37
Evidence-based Clinical Protocols 2) Patellofemoral Dysfunction CLINICAL EDITORS Morgan Boyle, III, MEd, ATC Steve Jacoby, ATC EDITOR Terry McLaughlin, MS, ATC CONTRIBUTORS Tab Blackburn, PT, ATC Terry Giove, PT Woody Goffinett, ATCs Steve Hoffman, PT, ATC Drew Hurley, ATC/L Ginger Kurmann, PT, ATC Terry Malone, PT, ATC John Stemm, MEd, PT, ATC Sarah Sydor, ATC Steve Tippett, PT, ATC Kim VanFleet, MS, ATC/L Michael Voight, PT, ATC Gary Wilkerson, Ed.D, ATC FN: 03-027

Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

Embed Size (px)

Citation preview

Page 1: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

Evidence-based

Clinical Protocols2) Patellofemoral Dysfunction

CLINICAL EDITORS

Morgan Boyle, III, MEd, ATC

Steve Jacoby, ATC

EDITOR

Terry McLaughlin, MS, ATC

CONTRIBUTORS

Tab Blackburn, PT, ATC

Terry Giove, PT

Woody Goffinett, ATCs

Steve Hoffman, PT, ATC

Drew Hurley, ATC/L

Ginger Kurmann, PT, ATC

Terry Malone, PT, ATC

John Stemm, MEd, PT, ATC

Sarah Sydor, ATC

Steve Tippett, PT, ATC

Kim VanFleet, MS, ATC/L

Michael Voight, PT, ATC

Gary Wilkerson, Ed.D, ATC

FN: 03-027

Page 2: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

INTRODUCTION........................................................................................................................................................................2-1REHABILITATION GOAL................................................................................................................................................2-2REHABILITATION PROGRAM CONSIDERATIONS............................................................................................................2-2DEFINITIONS...............................................................................................................................................................2-2

POST-INJURY/PRE-SURGERY PHASEGOALS (To progress to Phase I) ...................................................................................................................................2-3

PHASE I: Reduction of Acute SymptomsGOALS (To progress to Phase II)...................................................................................................................................2-3CLINICAL EVALUATION................................................................................................................................................2-3CLINICAL TREATMENT OPTIONS ..................................................................................................................................2-5SUPERVISED PROGRAM...............................................................................................................................................2-7HOME PROGRAM .......................................................................................................................................................2-8REPORTS .....................................................................................................................................................................2-8

PHASE II: Range of Motion and Initial StrengtheningGOALS (To progress to Phase III) ..................................................................................................................................2-9CLINICAL EVALUATION..............................................................................................................................................2-10CLINICAL TREATMENT OPTIONS ................................................................................................................................2-11SUPERVISED PROGRAM.............................................................................................................................................2-13HOME PROGRAM .....................................................................................................................................................2-14REPORTS ...................................................................................................................................................................2-14

PHASE III: Initial Weight-bearing and Intermediate StrengtheningGOALS (To progress to Phase IV) ...............................................................................................................................2-15CLINICAL EVALUATION..............................................................................................................................................2-16CLINICAL TREATMENT OPTIONS ................................................................................................................................2-17SUPERVISED PROGRAM.............................................................................................................................................2-19HOME PROGRAM .....................................................................................................................................................2-21REPORTS ...................................................................................................................................................................2-22

PHASE IV: Return to ActivityGOALS......................................................................................................................................................................2-23CLINICAL EVALUATION..............................................................................................................................................2-24CLINICAL TREATMENT OPTIONS ................................................................................................................................2-25SUPERVISED PROGRAM.............................................................................................................................................2-27HOME PROGRAM .....................................................................................................................................................2-29REPORTS ...................................................................................................................................................................2-30

STABILITY INDEX.....................................................................................................................................................................2-31

REFERENCES ...........................................................................................................................................................................2-33

© BIODEX MEDICAL SYSTEMS, INC.

