcranial magnetic stimulation
18.  Dehydration and Symptoms of Delayed-Onset Muscle Soreness in Hyperthermic Males 
Journal of Athletic Training  2005;40(4):288-297.
Context: Exercise in the heat produces cellular conditions that may leave skeletal muscle susceptible to exercise-induced microdamage. Delayed-onset muscle soreness (DOMS) is a clinical model of contraction-induced skeletal muscle injury.
Objective: To determine whether thermoregulation during exercise heat stress adversely affects muscle injury and the accompanying DOMS.
Design: Randomized group test-retest design.
Setting: Laboratory.
Patients or Other Participants: Ten healthy male volunteers were randomly assigned to either the euhydration/hyperthermic or dehydration/hyperthermic group.
Intervention(s): Participants were randomly assigned to treadmill walking in a hot, humid environmental chamber (40°C and 75% relative humidity) with either oral rehydration (euhydration/hyperthermic) or fluid restriction (dehydration/hyperthermic). Immediately after heat exposure and while hyperthermic, participants performed an eccentrically biased downhill run to induce DOMS.
Main Outcome Measure(s): We measured DOMS characteristics pre-exercise and at 0.5, 24, 48, 72, and 96 hours postexercise.
Results: Treadmill exercise and exposure to the hot ambient environment elicited a 0.9% body mass loss for the euhydrated/ hyperthermic (mean rectal temperature after 60 minutes of heat-stress trial = 38.2 ± 0.4°C) and 3.3% body mass loss for the dehydrated/hyperthermic participants (mean rectal temperature after 60 minutes of heat-stress trial = 38.1 ± 0.4°C). Quadriceps perceived pain was significantly higher (F5,40 = 18.717, P ≤ .001) than baseline at 24 and 48 hours postexercise, following the classic pattern of DOMS. Overall lower extremity perceived pain was significantly higher for the dehydration/hyperthermia group than the euhydration/hyperthermia group (F1,8 = 6.713, P = .032). Punctate tenderness of the vastus lateralis for the dehydration/hyperthermic group was 6.9% higher (F5,40 = 4.462, P = .003) than for the euhydration/ hyperthermic group. No clinically important findings were revealed for passive range of motion for knee flexion. For both groups, quadriceps isometric strength (F5,40 = 12.924, P ≤ .001) was 17.5% and 20.0% lower at 0.5 hours postexercise than at 72 and 96 hours postexercise, respectively. Further, quadriceps isometric strength remained 10.5% reduced at 24 hours postexercise compared with 96 hours postexercise.
Conclusions: Skeletal muscle microdamage, indirectly evidenced by DOMS, was exacerbated in hyperthermic participants dehydrated by exercise in a hot ambient environment. Individuals performing novel exercise, particularly with a significant eccentric component, should use caution when training in a hot, humid environment and implement frequent rest and rehydration breaks.
PMCID: PMC1323290  PMID: 16404450
heat stress; thermal physiology; isometric strength; pain; downhill running
19.  LUMBAR MANIPULATION AND EXERCISE IN THE MANAGEMENT OF ANTERIOR KNEE PAIN AND DIMINISHED QUADRICEPS ACTIVATION FOLLOWING ACL RECONSTRUCTION: A CASE REPORT 
Background and Purpose:
Quadriceps weakness is a common finding following knee injuries or surgery, and can be associated with significant functional limitations. This weakness or muscle inhibition may be due to central inhibitory mechanisms, rather than local peripheral dysfunction. Lumbopelvic manipulation has been shown to effect efferent muscle output by altering nociceptive processing. The purpose of this report is to describe the physical therapy management of anterior knee pain and chronic quadriceps weakness utilizing side‐lying rotational lumbar thrust manipulation and therapeutic exercise for an individual eight months status‐post ACL reconstruction
Case Description:
A 20 year‐old male presented to physical therapy eight months following anterior cruciate ligament (ACL) reconstruction of the left knee with primary complaints of residual anterior knee pain and quadriceps weakness. The subject was treated with a multimodal approach using side‐lying rotational lumbar thrust manipulation in addition to therapeutic exercise.
