What exercise uses muscle strength in a coordinated manner to stabilize movements

The neuromuscular exercise (NEMEX) program is aimed at improving sensorimotor control and attaining functional joint stabilization by addressing the quality of movement in all 3 movement planes.[1] It’s an evidence-based education and supervised neuromuscular exercise program targeting hip and knee Osteoarthritis. It forms part of successful implementation program for people with hip and knee osteoarthritis termed GLA:D™ (program developed by Ewa Roos and Soren Skou).

Key Facts

This 3 minute video outlines NEMEX within the GLAD program.

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The rationale for Neuromuscular Exercises[edit | edit source]

Neuromuscular control is defined as the unconscious trained response of a muscle to a signal regarding dynamic joint stability. The movements of the lower extremity, including the knee joint, are controlled through this system, which needs to provide the correct messaging for purposeful movement[4]. Neuromuscular training programs should address several aspects of sensorimotor function and functional stabilization to improve objective function and alleviate symptoms.

The neuromuscular training method that is described is based on biomechanical and neuromuscular principles and aims to improve sensorimotor control and achieve compensatory functional stability. Unlike conventional strength training, neuromuscular exercise addresses the quality of movement and emphasizes joint control in all three biomechanical/movement planes.[4]

Neuromuscular exercise has effects on functional performance, biomechanics, and muscle activation patterns of the surrounding joint musculature[5]. Simply restoring mechanical restraints is not enough for the functional recovery of a joint because the coordinated neuromuscular controlling mechanism required during daily living and sport-specific activities would be neglected.

Rehabilitation programs cannot alter mechanical joint instability but may affect neuromuscular control and dynamic joint stability. A lag in the neuromuscular reaction time can result in dynamic joint instability with recurrent episodes of joint subluxation and deterioration. Therefore, both mechanical stability and neuromuscular control are probably important for long-term functional outcome, and both aspects must be considered in the design of a neuromuscular rehabilitation program.[6]

Sensorimotor control or neuromuscular control is the ability to produce controlled movement through coordinated muscle activity. Functional stability or dynamic stability is the ability of the joint to remain stable during physical activity.

Mechanisms for Sensorimotor Deficiency[edit | edit source]

Impairments are present at different levels of the sensorimotor system,  from sensory input through integration and processing of information in the central nervous system to motor output to perform voluntary movements and maintain postural control. It has been suggested that sensorimotor dysfunction also may play a role in the development and progression of degenerative joint disease[7].

Neural inhibition caused by factors such as pain, swelling, inflammation, joint laxity, and damage to sensory receptors in the joint prevents the muscle to be activated fully likely through altered excitability of spinal and supraspinal pathways.[8]

Sensorimotor deficiencies also were found in the non-injured leg compared with controls possibly because of factors such as physical inactivity after the injury, inherently poor function, and/or disturbed sensory feedback from the injured joint with an inhibitory effect of muscle activation also on the non-injured side.

Principles of Neuromuscular Exercises[edit | edit source]

Neuromuscular training programs are found effective in improving function and reducing symptoms in people with knee issues[9]. Neuromuscular exercises in lower extremities emphasise on the quality and efficiency of movement, and the alignment of trunk and joints. They are usually multi-joint exercises performed in functional weight-bearing positions.

Exercises performed in closed kinetic chains in different positions (e.g., lying, sitting, standing) help in improving the sensorimotor control, and obtaining a low, evenly distributed articular surface pressure by muscular coactivation.

These exercises help to attain:

1. equilibrium of loaded segments in static and dynamic situations
2. postural control in situations resembling conditions of daily life and more demanding activities[7].

These exercise programmes need to be individualized because:

1. symptoms and functional limitations are heterogeneous in people with an injury or disease
2. the patient’s sensorimotor function differs individually
3. various factors related to the individual and the injury/disease need to be taken into account.[10]

Conclusion[edit | edit source]

There is evidence underlining the positive effects of Neuromuscular exercises in lower limb impairments, when given in conjunction with structured education. The quality of life, physical function and ADLs improved over a period of time when this exercise protocol was followed. However, its effect on pain still needs to be investigated further.[11]

Resources[edit | edit source]

References[edit | edit source]

1. ↑ Clausen B, Holsgaard-Larsen A, Roos EM. An 8-week neuromuscular exercise program for patients with mild to moderate knee osteoarthritis: a case series drawn from a registered clinical trial. Journal of Athletic Training. 2017 Jun;52(6):592-605. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5488851/(accessed 28.5.2022)
2. ↑ Trek NEMEX Available:https://nemex.trekeducation.org/ (accessed 28.5.2022)
3. ↑ Target Physio GLA:D Hip and Knee Osteoarthritis Info Video Available:https://www.youtube.com/watch?v=-Xkiad0x7_I(accessed 28.5.2022)
4. ↑ 4.0 4.1 Ageberg E, Link A, Roos EM. Feasibility of neuromuscular training in patients with severe hip or knee OA: the individualized goal-based NEMEX-TJR training program. BMC musculoskeletal disorders. 2010 Dec;11(1):126.
5. ↑ Clausen B. Neuromuscular exercise as treatment for knee osteoarthritis in middle aged patientsNeuromuscular exercise as treatment for knee osteoarthritis in middle aged patients(Doctoral dissertation), Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet).
6. ↑ Risberg MA, Mørk M, Jenssen HK, Holm I. Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. Journal of Orthopaedic & Sports Physical Therapy. 2001 Nov;31(11):620-31.
7. ↑ 7.0 7.1 Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.
8. ↑ Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. InSeminars in arthritis and rheumatism 2010 Dec 1 (Vol. 40, No. 3, pp. 250-266). WB Saunders.
9. ↑ Zech A, Hubscher M, Vogt L, Banzer W, Hansel F, Pfeifer K. Neuromuscular training for rehabilitation of sports injuries: a systematic review. Med Sci Sports Exerc. 2009 Oct 1;41(10):1831-41.
10. ↑ Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exercise and sport sciences reviews. 2015 Jan 1;43(1):14-22.
11. ↑ Health Quality Ontario. Structured Education and Neuromuscular Exercise Program for Hip and/or Knee Osteoarthritis: A Health Technology Assessment. Ont Health Technol Assess Ser. 2018 Nov 2;18(8):1-110. PMID: 30443280; PMCID: PMC6235070.