EVIDENCE-BASED CLINICALPROTOCOL FOR

REHABILITATION OFPATELLOFEMORAL DYSFUNCTION

table of contents

Page 3: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

INTRODUCTION clinical protocol

The information contained in this manual is presented by Biodex Medical Systems as part of our commitment to providecontinuing service to medical professionals and to the community at large.

IMPORTANT: READ BEFORE PROCEEDING

Suggested courses of rehabilitation for any specific conditions are meant as references of generalized program models, and are notintended as precise prescriptions for individual treatment. The data is a compilation of information based on the work of acknowl-edged experts that have been published in respected journals.

We believe it is representative of current trends in scientifically derived and clinically proven principles and methods of rehabilitationmedicine. Much of the published information that we review, however, is based on research and case studies involving very specif-ic patient or test subject populations. Many research subjects, for instance, are highly-trained and well conditioned athletes prior totreatment, or are chosen because they have no known medical problems other than the condition involved in the study. It shouldtherefore be noted that the application of any published methods should be done with extreme care and should be based onsound clinical judgment after thorough evaluation of the individual patient’s capabilities, limitations, and overall medical condition.In the presence of any doubt, or question, regarding the efficacy of initiating a procedure, seek advise from appropriate sourcesand/or consult with the patient’s physician.

Please send any comments or concerns to:

c/o Clinical EducationBiodex Medical Systems, Inc.20 Ramsay Rd.Shirley, NY 11967-4704

A special thanks goes to Terry McLaughlin, MS, ATC, Steven Jacoby, ATC and Morgan Boyle III, MEd, ATC, for their assistance in theorganization of this protocol.

© BIODEX MEDICAL SYSTEMS, INC. 2-1

Page 4: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

2-2 INTRODUCTION

REHABILITATION PROGRAM CONSIDERATIONS:

To successfully rehabilitate the patient with patellofemoral dysfunction the therapy team must understand:

• Basic anatomy and function of the patellofemoral joint and associated structures

• Mechanism of injuries

• Healing process following initial injury

• Methods to optimize:Patient compliance (assess potential; establish realistic goals)Reduction of pain and edemaIncreases in ROMIncreases in strength, power, and enduranceImprovement of agility (balance; proprioception)

• Appropriate allocations of resources and time to individual patient program

• Means of evaluating individual and overall program effectiveness

DEFINITIONS:

Goals: Specific improvements which must be met in order for patient to progress to next phase.

Clinical Evaluation: Evaluations that are only to be performed by certified and/or licensed ATC, PT or OT, in association withsupervising physician’s diagnosis.

Clinical Treatment Options: Treatment options that should only be performed under the supervision of certified and/or licensed clinicians.

Supervised Program: Rehabilitation program that should be done only under the direction of appropriately qualified personnel (i.e.Certified Strength and Conditioning Specialist).

Home Program: Rehabilitation program that after proper instruction by supervising clinician, can be done by patient without supervision.

Reports: Test reports are to be completed at the end of each phase to ensure progress to the next phase is indicated.

Page 5: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

PHASE I

GOALS:

• Mentally prepare patient for rehabilitation

• Education of patient to understand the problems of PF dysfunction

• Identify specific needs of patient and potential problems

• Restore normal flexibility

• Decrease joint effusion 4

• Maintain ankle ROM and strength

• Full knee PROM

• Decrease pain at rest to 0**Analog pain scale of 0-10

• Normalize gait deviations and correct biomechanical faultsStep Symmetry

• Identify contributory factors to conditionVastus Medialis (VMO): Vastus Lateralis (VL)

• Increase VMO:VL strength ratio to 50%

• OKC Proprioception < 40% deficit bilaterallyOpen Kinetic Chain (OKC)

• Isometric strength:QUAD < 30% deficitHAM < 30% deficit

• Stability Index*:70% of Normative value for bilateral stance*Note: See page 36 for normative values

CLINICAL EVALUATION:

• General patient history and observation

• Pain scale: 19

Severity, location, duration, quality, radiation

• Edema:Degree and character of swellingPatella ballottement test; mid-patella circumferential measurement