Outcomes:
The subject was seen in physical therapy for eight sessions over eight weeks. Lower Extremity Functional Scale (LEFS) scores improved from 58/80 to 72/80, quadriceps force, measured by hand‐held dynamometry (HHD), was improved from 70.6 lbs to 93.5 lbs and the subject was able to return to pain free participation in recreational sports.
Discussion:
Therapeutic exercises can facilitate improved quadriceps strength, however, in cases where quadriceps weakness persists and there is concurrent pain, other interventions should be considered. In this case, lower quarter stabilization exercise and lumbar thrust manipulation was associated with improved functional outcomes in a subject with anterior knee pain and quadriceps weakness. Side‐lying rotational lumbar thrust manipulation may be a beneficial adjunctive intervention to exercise in subjects with quadriceps weakness.
Level of Evidence:
5, Single case report
PMCID: PMC4275202  PMID: 25540713
ACL; knee; manipulation; manual therapy
20.  Effect of fluid ingestion on neuromuscular function during prolonged cycling exercise 
Objectives: To investigate the effects of fluid ingestion on neuromuscular function during prolonged cycling exercise.
Methods: Eight well trained subjects exercised for 180 minutes in a moderate environment at a workload requiring ∼60% maximal oxygen uptake. Two conditions, fluid (F) and no fluid (NF) ingestion, were investigated.
Results: During maximal voluntary isometric contraction (MVC), prolonged cycling exercise reduced (p<0.05) the maximal force generating capacity of quadriceps muscles (after three hours of cycling) and root mean square (RMS) values (after two hours of cycling) with no difference between the two conditions despite greater body weight loss (p<0.05) in NF. The mean power frequency (MPF) for vastus lateralis muscle was reduced (p<0.05) and the rate of force development (RFD) was increased (p<0.05) only during NF. During cycling exercise, integrated electromyographic activity and perceived exertion were increased in both conditions (p<0.05) with no significant effect of fluid ingestion.
Conclusions: The results suggest that fluid ingestion did not prevent the previously reported decrease in maximal force with exercise duration, but seems to have a positive effect on some indicators of neuromuscular fatigue such as mean power frequency and rate of force development during maximal voluntary contraction. Further investigations are needed to assess the effect of change in hydration on neural mechanisms linked to the development of muscular fatigue during prolonged exercise.
doi:10.1136/bjsm.2004.012393
PMCID: PMC1725175  PMID: 15793075
21.  Dynamic In Vivo Quadriceps Lines-of-Action 
Journal of biomechanics  2010;43(11):2106-2113.
Tissue stresses and quadriceps forces are crucial factors when considering knee joint biomechanics. However, it is difficult to obtain direct, in vivo, measurements of these quantities. The primary purpose of this study was to provide the first complete description of quadriceps geometry (force directions and moment arms) of individual quadriceps components using in vivo, 3D data collected during volitional knee extension. A secondary purpose was to determine if 3D quadriceps geometry is altered in patients with patellofemoral pain and maltracking. After obtaining informed consent, cine-phase contrast (PC) MRI sets (x,y,z velocity and anatomic images) were acquired from 25 asymptomatic knees and 15 knees with patellofemoral pain during active knee extension. Using a sagittal-oblique and two coronal-oblique imaging planes, the origins and insertions of each quadriceps line-of-action were identified and tracked throughout the motion by integrating the cine-PC velocity data. The force direction and relative moment (RM) were calculated for each line-of-action. All quadriceps lines-of-action were oriented primarily in the superior direction. There were no significant differences in quadriceps geometry between asymptomatic and subjects with patellofemoral pain. However, patellofemoral kinematics were significantly different between the two populations. This study will improve the ability of musculoskeletal models to closely match in vivo human performance by providing accurate 3D quadriceps geometry and associated patellofemoral kinematics during dynamic knee motion. Furthermore, determination that quadriceps geometry is not altered in patellofemoral pain supports the use of generalized a knee model based on asymptomatic quadriceps architecture.
doi:10.1016/j.jbiomech.2010.04.002
PMCID: PMC2914149  PMID: 20451912
22.  Quadriceps Activation Failure After Anterior Cruciate Ligament Rupture Is Not Mediated by Knee Joint Effusion 
STUDY DESIGN
Descriptive prospective cohort study.
OBJECTIVES
To investigate the relationships between knee joint effusion, quadriceps activation, and quadriceps strength. These relationships may help clinicians better identify impaired quadriceps activation.
