Article

Clinical Rehabilitation
26(3) 224236
Efficacy of electromyographic The Author(s) 2011
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DOI: 10.1177/0269215511419382
cre.sagepub.com
stimulation following arthroscopic
partial meniscectomy: a
randomized controlled trial

Nuray Akkaya1, Fusun Ardic1, Merih Ozgen2,

Semih Akkaya3, Fusun Sahin1 and Alper Kilic3

Abstract
Objective: To compare the effectiveness of electromyographic biofeedback training and electrical stim-
ulation therapy for rehabilitation following arthroscopic partial meniscectomy.
Design: Randomized, prospective, controlled single-blind trial.
Setting: Department of physical medicine and rehabilitation, university hospital.
Subjects: Forty-five patients who had undergone surgery for arthroscopic partial meniscectomy were
randomly divided into three groups with 15 patients in each group.
Interventions: The control group had home exercise, the second and third groups received electro-
myographic biofeedback training or electrical stimulation therapy to quadriceps muscle in addition to
home exercise.
Main measures: The patients were evaluated for: visual analogue scale, gait velocity (m/s), time using a
walking aid after surgery, Lysholm Knee Scoring Scale score, knee flexionextension angle, maximum and
average contraction powers of vastus medialis obliquus and vastus lateralis muscles on the day before the
operation and two and six weeks after.
Results: The time using a walking aid was 8.3 6 8.0, 1.5 6 2.5 and 4.5 6 5.5 days, respectively, for the
home exercise, electromyographic biofeedback training and electrical stimulation groups, and significantly
shorter in the electromyographic biofeedback training than in the home exercise group (P < 0.017). While
significant progress was detected in Lysholm Knee Scoring Scale score in the second and sixth postop-
erative weeks compared to the preoperative within-group evaluation for each of the three groups

3
University of Pamukkale, Medicine Faculty, Department of
Orthopedics and Traumatology, Denizli, Turkey
1
University of Pamukkale, Medicine Faculty, Department of Corresponding author:
Physical Medicine and Rehabilitation, Denizli, Turkey Nuray Akkaya, University of Pamukkale, Medicine Faculty,
2
University of Eskisehir Osmangazi, Medicine Faculty, Department of Physical Medicine and Rehabilitation, 20070,
Department of Physical Medicine and Rehabilitation, Eskis ehir, Denizli, Turkey
Turkey Email: nrakkaya@gmail.com.

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Akkaya et al. 225

(P < 0.017), there was significant difference in Lysholm Knee Scoring Scale in the second postoperative
week in favour of electromyographic biofeedback training compared to home exercise (P < 0.017). There
were significant differences in vastus medialis obliquus average and vastus lateralis maximum and average
contractions in favour of electromyographic biofeedback compared to home exercise and electrical stim-
ulation in the second postoperative week (P < 0.017).
Conclusions: The addition of electromyographic biofeedback training to a conventional exercise pro-
gramme following arthroscopic partial meniscectomy helps to speed up the rehabilitation process.

Keywords
Meniscectomy, rehabilitation, electromyographic biofeedback, electrical stimulation
Received: 2 March 2011; accepted: 16 July 2011

Although the importance of early active joint

Introduction
The most common surgery technique for menis-
cal lesions, which are injuries frequently encoun-
tered in sports and daily life, is arthroscopic
partial meniscectomy.1 After knee surgery,
rapid atrophy and weakness develop in the
quadriceps muscle, which is responsible for the
extensor mechanism of the knee, as a result of
reex inhibition of motor neurons and immobi-
lization. Quadriceps femoris muscle power and
knee-related quality of life have been shown to
decrease after arthroscopic partial
meniscectomy.2,3
Although it is a widely applied surgery, dis-
cussion about the rehabilitation programme to
be applied following partial meniscectomy con-
tinues, and it was reported that there is need for
further randomized trials.47 While some studies
suggest the need for observed physical therapy
for optimal results,811 others argue that home
exercise programmes are as eective as observed
physical therapy.12,13 However, the studies that
examine the same rehabilitation programme as
home programme or observed physical therapy
compare the compliance of the patients rather
than investigating the most eective treatment
modality.14
It was determined that joint range-of-motion
exercises started soon after surgery play a key
role in recovery after orthopaedic surgery.4
range-of-motion exercises in order to achieve
good results post arthroscopic partial meniscect-
omy rehabilitation was emphasized,4 there are
limited number of evidence-based studies
which compare the ecacy of physiotherapy
modalities for increasing quadriceps muscle
power in these patients.1518
Electromyographic biofeedback, one of the
physical therapy techniques for increasing the
strength of the quadriceps muscle, is a method
which allows retraining of the muscle by creat-
ing new feedback systems as a result of the con-
version of myoelectrical signals in the muscle
into visual and auditory signals.19 Electrical
stimulation increases muscle power by stimulat-
ing muscle bres and muscle contraction.20
While during electromyographic biofeedback
the patient has to do voluntary muscle contrac-
tions, in electrical stimulation the muscle con-
traction is provided by electrical stimulation of
the bres without the voluntary contraction
done by the patient. Studies comparing the e-
cacy of electromyographic biofeedback and elec-
trical stimulation treatments following anterior
cruciate ligament surgery are available in the lit-
erature.20 Although electromyographic biofeed-
back1517 or electrical stimulation18 practices
versus an exercise programme for rehabilitation
following arthroscopic partial meniscectomy
were compared, the eectiveness of

