The Use of Cryotherapy to Alter Lower Extremity Motoneuron Pool Excitability in a Patient with an Acute Lateral Ankle Sprain- A Case Report

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1 The Use of Cryotherapy to Alter Lower Extremity Motoneuron Pool Excitability in a Patient with an Acute Lateral Ankle Sprain- A Case Report R. Daniel Sherman, SPT Sam Morton, MS, CSCS, USAW Terry L. Grindstaff PT, PhD, ATC, SCS, CSCS

2 Lateral Ankle Sprain Common orthopedic injury 1-2 million/year US High recurrence rate (van Rijn et al, 2008) Mechanism Inversion and Plantarflexion

3 Common Impairments Acute Ankle Sprain Pain Decreased range of motion Decreased balance *Altered motor neuron pool excitability Result of pain and decreased ROM Goal of interventions are to address cause of dysfunction

4 H Reflex Research H-reflex is analogous to muscle stretch reflex Used to study altered motor neuron pool excitability Injected ankle joint effusion (Palmieri et al, 2004; Petrik et al, 1996) Increased soleus, peroneal, tibialis anterior Increased muscle co-contraction aimed at immobilizing Acute lateral ankle sprain (Klykken et al, 2011) Increased soleus, decreased tibialis anterior Positions ankle in the most comfortable position

5 Common Interventions s/p Ankle Sprain Cryotherapy and compression Decrease pain Improve function Cryotherapy Alters motoneuron pool excitability in individuals with chronic ankle instability (McVey et al, 2005) Has not been investigated following an acute injury

6 Purpose To describe changes in soleus and fibularis longus motoneuron pool excitability following an acute lateral ankle sprain

7 Subject 26 year old recreational basketball player height= 194 cm, mass= 105 kg Inversion ankle sprain (left) PMHx: Left leg: no previous ankle injuries Right leg: ankle sprains and fibular fracture resulting in ORIF in 2006 Foot and Ankle Ability Measure ADL: 96%; Sport: 78% Examination Point tenderness along ATF ligament Positive anterior drawer Moderate swelling per visual observation Negative Ottawa Ankle Rules no ankle fracture

8 Motor Neuron pool excitability of Soleus and Fibularis Longus Surface EMG Maximum values for H- reflex and M-response Pre and post intervention H-Max-stimuli delivered in 0.2V increments 3 measurements recorded M-Max delivered in 1.0mV increments beyond H-Max

9 Intervention Cryotherapy & compression (Game Ready) 20 minutes Ice water at 34 F Intermittent Compression 5-50 mmhg (3 min)

10 Results Pre Post Percent Change Soleus H/M Ratio % Fibularis Longus H/M Ratio %

11 Conclusion/Clinical Relevance Cryotherapy and compression may alter motoneuron pool excitability Increase soleus Decrease fibularis longus Clinical relevance May help restore postural control May decrease splinting and increase function

12 Limitations Single subject case study Can not establish cause & effect Ankle circumference not measured Visual interpretation of swelling only Clinical relevance of change in motor neuron pool excitability has not been established

13 Future Research Investigate the use of cryotherapy and compression as interventions to alter lower extremity motoneuron pool excitability and better determine the effects on functional outcomes

14 Questions?

15 References Palmieri R, Ingersoll C, Hoffman M. The hoffmann reflex: methodologic considerations and applications for use in sports medicine and athletic training research. Journal Of Athletic Training [serial online]. July 2004;39(3): Available from: MEDLINE, Ipswich, MA. Klykken L, Pietrosimone B, Kim K, Ingersoll C, Hertel J. Motor-neuron pool excitability of the lower leg muscles after acute lateral ankle sprain. Journal Of Athletic Training [serial online]. 2011;46(3): Available from: MEDLINE, Ipswich, MA. Palmieri R, Ingersoll C, Stone M, et al. Arthrogenic muscle response to a simulated ankle joint effusion. British Journal Of Sports Medicine [serial online]. February 2004;38(1): Available from: MEDLINE, Ipswich, MA. \ Petrik J, Amendola A, Rampersand R, Mabey S, Hayes KC. The effects of an isolated ankle effusion on H-reflex amplitude, viscoelasticity, and postural control of the ankle. Paper presented at 22nd Annual Meeting American Orthopedic Society of Sports Medicine; 1996; Rosemont, IL. Nishikawa T, Grabiner MD. Peroneal motoneuron excitability increases immediately following application of a semirigid ankle brace. J OrthopSports Phys Ther. 1999;29: ; discussion McVey E, Palmieri R, Docherty C, Zinder S, Ingersoll C. Arthrogenic muscle inhibition in the leg muscles of subjects exhibiting functional ankle instability. Foot & Ankle International / American Orthopaedic Foot And Ankle Society [And] Swiss Foot And Ankle Society [serial online]. December 2005;26(12): Available from: MEDLINE, Ipswich, MA. Accessed March 25, 2012.

16 Hoffman Reflex Electrically induced muscle stretch reflex Estimates αmn excitability (Palmieri et al, 2004) Musculoskeletal injuries Effects of therapeutic modalities Pain response Arthrogenic muscle response with joint effusion

17 Hoffmann reflex (H-reflex) and muscle response (M-wave) pathways. (Palmieri et al, 2004)

18 Sensory Stimuli and Inhibition Fig 2. Pickar, 2002

19 Hoffmann Reflex Measure of motoneuron (MN) recruitment Electrical stimulation of mixed nerve Two distinct EMG responses M-response- efferent motor axon H-reflex- afferent (Ia sensory) fibers

20 H-Reflex H-reflex Measure of maximal reflex activation (MN pool) M-response Represents activation of entire MN pool H max /M max Proportion of entire MN pool that can be recruited

21 H-Reflex Limitations Unable to determine amount of muscle activation in single session Individual variability Electrically induced reflex does not occur naturally Muscle spindle is neglected

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