Outline. ⢠Challenges / Targets. ⢠Pre-op work up. ⢠Time frame targets. ⢠Hurdles. ⢠Optimization. ⢠Outcome analysis. ⢠Conclusion. ⢠Take Home Message ...
Post Operative Rehabilitation in ACL Reconstruction
J.Mohanakrishnan PhD Physical Therapist Jipmer
Ohm Gurubhyo Namaha Harihi Ohm……..
Lynn Snyder-Mackler PT, Professor, Department of Physical Therapy, University of Delaware
Outline • • • • • • • •
Challenges / Targets Pre-op work up Time frame targets Hurdles Optimization Outcome analysis Conclusion Take Home Message
Challenges / Targets • Mobility(M) • M(Fle) 90o/M(Ext) 5o
• Strength(S) • S(Q’ceps) 50 %
• Loading(L) – Full with support, Full with out support • (Example - L+s , L-S)
Pre- operative work up • • • • •
Full Extension Containing the joint (Cryopacks) Progressive range of motion Restoration of Neuro-Muscular Control Progressive Loading
Time frame Targets
I Year Definite symmetry, Hop test > 90% 3 Months Symmetry , KOS-sports > 85% 2 Months Quads >80%, Normal gait I Month E(70),F(Full),Quads (>50% ) II Week E(5-7 o), F(>90o),Quads (>25% ), L+s , KOS-ADL > 85%
I Week
E(0o), F(80o) ,Quads activation, L+s
*Adams, D., Logerstedt et al(2012). Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion–Based Rehabilitation Progression. The Journal of Orthopaedic and Sports Physical Therapy, 42(7), 601–614. h
Present Status (JIPMER)
Hurdles
CKC vs OKC • Both are beneficial • Synergic pattern is Superior to selective training • Holistic / Conceptual approach is essential • Iso-Inertial training is suitable for sports specific training
*Daniel Jewiss, Cecilia Ostman, and Neil Smart, 2017 “Open versus Closed Kinetic Chain Exercises following an Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis,” Journal of Sports Medicine
Evidence
Loaded vs Unloaded • Loaded is superior • Cautious progression is mandatory • Absolute contraindication in meniscal repair
WB Vs NWB • Essential in restoring symmetry • Gradual and timely weaning avoids gait deviation • Look out for meniscal repair in early loading
*Palmieri-Smith R, Lepley L(2015). Quadriceps Strength Asymmetry Following ACL Reconstruction Alters Knee Joint Biomechanics and Functional Performance at Time of Return to Activity. The American journal of sports medicine..
Bracing Vs Unbracing • • • •
May be beneficial Facilitates early Loading Reduces the incidence of KED Proximal muscular facilitation
Evidence
Flexion Vs Extension • Achieving full extension is the key • Gradual gain in flexion ensures functional independence
*M.S. Haro, K.D. Shelbourne 2015 Prevention and Management of Loss of Motion in Anterior Cruciate Ligament Surgery ,Operative tecniques in sports medicine
Full extension!
Return To Sports
Only about half of patients return to competitive sport after ACL reconstruction surgery
Ardern CL et al 2011,Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med Jun;45(7):596-606
Neuro-Muscular vs Muscular Predictive Biomechanical factors • Net internal rotator moment of the uninvolved hip upon landing • Increased frontal plane knee motion during landing • Sagittal plane knee moment asymmetries at initial contact • Deficits in postural stability
Stasi, S. D., Myer, G. D., & Hewett, T. E. (2013). Neuromuscular Training to Target Deficits Associated With Second Anterior Cruciate Ligament Injury. The Journal of Orthopaedic and Sports Physical Therapy, 43(11), 777–11.
Neuro-Muscular vs Muscular Phase
Tasks-Components
Goal
1
Bilateral +Unidirectional
Basics
2
Unilateral + Challenge the base of support Basics + Task
3
Unilateral + Perturbation
Basics + Task + Balance
4
Unilateral + Unstable Surfaces + Challenging Perturbations + Explosive complex movement patterns
Basics+ Quick + Precision+ Feed forward
Stasi, S. D., Myer, G. D., & Hewett, T. E. (2013). Neuromuscular Training to Target Deficits Associated With Second Anterior Cruciate Ligament Injury. The Journal of Orthopaedic and Sports Physical Therapy, 43(11), 777–11.
Optimization
Goals • • • •
Strength Index Mobility Index Balance Index Return to (Pre-op )activity/sports
Altered Loading!
Perturbation
Per. (B/L Semi squats)
Per. (Semi squats)
Per. (Feed forward)
Per. (Feed forward)
Outcome Analysis
Outcome measures • IKDC • Lysholm Knee Scale • Tegner activity level scale
Activity measures
• Hop Test
Conclusion • Adequate pre-operative physical training with counseling followed up post operatively by timed progression with regular follow up and adequate reassurance ensures complete rehabilitation
Take Home Message A well planned and a well executed “Physical Therapy” is the corner stone in ACL reconstruction procedures
Merci…Beaucoup