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226
electromyographic biofeedback had not been
compared with that of electrical stimulation.
The objective of this study was to compare
the eects of electromyographic biofeedback
with electrical stimulation therapy in addition
to conventional home exercise programme on
muscle power and functional status following
arthroscopic partial meniscectomy.
Methods
Patients who were to undergo electively arthro-
scopic partial meniscectomy surgery were
included in the study. The presence of neurolog-
ical disease that aects the lower extremities,
having undergone surgery on the same knee
within the last six months, application of extra
surgical procedures except for arthroscopic par-
tial meniscectomy (e.g. repair of anterior cruci-
ate ligament), fracture experienced in the
operated knee, the presence of a deformity
which develops in association with conditions
such as inammatory arthropathy, and use of
cardiac pacemaker, severe arrhythmia or epi-
lepsy which prevents electrical stimulation were
Figure 1. Flow diagram of the study.
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Clinical Rehabilitation 26(3)
determined as criteria for exclusion from the
study.
Forty-nine patients were initially evaluated in
the study. Two of them were excluded from the
study since they did not come to surgery, and the
other two were excluded since they received sur-
gery other than meniscectomy at the time of
operation, hence the study was continued with
45 patients (Figure 1).
Approval was obtained from Pamukkale
University Medical School Ethics Committee.
Before the study, the patients were given
information about the study and their informed
consent was obtained.
The study was planned as a prospective, ran-
domized, single-blind, clinical study. The asses-
sor physician was blinded, but the patients and
the physician who applied the therapy were not.
A balanced randomization was performed by
selection of a sealed envelope from opaque enve-
lopes including the group assignment numbers
which were produced by a computer random
number generator.
Demographic data: age (years), gender,
height (m), weight (kg), body mass index
(kg/m2), educational status, occupation, period
Akkaya et al.
of knee pain (months), history of knee trauma
(yes/no), side which has received arthroscopic
partial meniscectomy and dominant side were
asked about.
The meniscus rupture phases of the patients
were recorded as 1, 2, 3 or 4 according to knee
magnetic resonance imaging, which was carried
out in our hospital before the surgery.21
Since osteoarthritis may aect the severity of
symptoms and examination ndings of the
patients, in order to determine the presence
and stage of osteoarthritis in the knee which
received arthroscopic partial meniscectomy, the
stages of medial, lateral tibiofemoral and patel-
lofemoral joint osteoarthritis were determined as
1, 2, 3, 4 according to the Outerbridge classi-
cation22 by an orthopaedist at the time of sur-
gery. Meniscectomy type applied at the
arthroscopy and meniscectomy region were
recorded.
The patients included in the study were ran-
domly divided into three groups: rst group
(n 15) received home exercise programme
(home exercise group), second group (n 15)
received electromyographic biofeedback training
to quadriceps muscle in addition to home exer-
cise programme (electromyographic biofeedback
group), third group (n 15) received electrical
stimulation to quadriceps muscle in addition to
home exercise programme (electrical stimulation
group).
An illustrated exercise booklet describing the
exercises the patients do for a period of one
month as from the day of surgery were given
to all patients as the home exercise programme
and exercises were taught to the patients. The
rst phase (days 17) of the applied exercise pro-
tocol comprised ice application, elevation, appli-
cation of mild compression bandage on the knee
and quadriceps setting, hamstring stretching,
straight leg rising and ankle pumping exercises;
second phase (days 714) comprised hip abduc-
tionadduction, knee exionextension, gastroc-
nemius and quadriceps muscles stretching
exercises in addition to the foregoing; third
phase (weeks two to four) comprised closed
kinetic chain exercises and side-stepping
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227
exercises in addition to the above; fourth phase
(following the fourth week) comprised progres-
sive resistive exercises to the muscles surround-
ing the knee as a follow-up and in addition to
the previous exercises.13,15,23 The patients were
asked to determine the period of using crutches
according to the level of their pain.
In addition to home exercise programme, the
electromyographic biofeedback group received
daily electromyographic biofeedback training
for isometric contraction of quadriceps muscle
with a Myomed 932 (Enraf-Nonius, The
Netherlands) device for 5 days a week and two
weeks in total as from the rst postoperative
day. While the patient sits on the stretcher
with his or her legs stretched, the surface elec-
trodes of the device were placed on the operated
leg in the following manner: two active elec-
trodes of its rst channel were placed 4 cm
above and 3 cm medial to the upper end of the
patella for vastus medialis obliquus muscle,
active electrodes of its second channel were
placed 10 cm above and 68 cm lateral to the
upper edge of the patella for vastus lateralis
muscle, earth electrode was placed 23 cm
below the patella on the same side.15
Quadriceps muscle isometric contraction thresh-
old value was established on the rst postoper-
ative day. The patients were asked to do
isometric quadriceps contraction with time of
contraction over a specied threshold value
being 10 seconds, time of rest being 20 seconds
and total time of work being 20 minutes. Visual
feedback was provided to the patients by watch-
ing contraction in the monitor and audio feed-
back was provided by adjusting the signal so
that it can be heard when threshold value is
exceeded. By increasing the threshold value
every day, the patients had to contract their
quadriceps muscle more strongly.
In addition to the home exercise programme,
the electrical stimulation group received daily
electrical stimulation therapy for quadriceps
muscle with an Endomed 582 device for 5 days
a week and two weeks in total from the rst
postoperative day. With two active electrodes
of one channel of the device on vastus medialis
228
obliquus muscle and active electrodes of the
other channel on vastus lateralis muscle, they
were placed on both ends of the muscle accord-
ing to bipolar electrode placement technique.
Isometric contraction of the quadriceps muscle
was provided by applying electrical stimulation
with intermittent alternative current to vastus
medialis obliquus and vastus lateralis muscles
for 23 minutes in accordance with the Russian
stimulation protocol in the device.
All patients were evaluated three times: pre-
operatively, in the second postoperative week
and in the sixth postoperative week by a physi-
cian unaware of the treatment modality.
Outcome measures
1. Pain: Pain during walking was measured on a
10-cm line with a visual analogue pain scale;
