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A Thesis Entitled Relationship Between Hamstring Strength And A Thesis entitled Relationship Between Hamstring Strength and Agonist-Antagonist Co-Activation by Meghan Gregoire Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Master of Science Degree in Exercise Science with a Concentration in Athletic Training ___________________________________________ Grant Norte, PhD, AT, ATC, CSCS, Committee Chair ___________________________________________ Neal Glaviano, PhD, AT, ATC, Committee Member ___________________________________________ Amanda Murray, PT, DPT, PhD, Committee Member ___________________________________________ Lucinda Bouillon, PT, DPT, PhD, Committee Member ___________________________________________ Cyndee Gruden, PhD, Dean College of Graduate Studies The University of Toledo May 2019 Copyright 2019, Meghan Gregoire This document is copyrighted material. Under copyright law, no parts of this document may be reproduced without the expressed permission of the author. An Abstract of Relationship Between Hamstring Strength and Agonist-Antagonist Co-Activation by Meghan Gregoire Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Master of Science Degree in Exercise Science The University of Toledo May 2019 Introduction: Anterior cruciate ligament (ACL) injury is common among females due to several neuromuscular risk factors. Decreased hamstrings to quadriceps (H:Q) ratio is one neuromuscular factor that place females at an increased risk of ACL injury. Increased activation of the hamstrings during functional tasks help assist the static stabilizes of the knee, decrease strain on the ACL and reduce anterior tibial translation. Objectives: The objective of this study was to (1) identify the relationship between H:Q strength and co- activation ratio in the medial and lateral compartments of the knee during the stance phase of walking gait as well as (2) compare H:Q ratio between high and low groups. Methods: Ten healthy active females participated. Isokinetic flexion/extension contractions were assessed during five reputations at 60°/s, isokinetic peak torque (Nm/kg) was recorded and normalized to body mass. Maximal voluntary isokinetic contraction of the knee extensors and flexors was assed at a joint angle of 60°. Participants were asked to walk at three miles per hour for four minutes on a treadmill. Participants were given a three-minute warm-up at a preselected speed of three miles per hour. At the end of the warm up patients were asked to quantify their rate of perceived exertion. Surface electromyography was used to quantify muscle activity of the iv quadriceps (vastus lateralis and vastus medialis) and hamstrings (semitendinosus and biceps femoris) during the last minute of the walking task and was normalized to the mean value of the MVIC data. Results: A significant moderate correlation was found between H:Q strength and co-activation in the lateral compartment (r= 0.663, p=0.052). The low H:Q strength group had higher co-activation when compared to the high H:Q strength group. A significant difference (p=0.034) was found between low H:Q strength and co-activation in the lateral compartment. There was no relationship found in the medial compartment when comparing H:Q strength and co-activation. Conclusion: The results of this study indicate that lower hamstrings to quadriceps strength is associated with higher hamstrings to quadriceps co-activation in the lateral compartment during the loading response of walking. v Acknowledgements First and foremost, I would like to thank my committee chair and thesis advisor, Dr. Grant Norte, without his unwavering support and expertise the completion of this study would not have been possible. I would also like to thank those on my thesis committee, Dr. Neal Glaviano, Dr. Amanda Murry and Dr. Lucinda Bouilion, for their contribution and continued involvement throughout the entire research process. vi Table of Contents Abstract iii Acknowledgements vi Table of Contents vii List of Tables viii List of Figures ix List of Abbreviations x I. Manuscript 1 A Introduction 1 B. Methods a. Design 2 b. Participants 3 C. Procedures a. Patient Reported Outcomes 3 b. Limb Dominance 3 c. Surface EMG Set-up 3 d. Isokinetic Strength 4 e. Maximal Voluntary Isometric Contraction 4 f. IMU Set-up 4 g. Walking Task 5 D. Data Processing 5 a. Statistical Analysis 5 E. Results 5 vii a. Medial Compartment 5 b. Lateral Compartment 6 F. Discussion 8 G. Conclusion 11 References 12 Appendices A. The Problem 17 B. Literature Review 19 C. Additional Methods 26 D. Back Matter 51 E. Bibliography 54 viii List of Tables Table 1 Physical Characteristics of the Subjects ...........................................................3 ix List of Figures Figure 1 Relationship between H:Q strength and