BACKGROUND
After anterior cruciate ligament (ACL) injury, the involved quadriceps may demonstrate weakness. Experimental data have shown that quadriceps activation and strength may be directly mediated by intracapsular joint pressure created by saline injection. An inverse relationship between quadriceps activation and the amount of saline injected has been reported. This association has not been demonstrated for traumatic effusion. We hypothesized that traumatic joint effusion due to ACL rupture and postinjury quadriceps strength would correlate well with quadriceps activation, allowing clinicians to use effusion and strength measurement as a surrogate for electrophysiological assessment of quadriceps activation.
METHODS
Prospective data were collected on 188 patients within 100 days of ACL injury (average, 27 days) referred from a single surgeon. A complete clinical evaluation of the knee was performed, including ligamentous assessment and assessment of range of motion and effusion. Quadriceps function was electrophysiologically assessed using maximal volitional isometric contraction and burst superimposition techniques to quantify both strength and activation.
RESULTS
Effusion grade did not correlate with quadriceps central activation ratio (CAR) (zero effusion: mean ± SD CAR, 93.5% ± 5.8%; trace effusion: CAR, 93.8% ± 9.5%; 1+ effusion: CAR, 94.0% ± 7.5%; 2+/3+ effusion: CAR, 90.6% ± 11.1%). These values are lower than normative data from healthy subjects (CAR, 98% ± 3%).
CONCLUSION
Joint effusion after ACL injury does not directly mediate quadriceps activation failure seen after injury. Therefore, it should not be used as a clinical substitute for electrophysiological assessment of quadriceps activation. Patients presenting to physical therapy after ACL injury should be treated with high-intensity neuromuscular electrical stimulation to help normalize this activation.
doi:10.2519/jospt.2012.3793
PMCID: PMC3597089  PMID: 22523081
ACL; effusion; electrophysiological assessment; swelling
23.  Enhancing Muscle Force and Femur Compressive Loads via Feedback-Controlled Stimulation of Paralyzed Quadriceps in Humans 
Objective
To compare paralyzed quadriceps force properties and femur compressive loads in an upright functional task during conventional constant-frequency stimulation and force feedback-modulated stimulation.
Design
Crossover trial.
Setting
Research laboratory.
Participants
Twelve men and one woman with motor complete SCI.
Intervention
Subjects performed 2 bouts of 60 isometric quadriceps contractions while supported in a standing frame. On separate days subjects received constant-frequency stimulation at 20 Hz (CONST) or frequency-modulated stimulation (FDBCK). During FDBCK, a computer algorithm responded to each 10% reduction in force with a 20% increase in stimulation frequency.
Main Outcome Measure
A biomechanical model was used to derive compressive loads upon the femur, with a target starting dose of load equal to 1.5 times body weight.
Results
Peak quadriceps force and fatigue index were higher for FDBCK than CONST (p<0.05). Within-train force decline was greater during FDBCK bouts but mean force remained above CONST values (p<0.05). As fatigue developed during repetitive stimulation, FDBCK was superior to CONST for maintenance of femur compressive loads (p<0.05).
Conclusions
Feedback-modulated stimulation in electrically-activated stance is a viable method to maximize the physiologic performance of paralyzed quadriceps muscle. Compared to CONST, FDBCK yielded compressive loads that were closer to a targeted dose of stress with known osteogenic potential. Optimization of muscle force with FDBCK may be a useful tactic for future training-based anti-osteoporosis protocols.
doi:10.1016/j.apmr.2010.10.031
PMCID: PMC3056337  PMID: 21272720
spinal cord injuries; fatigue; electrical stimulation; osteoporosis
24.  Peripheral muscle endurance and the oxidative profile of the quadriceps in patients with COPD 
Thorax  2004;59(8):673-678.
Background: Based on previously reported changes in muscle metabolism that could increase susceptibility to fatigue, we speculated that patients with chronic obstructive pulmonary disease (COPD) have reduced quadriceps endurance and that this will be correlated with the proportion of type I muscle fibres and with the activity of oxidative enzymes.