the patients were asked to mark the severity
of their pain on the scale after they were told
0 is painless and 10 is the most severe pain
one can endure.
2. Gait velocity: Gait velocity was measured as
the time to walk a distance of 2 m and
assessed in m/s.
3. The time using a walking aid was registered.
4. Functional evaluation: The Lysholm Knee
Scoring Scale was used for functional evalu-
ation. This scale was created to evaluate the
results of knee ligament reconstruction.24 It
was also shown to be valid in the evaluation
of patients with meniscus injury.25 The
Lysholm Knee Scoring Scale classies knee
function under eight headings: limping (5
points), using a walking aid (5 points), climb-
ing stairs (10 points), instability (25 points),
pain (25 points), swelling (10 points), squat-
ting (5 points) and locking sensation (15
points). Maximal score (100 points) corre-
sponds to normal knee function. In the eval-
uation of results, a score of 95100 points is
considered excellent functional state, 8494
points good functional state, 6583 points
fair functional state and 064 points bad
functional state.
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Clinical Rehabilitation 26(3)
5. Evaluation of joint range of motion: Active
exion angle and extension loss of the knee
joint was measured by a goniometer and
recorded in degrees.
6. Joint swelling and quadriceps volume: Knee
circumference from the middle of the patella
and thigh circumference 10 cm above the
patella of the operated knee were measured
in centimetres using a measuring tape.
7. Muscle power evaluation: This was measured
over the vastus medialis obliquus and vastus
lateralis muscles using the electromyographic
biofeedback device Myomed 932 (Enraf-
Nonius). The surface electrodes of the
device were placed on the points mentioned
previously in the treatment method for the
electromyographic biofeedback group and
the patient was asked to do 10 seconds of
isometric quadriceps contraction and then
rest for 20 seconds. This exercise was repeated
three times. The mean value of three measure-
ments was taken for vastus medialis obliquus
and vastus lateralis muscles average contrac-
tion and maximum contraction values and
recorded in microvolts (mV).15
Statistical analysis
Statistical Package for Social Sciences for
Windows 17.0 programme (SPSS 17.0, SPSS
Inc., Chicago, IL, USA) was used in the statis-
tical evaluation of the data. During the investi-
gation of whether there is any dierence between
the groups in terms of socio-demographic data
before therapy, KruskalWallis test and Mann
Whitney U-test (with Bonferroni correction)
were used for numerical data and chi-square
test for categorical data. While KruskalWallis
test (P < 0.05 signicance value was accepted)
was used in order to establish if there are any
dierences between the groups in terms of eval-
uation criteria before therapy, at two and six
weeks after the therapy, MannWhitney U-test
(P < 0.017 signicance value was accepted with
Bonferroni correction) was used to establish
from which group the dierences arose. In the
Akkaya et al.
investigation of dierence between the groups
during therapy, repeated measures (repeated
ANOVA, repetitive variance analysis) were
used. The presence of any signicant in-group
dierence within each group was investigated
by Friedman test (P < 0.05 was accepted as sig-
nicant). When signicant dierence was
detected inside a group by Friedman test, the
presence of any statistically signicant dierence
in in-group change (before the surgerysecond
postoperative week, before the surgerysixth
postoperative week, second postoperative
weeksixth postoperative week) was assessed
by Wilcoxon test (with Bonferroni correction)
and P < 0.017 was accepted as signicant.
Results
A total of 45 patients (26 female, 19 male), aged
2767 (mean age 46.9 years) were included in the
study. All of the patients completed the study
programme. There was no statistically signi-
cant dierence between the groups in terms of
demographic, clinical, imaging and evaluation
parameters during preoperative evaluation
(P > 0.05) (Table 1). When the distribution of
preoperative osteoarthritis grading among the
patients according to Outerbridge
Classication was examined, no statistically sig-
nicant dierence was established between the
treatment groups (P > 0.05) (Table 2).
While signicant progress was detected for
walking VAS in the second and sixth weeks
after the operation compared to preoperative
values in within-group evaluation for each of
three groups (P < 0.017), no signicant dier-
ence was detected among the three groups in
all evaluation times (P > 0.05) (Table 3).
A statistically signicant change was not
detected for gait velocity within the group for
each of three groups, and there was no signi-
cant dierence among the groups in evaluation
days (P > 0.05) (Table 3).
The time using a walking aid after the surgery
was found to be 8.3 (8.0), 1.5 (2.5) and 4.5 (5.5)
days respectively for home exercise, electromyo-
graphic biofeedback and electrical stimulation
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229
groups, and the dierence among the groups
was signicant (P < 0.05). The time using a
walking aid was established as statistically sig-
nicantly shorter in the electromyographic bio-
feedback group than in the home exercise group
(P < 0.017).
While signicant progress was detected for
Lysholm Knee Scoring Scale score in the
second and sixth weeks after the operation com-
pared to the preoperative within-group evalua-
tion for each of three groups (P < 0.017),
average Lysholm Knee Scoring Scale score in
thes second postoperative week was found to
be signicantly better in the electromyographic
biofeedback group than in the home exercise
group (P < 0.017) (Table 3).
For active knee exion angle, while signi-
cant deterioration was detected in the home
exercise group in the second postoperative
week compared to the preoperative value, signif-
icant progress was detected in the electromyo-
graphic biofeedback and electrical stimulation
groups in the sixth postoperative week com-
pared to thes second postoperative week
(P < 0.017). In the case of limitation in knee
extension and measurements of knee and thigh
circumference, no statistically signicant change
was detected in within-group evaluation for each
of three groups, and there was no signicant dif-
ference among the groups on the days of evalu-
ation (P > 0.05) (see online Table 4).
When muscle contraction strengths were
compared, there was no signicant dierence
among the groups in the preoperative period
(P > 0.05). Within-group evaluation for each of
the three groups, only in electromyographic bio-
feedback group was signicant increase was
detected in vastus medialis obliquus average
contraction value in the second postoperative
week compared to the preoperative value and
statistically signicant progress was established
in vastus lateralis average contraction value in
the second and sixth postoperative weeks com-
pared to the preoperative value (P < 0.017). In
the comparison of the three groups, a signicant
dierence was found in the second postoperative
week in terms of vastus medialis obliquus
 Table 1. Demographic and clinical characteristics of the patients
230