• Active and Passive range of motion

• Patella assessment:Physical exam palpation and radiographs

© BIODEX MEDICAL SYSTEMS, INC. 2-3

reduction of acute symptoms

Page 6: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL EVALUATION (CONT):

• Neurological assessment:Myotomes, dermatomes and reflexes for L2 – S1

• Clinical tests:Supine hamstring flexibility measurementOber test (IT Band tightness) 21

Thomas test (Rectus femoris tightness)Plica test

• Palpation/Observation: 17

Identify VMO dysplasiaBiofeedback ratio

• Goniometry: 12

Knee flexion/extension (0-135º knee flexion) active and passive

• Patella assessment/mobility:Radiological: Patella alto (congenital formation) Insall and Salvati method, independent of the knee flexion angle, thelength of the patella tendon should be equal to the longest (diagonal) length of the patella ligament. Patella baja (postsurgical condition). 13

Palpable: Tested with knee flexion at 30º-45º of knee flexion over a pillow or examiners knee. The patella should glideone half its width medially & laterally. 14

Physical: 18

Medical/lateral tiltInferior/superior tiltMedial/lateral glideInternally/externally rotated

TEST: Biodex Gait Trainer evaluationGait symmetryA-angleQ-AngleFoot biomechanics

*NOTE: The treatment of patellofemoral pain (chondromalacia patella or patellofemoral syndrome) has been shown tobe more successful when foot orthoses are used in conjunction with other treatment modalities.3

TEST: Bilateral Isometric knee extension/flexion evaluationDevice: Biodex Multi-Joint SystemPad Placement: NormalSetup: 60º of knee flexionMode: IsometricSets and Duration: 1 x 10 reps x 5 seconds eachRecommendations: Must be performed pain free and without crepitis

TEST: Biodex Open Kinetic Chain (OKC) ProprioceptionDevice: Biodex Multi-Joint SystemPassive and Active Joint position sensePattern: Knee extension/flexionMode: Passive and IsokineticSets and Reps: 1 x 5 each target angleTarget angles: 90º/60º/30ºRecommendations: There should be no incidence of pain or inhibition with movement

2-4 PHASE I: REDUCTION OF ACUTE SYMPTOMS

Page 7: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS:

• Rehabilitation process education:Introduce patient to clinic/staffDescribe rehabilitation processDefine goals to the patient

• Patellofemoral bracing or strapping 15

NOTE: It has been noted in the literature that by strapping the knee, you will increase not only the force output bothconcentrically and eccentrically, but decrease the perceived amount of pain.

This was not noted for the bracing. Bracing increased eccentric force and decreased pain, but noconcentric changes were noted. 6

• Avoid Weight-bearing ADL's which compromise articular surface 7

• Correct lower extremity biomechanical with ambulation training

• Reduce joint effusion/manage pain:P.R.I.C.E.

• Patella mobilizations for hypomobility PRN:Medial, superior and inferior glidesStress medially to stretch lateral retinaculum

• Cardiovascular training:

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticDuration: 10 minSpeed: 120 deg/secIntensity: 70% Maximum Heart Rate (MHR)

Device: Biodex Upper Body CycleMode: IsokineticDuration: 5-7 minSpeed: 90 deg/secIntensity: 70% Maximum Heart Rate (MHR)

• Isometric strengthening:Device: Biodex Multi-Joint SystemMode: IsometricPattern: Knee Ext/FlexSetup: 90º/60º/30º/0ºSets and Reps: 2 x 10 x 10 sec hold eachRecommendation: Use electrical stimulation to increase motor unit recruitment.6

© BIODEX MEDICAL SYSTEMS, INC. 2-5

Page 8: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS (cont):

• Quadriceps re-education for disuse atrophy:Device: "Quad sets" with Electro Neuromuscular Stimulation (ENS) and biofeedback. 27

Enhance VMO:VL ratio towards uninvolved level (normal is 1:1)Sets and Reps: 3 x 10 –12Duration: 10 sec holdRepeat: 3-4 times daily