Methods: The endurance of the quadriceps was evaluated during an isometric contraction in 29 patients with COPD (mean (SE) age 65 (1) years; forced expiratory volume in 1 second 37 (3)% predicted) and 18 healthy subjects of similar age. The electrical activity of the quadriceps was recorded during muscle contraction as an objective index of fatigue. The time at which the isometric contraction at 60% of maximal voluntary capacity could no longer be sustained was used to define time to fatigue (TF). Needle biopsies of the quadriceps were performed in 16 subjects in both groups to evaluate possible relationships between TF and markers of muscle oxidative metabolism (type I fibre proportion and citrate synthase activity).
Results: TF was lower in patients with COPD than in controls (42 (3) v 80 (7) seconds; mean difference 38 seconds (95% CI 25 to 50), p<0.001). Subjects in both groups had evidence of electrical muscle fatigue at the end of the endurance test. In both groups significant correlations were found between TF and the proportion of type I fibres and citrate synthase activity.
Conclusion: Isometric endurance of the quadriceps muscle is reduced in patients with COPD and the muscle oxidative profile is significantly correlated with muscle endurance.
doi:10.1136/thx.2003.020636
PMCID: PMC1747097  PMID: 15282387
25.  Posterior muscle chain activity during various extension exercises: an observational study 
Background
Back extension exercises are often used in the rehabilitation of low back pain. However, at present it is not clear how the posterior muscles are recruited during different types of extension exercises. Therefore, the present study will evaluate the myoelectric activity of thoracic, lumbar and hip extensor muscles during different extension exercises in healthy persons. Based on these physiological observations we will make recommendations regarding the use of extensions exercises in clinical practice.
Methods
Fourteen healthy subjects performed four standardized extension exercises (dynamic trunk extension, dynamic-static trunk extension, dynamic leg extension, dynamic-static leg extension) in randomized order at an intensity of 60% of 1-RM (one repetition maximum). Surface EMG signals of Latissimus dorsi (LD), Longissimus thoracis pars thoracic (LTT) and lumborum (LTL), Iliocostalis lumborum pars thoracic (ILT) and lumborum (ILL), lumbar Multifidus (LM) and Gluteus Maximus (GM) were measured during the various exercises. Subsequently, EMG root mean square values were calculated and compared between trunk and leg extension exercises, as well as between a dynamic and dynamic-static performance using mixed model analysis. During the dynamic exercises a 2 second concentric contraction was followed by a 2 second eccentric contraction, whereas in the dynamic-static performance, a 5 second isometric interval was added in between the concentric and eccentric contraction phase.
Results
In general, the muscles of the posterior chain were recruited on a higher level during trunk extension (mean ± SD, 56.6 ± 30.8%MVC) compared to leg extension (47.4 ± 30.3%MVC) (p ≤ 0.001). No significant differences were found in mean muscle activity between dynamic and dynamic-static performances (p = 0.053). The thoracic muscles (LTT and ILT) were recruited more during trunk extension (64.9 ± 27.1%MVC) than during leg extension (54.2 ± 22.1%MVC) (p = 0.045) without significant differences in activity between both muscles (p = 0.138). There was no significant differences in thoracic muscle usage between the dynamic or dynamic-static performance of the extension exercises (p = 0.574).
Lumbar muscle activity (LTT, ILL, LM) was higher during trunk extension (70.6 ± 22.2%MVC) compared to leg extension (61.7 ± 27.0%MVC) (p = 0.047). No differences in myoelectric activity between the lumbar muscles could be demonstrated during the extension exercises (p = 0.574). During each exercise the LD (19.2 ± 13.9%MVC) and GM (28.2 ± 14.6%MVC) were recruited significantly less than the thoracic and lumbar muscles.
Conclusion
The recruitment of the posterior muscle chain during different types of extension exercises was influenced by the moving body part, but not by the type of contraction. All muscle groups were activated at a higher degree during trunk extension compared to leg extension. Based on the recruitment level of the different muscles, all exercises can be used to improve the endurance capacity of thoracic muscles, however for improvement of lumbar muscle endurance leg extension exercises seem to be more appropriate. To train the endurance capacity of the LD and GM extension exercises are not appropriate.
doi:10.1186/1471-2474-14-204
PMCID: PMC3716991  PMID: 23834759
Trunk extensor muscles; Multifidus; Posterior muscle chain; Extension exercise; Electromyography; Spine

Results 1-25 (1161581)