EMG-B + Home exercise ES + Home exercise

Home exercise (N 15) (N 15) (N 15)
Mean  SD Mean  SD Mean  SD P-value

Age (years) 49.8 (11.6) 48.3 (9.3) 42.7 (10.2) 0.131

BMI (kg/m2) 30.1 (3.4) 29.5 (3.8) 30.4 (6.2) 0.840
Duration of knee pain (months) 16.2 (15.0) 22.7 (9.8) 23.5 (27.8) 0.082
The number The number The number
of patients (%) of patients (%) of patients (%)

Gender
F 7 (46.7) 10 (66.7) 9 (57.8) 0.529
M 8 (53.3) 5 (33.3) 6 (42.2)
Education
Primary/secondary 10 (66.7) 9 (60) 8 (53.3) 0.452
Lycee/high school 5 (33.3) 6 (40) 7 (46.6)
History of trauma
Present 3 (20) 2 (13.3) 4 (26.7) 0.659
Absent 12 (80) 13 (86.7) 11 (73.3)
MRI grades of meniscal tear
1
2 1 (6.7) 1 (6.7) 1 (6.7) 0.968
3 13 (86.7) 12 (80) 13 (86.7)
4 1 (6.7) 2 (13.3) 1 (6.7)

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Operated knee
Right 10 (66.7) 5 (33.3) 5 (33.3) 0.105
Left 5 (33.3) 10 (66.7) 10 (66.7)
The region of meniscectomy
Medial 13 (86.7) 11 (73.3) 8 (66.7) 0.573
Lateral 1 (6.7) 2 (13.3) 1 (6.7)
Medial+lateral 1 (6.7) 2 (13.3) 4 (26.7)
The values were expressed as mean  standard deviation or number of patients (%).
Clinical Rehabilitation 26(3)

EMG-B, electromyographic biofeedback; ES, electrical stimulation; BMI, body mass index; MRI, magnetic resonance imaging.
Akkaya et al. 231

Table 2. The distribution of Outerbridge osteoarthritis grades of the medial, lateral tibiofemoral and patellofemoral
joints among groups

Home exercise EMG-B + Home ES + Home exercise

(N 15) exercise (N 15) (N 15) P-value

Medial TF joint
N 1 (6.7)
1 1 (6.7) 1 (6.7) 2 (13.3)
2 5 (33.3) 6 (40.0) 4 (26.7) 0.789
3 4 (26.7) 5 (33.3) 6 (40.0)
4 5 (33.3) 3 (20) 2 (13.3)
Lateral TF joint
N 7 (46.7) 2 (13.3) 7 (46.7)
1 2 (13.3) 4 (26.7) 2 (13.3)
2 5 (33.3) 7 (46.7) 5 (33.3) 0.378
3 1 (6.7) 2 (13.3)
4 1 (6.7)
Patellofemoral joint
N 1 (6.7) 1 (6.7)
1 5 (33.3) 2 (13.3) 0.187
2 3 (20.0) 7 (46.7) 8 (53.3)
3 3 (20.0) 6 (40.0) 3 (20.0)
4 3 (20.0) 2 (13.3) 1 (6.7)
The values were expressed as number of patients (%).
EMG-B, electromyographic biofeedback; ES, electrical stimulation; TF, tibiofemoral; N, normal.