Device: Biodex Multi-Joint SystemPattern: Knee FLEX/EXTPad Placement: NormalROM: 45º of flexion to full extensionMode: PassiveSpeed: 10 deg/secPause: 10 sec in extensionDuration: 10 min.Recommendations: Set torque limits to half of limb weight. Instruct patient to maintain constant movement of 10 deg/sec.Patient should perform a "Quad set" during pause. Use electrical stimulation to increase motor unit recruitment. 6

• Weight-bearing Proprioception/Stability:Device: Biodex Balance SystemStance: Bilateral (Two feet)Eyes: OpenSetup: Dynamic Balance TrainingStability level: 8 (most stable) progress to 6 (less stable)Duration: 3 bouts of 30 sec (progress to 5 bouts as tolerated)Recommendations: Utilize Biodex Unweighing System if patient is able to partially weigh bear (PWB) during exercise.Unweigh patient up to 60% of body weight. Patient should be instructed to hold handrails during initial training.

• Weight-bearing Proprioception:Device: Biodex Multi-Joint SystemPassive and Active Joint position sensePattern: Knee FLEX/EXTMode: Passive and IsokineticSets and Reps: 3 x 5 each target angleTarget angles: 90º/60º/30ºRecommendations: There should be no incidence of pain or inhibition with movement

• Flexibility program: 23

Hamstrings seatedIT band Supine over the tableQuadricepsGastrocnemius/SoleusHold each stretch for 20 sec repeat 5-6 timesNOTE: May have to hold some quad stretching if the patient has medial/adductor patella facet syndrome.

2-6 PHASE I: REDUCTION OF ACUTE SYMPTOMS

Page 9: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

SUPERVISED PROGRAM:

(frequencies prescribed on individual basis)

• Reduce swelling and manage pain:P.R.I.C.E.

• Patellofemoral bracing/strapping

• Muscle re-education for disuse atrophyBiofeedback Electrical Stimulation (EMS) as prescribed

• Cardiovascular Training:

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticDuration: 12 minSpeed: 110 deg/secIntensity: 75% MHR

Device: Biodex Upper Body CycleMode: IsokineticDuration: 7-10 minSpeed: 80 deg/secIntensity: 75% MHR

Device: Biodex Rehabilitation TreadmillSpeed: 2.0 mphIncline: O%Position: Straight ahead walkingTime: 5-7 minIntensity: 65-75% MHR

• Flexibility:Hamstrings seatedIT bandSupine over table rectus femoris/quadsGastrocnemius/SoleusHold each stretch for 20 sec repeat 5-6 times

• Muscle Re-education and strengthening:Leg Raises: FLEX/EXT/ADDHold from initiating abduction leg raises due to possible tight lateral structures andweak medial musculature. 9

Seated Isometrics90, 75, and 60º of knee flexion 1

Sets and Reps: 3 x 10 each angle

© BIODEX MEDICAL SYSTEMS, INC. 2-7

Page 10: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

HOME PROGRAM

• Control pain and edema:P.R.I.C.E.Modalities/Medications as prescribed

• Range of Motion (ROM) exercises:PROM knee FLEX/EXT with contralateral limbSets and Reps: 3 x 10Repeat: 4x/day

• Strengthening"Quad sets" at 0º and 90º of knee flexionSets and Reps: 1x 10Hold contraction: 10 secondsRepeat: 2x/day

Mini squats:Sets and Reps: 3 x 10Repeat: 2x/dayRecommendations: Stand between two chairs, feet shoulder width apart, keeping the patellaover the second metatarsal. Squat down to 30º knee flexion and slowly return to standing.