co-activation in the medial compartment. .....................................................................................................6 Figure 2 Co-activation: High versus low strength in the medial compartment. ..............7 Figure 3 Individual muscle response of the medial compartment. ..................................7 Figure 4 Relationship between strength and co-activation in the lateral compartment. ..7 Figure 5 Co-Activation: High versus low strength in the lateral compartment ...............8 Figure 6 Individual muscle response of the lateral compartment ....................................8 Figure C1 Informed Consent ............................................................................................31 Figure C2 Tegner Activity Scale .....................................................................................37 Figure C3 Marx Activity Scale .........................................................................................37 Figure C4 International Physical Activity Scale ..............................................................38 Figure C5 Eligibility Checklist ........................................................................................42 Figure C6 Data Collection Form ......................................................................................43 x List of Abbreviations ACL............................Anterior Cruciate Ligament EMG ...........................Electromyography H:Q .............................Hamstrings to Quadriceps IMU ............................Inertial Measurement Units MVIC .........................Maximal Voluntary Isometric Contraction xi Chapter One Manuscript Introduction Non-contact anterior cruciate ligament (ACL) injuries account for 70% of all ACL injuries.1 The most common mechanism of injury occurs in sports that require pivoting, rapid change of direction, as well as frequent single-leg landings.2,3 It is important to recognize that females with muscular imbalances are more likely to suffer from any lower extremity injury.4 Also, female athletes are also four to six times more likely to suffer from a non-contact ACL injury than males.4,5 It has been noted that decreased strength of the quadriceps and hamstring muscles, decreased hamstring stiffness, delayed hamstring activation, decreased joint proprioception and decreased hamstrings to quadriceps (H:Q) strength ratio are all neuromuscular factors that have been identified to place females at increased risk of ACL injury.6-9 The most commonly reported strength ratio of the muscles of the knee is concentric hamstring-quadriceps ratio.10 H:Q ratios of 0.6 and greater have been reported to decrease the risk of hamstring and ACL injuries,11 where ratios closer to 1 indicate high activation of the hamstring muscles.12 However, H:Q ratio is dependent on many different factors including angular velocity, test position, population group and use of gravity compensation each one of these factors can change the results of the study.10 Isokinetic strength testing at an angular velocity of 60°/s is the most commonly reported parameter to establish H:Q strength. The average H:Q strength ratio for females at an angular velocity of 60°/s has been reported as 0.53.13 Activation of the hamstrings during functional tasks such as running and jumping can reduce anterior tibial translation and decrease strain on the ACL. 14-16 1 Unbalanced co-activation of the hamstrings and quadriceps place females at increased risk for lower extremity injury.17,18 Co-activation is reported as the simultaneous activity of muscles acting around a joint.8 Co-activation of the hamstrings and quadriceps help assist the static stabilizers as well as helps balance the surface pressure on articular surfaces of the knee joint.19 Increased co-activation is essential in early ACL reconstruction rehabilitation to help reduce strain on the new ACL graft, to allow for graft healing. Strength, recruitment and co-activation of the quadriceps and hamstring are vital components of successful stabilization and protection of the knee joint.20,21 However, increased co-activation could potentially have a negative long term effect on the knee joint. Increased co-activation at the knee joint implies that there is an increase in compressive forces across the joint, which may lead to cartilage loss.22 Previous research has also shown that increased stability due to increased hamstring activity, can cause accelerated joint degeneration at the knee.23 To date there are no studies looking at the relationship between thigh muscle imbalance and co-activation at the knee. Therefore the purpose of this study is to look at the relationship between hamstring to quadriceps coactivation relative to hamstring and quadriceps strength.
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