average, vastus lateralis maximum and average
muscle powers (P < 0.05). Vastus medialis obli-
quus average, vastus lateralis maximum and
average contraction values in the second postop-
erative week were found to be signicantly
higher in the electromyographic biofeedback
group than in the home exercise and electrical
stimulation groups (P < 0.017). Although the
electromyographic biofeedback group had a
higher value than the home exercise and electri-
cal stimulation groups in the second postopera-
tive week for vastus medialis obliquus maximum
contraction, this dierence did not reach statis-
tical signicance (see online Table 5).
Discussion
The results of this study reveal that the addition
of electromyographic biofeedback training
following arthroscopic partial meniscectomy
for strengthening of quadriceps muscle ensures
early recovery of knee extensor muscle power,
and better knee functional state in the early
postoperative period which may be accompa-
nied by problems such as pain and oedema.
In dierent studies using surface electromy-
ography or isokinetic tests for measurements of
neurological function of quadriceps femoris fol-
lowing meniscectomy it was found that weak-
ness detected in the quadriceps femoris during
the postoperative immobilization period was not
related to nerve or muscle injury but was caused
by reex inhibition of motor neurons.15,26 It was
found that maximal contraction rather than sub-
maximal power was aected and the decrease in
muscle power still continues in the sixth postop-
erative month when evaluated by surface elec-
tromyography and isokinetic dynamometer.27

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 232

Table 3. The comparison of the mean values of walking visual analogue scale, gait velocity and Lysholm Knee Scoring Scale among groups and
within groups

The evaluation Home exercise EMG-B + Home ES + Home

parameters Time (N 15) exercise (N 15) exercise (N 15) P-value

Walking VAS Preoperative 6.6 (2.2) 5.3 (2.1) 6.9 (2.7) 0.171
2nd postoperative week 3.6 (2.6)a 2.2 (1.7)a 3.4 (2.6)a 0.300
6th postoperative week 3.4 (2.9)b 2.3 (2.1)b 3.4 (2.5)b 0.386
Gait velocity (m/s) Preoperative 0.84 (0.27) 0.86 (0.20) 0.82 (0.35) 0.578
2nd postoperative week 0.75 (0.33) 0.93 (0.22) 0.91 (0.31) 0.248
6th postoperative week 0.89 (0.24) 1.03 (0.25) 0.99 (0.28) 0.424
Lysholm Knee Scoring Scale Preoperative 54.1 (12.2) 62.2 (10.6) 53.1 (13.5) 0.066
2nd postoperative week 75.3 (9.9)a 85.6 (5.1)a 78.3 (14.0)a 0.002 EMG-B>
Home exercise
6th postoperative week 77.2 (14.3)b 85.9 (7.0)b 81.0 (7.4)b 0.087
The values were expressed as mean  standard deviation.
VAS, visual analogue pain scale; EMG-B, electromyographic biofeedback; ES, electrical stimulation.
Bold P-values show that the significant difference among the three groups at evaluation P < 0.05.
a
The significant difference between 2nd postoperative weekpreoperative day within-group evaluation, P < 0.017.

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b
The significant difference between 6th postoperative weekpreoperative day within-group evaluation, P < 0.017.
Clinical Rehabilitation 26(3)
Akkaya et al.
The detection of 22% decrease in quadriceps
muscle power and 13% decrease in muscle vol-
ume by functional muscle magnetic resonance
imaging, suggests that maximal muscle power
development is required for eective rehabilita-
tion after arthroscopic meniscectomy.28
By the addition of electromyographic bio-
feedback into conventional therapy pro-
grammes applied in the rehabilitation of
muscle weakness associated with the immobili-
zation period following arthroscopic partial
meniscectomy, the compliance of the patient
to the exercise programme may be
enhanced.16,20 It was reported that electromyo-
graphic biofeedback training was an eective
method for increasing quadriceps muscle
power as evaluated either by surface electromy-
ography or by isokinetic dynomometer.16,29,30
In one of these studies, it was reported that
while signicant increase was detected in quad-
riceps muscle power in favour of the electromy-
ography group, there was no dierence between
the groups in terms of loading the operated
knee.16 However, we detected improvements
in favour of electromyographic biofeedback
compared to home exercise for both the time
using a walking aid and knee function, as well
as improvements in muscle power. The detec-
tion of these clinical improvements in favour of
electromyographic biofeedback training indi-
cated that the electromyographic biofeedback
was eective both in clinical parameters and
in muscle power.
It was suggested that the signicant develop-
ment in torque that took place without any sig-
nicant change in thigh circumference
measurements, in other words without any
muscle hypertrophy after electromyographic
biofeedback training, may be caused by motor
learning.30 Similarly, no dierence in thigh cir-
cumference measurements was detected in
within-group evaluation for each of the three
groups in our study. Therefore, the development
established in quadriceps muscle power in elec-
tromyographic biofeedback group was thought
to be associated with motor learning, rather
than a result of muscle hypertrophy.
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233
In a study by Kirnap et al.15 the eects of
home exercise and electromyographic biofeed-
back after arthroscopic meniscectomy was com-
pared and they found a signicant increase in
Lysholm Knee Scoring Scale score, knee exion
angle, vastus medialis obliquus and vastus later-
alis muscle electrical activity measured by sur-
face electromyography and quadriceps muscle
power in the second and sixth postoperative
weeks in the group which received electromyo-
graphic biofeedback. In our study, in the second
postoperative week, vastus medialis obliquus
average and vastus lateralis maximum and aver-
age contraction values were signicantly better
in the electromyographic biofeedback group
than the home exercise and electrical stimulation
groups, and Lysholm Knee Scoring Scale score
was signicantly higher in the electromyo-
graphic biofeedback group than in the home
exercise group.
Electrical stimulation is a conventional
method which has the feature of articially stim-
ulating intramuscular branches of motor nerve
and is used to increase muscle power.20 In a
study comparing the eectiveness of electrical
stimulation and isometric exercise for quadri-
ceps muscle after open meniscectomy it was
reported that muscle volume and muscle power
loss were less in the electrical stimulation group
four weeks after surgery and the electrical stim-
ulation group used crutches for a shorter time.31
In our study, the time using a walking aid in the
electromyographic biofeedback group was sig-
nicantly shorter than that in the home exercise
group. Although the dierence was not signi-
cant, the time using a walking aid in the electri-
cal stimulation group was longer than that in the
electromyographic biofeedback group and
shorter than that in the home exercise group.
It was reported that isokinetic quadriceps
power increased in both the electrical stimula-
tion and home exercise groups after arthroscopic
meniscectomy.18 However, in a study comparing
the addition of electromyographic biofeedback
or electrical stimulation therapy to an exercise
programme following anterior cruciate ligament
surgery it was reported that better recovery on
234
peak torque power of quadriceps muscle in iso-
kinetic measurement and active knee extension
were detected in favour of the electromyo-
graphic biofeedback group.20 In our study,
muscle power evaluation was carried out by sur-
face electromyography instead of isokinetic
dynomometer, and results obtained in terms of
muscle power were in favour of the electromyo-
graphic biofeedback group. However, no signif-
icant dierence was detected among groups in
terms of active knee extension, and no superior-
ity in terms of pain severity, Lysholm Knee
Scoring Scale score and improvement in
muscle power was found in the electrical stimu-
lation group compared to the home exercise
group.
Normally, recovery of active range of motion
is reported 2448 hours after arthroscopic knee
surgery, and quadriceps and hamstring muscles
allow early rehabilitation.23 Since no complica-
tions were observed in our patients, active joint
range-of-motion exercises were started early. In
our study, while the electrical stimulation and
electromyographic biofeedback groups exhib-
ited signicant progress in knee exion in the
sixth postoperative week in comparison to the
second postoperative week, the home exercise
group exhibited signicant deterioration in
active knee exion in the second postoperative
week compared to preoperative value. Kirnap
et al.15 reported signicant dierences in
favour of the electromyographic biofeedback
group for exion angle at two and six weeks
after arthroscopic meniscectomy in a compari-
son between home exercise and electromyo-
graphic biofeedback groups. The severity of
pain of the patients was not evaluated in
Kirnap et al.s study.15 Since pain in the postop-
erative period is an eective factor in quadriceps
muscle inhibition, the severity of pain experi-
enced by the patients during walking was also
evaluated in our study. In all three groups, a
signicant decrease in pain experienced during
walking was detected in the second and sixth
postoperative weeks compared to the preopera-
tive period. Although decrease in severity of
pain was detected in the second postoperative
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Clinical Rehabilitation 26(3)
week in the home exercise group, a deterioration
in knee active exion was an interesting nding.
Postoperative rehabilitation protocols and
quadriceps muscle strengthening exercises
with conservative therapy are important in
terms of providing normal walking pattern.32
Arthroscopic meniscectomy patients were
reported to be able to generally walk without a
walking aid within one week postoperatively,
and to go back to work within several days to
six weeks depending on their physical require-
ments.33 In our study, it was determined that
the patients in home exercise group had to use
a walking aid for longer period of time com-
pared to the electromyographic biofeedback
group.
In a study carried out by Koutras et al.34 to
evaluate the eects of isotonic, isokinetic and
home exercise programmes after arthroscopic
meniscectomy, it was suggested that taking mea-
surements of the unoperated knee would be ben-
ecial to make correct comparisons between the
groups. In contrast, it was reported that abso-
lute values of the operated knee were preferred
in a study investigating the eects of functional
exercise training following arthroscopic menis-
cectomy on muscle power, since the certain
patients had also complained about the unoper-
ated knee from time to time.11 Similarly, since
certain patients had also complained about the
unoperated knee in our study, only data from
the operated knee were used.
Fabricant et al.35 reported that early recovery
after arthroscopic partial meniscectomy was
negatively related to female gender and severe
osteoarthritis, however there was no relationship
between age, body mass index, meniscus rupture
or size of resection and recovery in the rst year.
In our study, there was no signicant dierence
in terms of age, gender, body mass index, grade
of osteoarthritis among the patients in all three
groups. The homogeneous nature of the groups
in terms of demographic and surgical features in
our study is a benecial factor for the pure eval-
uation of the treatment modalities.
In our study, the reduced time using a walk-
ing aid by the addition of electromyographic
Akkaya et al.
biofeedback training compared to home exercise
only is an important clinical result. In terms of
muscle power, the results of our study are in
favour of electromyographic biofeedback train-
ing, but because electromyographic biofeedback
therapy and measurements were made with the
same device in our study, it is not possible to
eliminate the eect of learning on measurement
values. This is one of the limitations of our
study, the other one being the very small
number of patients.
According to the results of our study, the
addition into conventional exercise pro-
gramme following arthroscopic partial menis-
cectomy of electromyographic biofeedback
training, which increases active participation
of the patient in exercise therapy by providing
visual and audial stimulation, enables the
patient to achieve preoperative muscle
powers earlier and provides better knee func-
tional status in the postoperative early period.
Therefore, it can be concluded that the addi-
tion of electromyographic biofeedback train-
ing into a conventional exercise programme
after arthroscopic partial meniscectomy con-
tributes to speeding up the rehabilitation pro-
cess. Although the addition of electrical
stimulation therapy showed superiority over
the home exercise group in terms of shorter
time using a walking aid and better recovery
in knee exion, these dierences were not sta-
tistically and clinically signicant.
Furthermore, the electrical stimulation group
did not show superiority over home exercise
and electromyographic biofeedback groups in
terms of pain, gait velocity, the time using a
walking aid, muscle power, and progress in
functional status.
A limited number of studies have been car-
ried out on electromyographic biofeedback for
increasing muscle power in arthroscopic
meniscectomy rehabilitation, hence investiga-
tion of the long-term eects of electromyo-
graphic biofeedback on the recovery of
quadriceps muscle power by randomized, con-
trolled and blind studies with broader partic-
ipation is needed.
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235
Clinical messages
. Addition of electromyographic biofeed-
back training to conventional exercise fol-
lowing arthroscopic partial meniscectomy
reduces the time using a walking aid.
. Electromyographic biofeedback training
following arthroscopic partial meniscect-
omy improves knee extensor muscle
power recovery and knee function in the
early postoperative period.
Acknowledgements
This paper was presented, in part, at the 21st National
Congress of Physical Medicine and Rehabilitation,
Antalya, Turkey, 2429 October 2007.
Conflict of interest
None declared.
Funding
This research received no specic grant from any
funding agency in the public, commercial, or
not-for-prot sectors.
References
1. Goodwin PC, Morrissey MC, Omar RZ, Brown M,
Southall K and McAuliffe TB. Effectiveness of super-
vised physical therapy in the early period after arthro-
scopic partial meniscectomy. Phys Ther 2003; 83:
520535.
2. St-Pierre DM. Rehabilitation following arthroscopic
meniscectomy. Sports Med 1995; 20: 338347.
3. Durand A, Richards CL, Malouin F and Bravo G.
Motor recovery after arthroscopic partial meniscect-
omy: analyses of gait and the ascent and descent of
stairs. J Bone Joint Surg Am 1993; 75: 202214.
4. Kelln BM, Ingersoll CD, Saliba S, Miller MD and
Hertel J. Effect of early active range of motion rehabil-
itation on outcome measures after partial meniscectomy.
Knee Surg Sports Traumatol Arthrosc 2009; 17: 607616.
5. Goodyear-Smith F and Arroll B. Rehabilitation after
arthroscopic meniscectomy: a critical review of the clin-
ical trials. Int Orthop 2001; 24: 350353.
6. Coppola SM and Collins SM. Is physical therapy more
beneficial than unsupervised home exercise in treatment
236
of post surgical knee disorders? A systematic review.
Knee 2009; 16: 171175.
7. Thomson LC, Handoll HH, Cunningham A and Shaw
PC. Physiotherapist-led programmes and interventions
for rehabilitation of anterior cruciate ligament, medial
collateral ligament and meniscal injuries of the knee in
adults. Cochrane Database Syst Rev 2002; 2: CD001354.
8. Matthews P and St-Pierre DM. Recovery of muscle
strength following arthroscopic meniscectomy.
J Orthop Sports Phys Ther 1996; 23: 1826.
9. Moffet H, Richards CL, Malouin F, Bravo G and
Paradis G. Early and intensive physiotherapy accelerates
recovery postarthroscopic meniscectomy: Results of a
randomized controlled study. Arch Phys Med Rehabil
1994; 75: 415426.
10. Morrissey MC, Milligan P and Goodwin PC. Evaluating
treatment effectiveness: benchmarks for rehabilitation
after partial meniscectomy knee arthroscopy. Am J
Phys Med Rehabil 2006; 85: 490501.
11. Ericsson YB, Dahlberg LE and Roos EM. Effects of
functional exercise training on performance and
muscle strength after meniscectomy: a randomized
trial. Scand J Med Sci Sports 2009; 19: 156165.
12. Goodwin PC and Morrissey MC. Physical therapy after
arthroscopic partial meniscectomy: is it effective? Exerc
Sport Sci Rev 2003; 31: 8590.
13. Jokl P, Stull PA, Lynch JK and Vaughan V.
Independent home versus supervised rehabilitation fol-
lowing arthroscopic knee surgery a prospective ran-
domized trial. Arthroscopy 1989; 5: 298305.
14. Vervest JS, Maurer J, Schambergen R, Bie RA and
Bulstra SK. Effectiveness of physiotherapy after menis-
cectomy. Knee Surg Sports Traumatol Arthrosc 1999; 7:
360364.
15. Kirnap M, Cals M, Turgut AO, Halc M and Tuncel
M. The efficacy of EMG-biofeedback training on quad-
riceps muscle strength in patients after arthroscopic
meniscectomy. NZ Med J 2005; 28: 118224.
16. Krebs DE. Clinical electromyographic feedback follow-
ing meniscectomy: A multiple regression experimental
analysis. Phys Ther 1981; 61: 10171022.
17. Levitt R, Deisinger JA, Remondet Wall J, Ford L and
Cassisi JE. EMG feedback-assisted postoperative reha-
bilitation of minor arthroscopic knee surgeries. J Sports
Med Phys Fitness 1995; 35: 218223.
18. Williams RA, Morrissey MC and Brewster CE. The
effect of electrical stimulation on quadriceps strength
and thigh circumference in meniscectomy patients. J
Orthop Sports Phys Ther 1986; 8: 143146.
19. Basmajian JV. Biofeedback in physical medicine and
rehabilitation. In: DeLisa JA (ed.) Rehabilitation medi-
cine: priciples and practice. Philadelphia: Lippincott-
Raven, 1993, pp.425439.
20. Draper V and Ballard L. Electrical stimulation versus
electromyographic biofeedback in the recovery of
Downloaded from cre.sagepub.com at PENNSYLVANIA STATE UNIV on February 18, 2016
Clinical Rehabilitation 26(3)
quadriceps femoris muscle function following anterior
cruciate ligament surgery. Phys Ther 1991; 71: 455461.
21. Crues J, Mink J and Levy T. Meniscal tears of the knee:
accuracy of MR imaging. Radiology 1987; 164: 445448.
22. Outerbridge RE. The etiology of chondromalacia patel-
lae. J Bone Joint Surg Br 1961; 43: 752757.
23. Zarins B, Boyle J and Harris BA. Knee rehabilitation
following arthroscopic meniscectomy. Clin Orthop 1985;
198: 3642.
24. Lysholm J and Gillquist J. Evaluation of knee ligament
surgery results with special emphasis on use of a scoring
scale. Am J Sports Med 1982; 10: 150154.
25. Briggs KK, Kocher MS, Rodkey WG and Steadman JR.
Reliability, validity, and responsiveness of the Lysholm
knee score and Tegner activity scale for patients with
meniscal injury of the knee. J Bone Surg Am 2006; 88:
698705.
26. Moffet H, Richards CL, Malouin F, Bravo G and
Paradis G. Effects of the type of meniscal lesion on
knee function. J Electromyogr Kinesiol 1998; 8: 411422.
27. Glatthorn JF, Berendts AM, Bizzini M, Munzinger U
and Maffiuletti NA. Neuromuscular function after
arthroscopic partial meniscectomy. Clin Orthop Relat
Res 2010; 468: 13361343.
28. Akima H, Hioki M and Furukawa T. Effect of arthro-
scopic partial meniscectomy on the function of quadri-
ceps femoris. Knee Surg Sports Traumatol Arthrosc
2008; 16: 10171025.
29. Draper V. Electromyographic biofeedback and recovery
of quadriceps femoris muscle function following ante-
rior cruciate ligament reconstruction. Phys Ther 1990;
70: 1117.
30. Lucca JA and Recchiuti SJ. Effect of electromyographic
biofeedback on isometric strengthening program. Phys
Ther 1983; 63: 200203.
31. Gould N, Donnermeyer D, Gammon GG, Pope M and
Ashikaga T. Transcutaneous muscle stimulation to
retard disuse atrophy after open meniscectomy. Clin
Orthop Relat Res 1983; 178: 190197.
32. Lewek M, Rudolph K, Axe M and Synder-Mackler L.
The effect of insufficent quadriceps strength on gait after
anteior cruciate ligament reconstruction. Clin Biomech
2002; 17: 5663.
33. Aglietti P, Buzzi R, Bassi PB and Pisaneschi A. Results
of arthroscopic meniscectomy. Ital J Orthop Traumatol
1986; 12: 315325.
34. Koutras G, Pappas E and Terzidis IP. Crossover train-
ing effects of three different rehabilitation programs
after arthroscopic meniscectomy. Int J Sports Med
2009; 30: 144149.
35. Fabricant PD, Rosenberg PH, Jokl P and Ickovics JR.
Predictors of short-term recovery differ from those of
long-term outcome after arthroscopic partial meniscect-
omy. Arthroscopy 2008; 24: 769778.