• Flexibility training: (static stretch only)QuadricepsHamstringsIT bandGastrocnemius/SoleusSets and duration: 5-6 x 20 secondsRepeat: 2x/day

REPORTS:

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60 deg/sec

• Biodex Gait Trainer evaluation

• Biodex Stability Index

2-8 PHASE I: REDUCTION OF ACUTE SYMPTOMS

Page 11: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

PHASE II

GOALS:

• Decrease pain and inflammation

• Increase flexibility with pain-free PROM and AROM

• Decrease symptoms with ADL’s

• Restore full AROM

• Restore normal patellar mobility

• Increase cardiovascular conditioning

• Increase VMO:VL ratio to > 75%

• OKC Proprioception < 25% deficit

• Isometric QUAD/HAM strength < 10% deficit

• Isokinetic QUAD/HAM strength < 30% deficit

• Stability Index: Bilateral stance < 25% deficit from normative goal

© BIODEX MEDICAL SYSTEMS, INC. 2-9

range of motion & initial strengthening

Page 12: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL EVALUATION:

• Pain scale:Severity, location, duration, quality, radiation

• Edema:Degree and character of swellingPatella ballottement test; mid-patella circumferential measurement

• Goniometry: 12

Knee flexion/extension (0-135º knee flexion) active and passive

• Biofeedback evaluation: Vastus medialis:lateralis (VMO:VL) ratio 16

TEST: Bilateral Isometric knee FLEX/EXT evaluationDevice: Biodex Multi-Joint SystemPad Placement: NormalSetup: 30º/60º/90º of knee flexionMode: IsometricSets and Duration: 1 x 10 reps x 5 seconds eachRecommendations: Must be performed pain free and without crepitis

TEST: Bilateral Isokinetic knee FLEX/EXT evaluationDevice: Biodex Multi-Joint SystemPad Placement: normalSetup: pain free ROMMode: IsokineticSets and Reps: 1 x 5 @ 180 deg/sec1 x 15 @ 300 deg/sec

Recommendations: ROM should be limited to avoid crepitis and allow for safe speed training.

TEST: Bilateral OKC Proprioception testDevice: Biodex Multi-Joint SystemPassive and Active position sensePattern: Knee FLEX/EXTMode: Passive and IsokineticSets and Reps: 1 x 3 each target angleTarget angles: 90º/60º/30ºRecommendations: There should be no incidence of pain or inhibition with movement

TEST: Stability Index 24

Device: Biodex Balance SystemStability level: Level 6Trials and Duration: 3 x 30 secondsEyes: openRecommendation: Prepare to support patient during test. Instruct patient to use handrails as needed.

2-10 PHASE II: RANGE OF MOTION AND INITIAL STRENGTHENING

Page 13: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS:

• Reduce joint effusion/manage pain:P.R.I.C.E.

• Patella mobilizations:Medial, superior and inferior glides

• Patellofemoral bracing/strapping

• Cardiovascular Training:

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticDuration: 15 minSpeed: 120 deg/secIntensity: 75% MHR

Device: Biodex Upper Body CycleMode: IsokineticDuration: 10 minSpeed: 90 deg/secIntensity: 75% MHR

• Retroambulation: 8

Device: Biodex Rehabilitation TreadmillSpeed: 2.0 mphIncline: 12%Duration: 10 min

• Postural Control Exercises

• Strengthening:Device: Biodex Multi-Joint SystemMode: IsometricPattern: Knee Ext/FlexSetup: 90º/60º/30º/0ºSets and Reps: 2 x 10 x 10 sec hold eachRecommendation: With poor "quad set", use electrical stimulation to increase motor unit recruitment.

Device: Biodex Multi-Joint SystemPattern: knee FLEX/EXTMode: IsokineticPad Placement: normalSetup: Pain-free ROM and limit crepitisSpeeds: 180 and 300 deg/sec in both directions27

Sets and Reps: 3 x 15 (progress to 20-30)

© BIODEX MEDICAL SYSTEMS, INC. 2-11

Page 14: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS (cont):

• Strengthening (Cont):Device: Biodex Multi-Joint System Closed Chain AttachmentPattern: Leg pressMode: IsokineticSetup: 0-45ºSpeeds: 60 deg/secSets and Reps: 3 x 10

3 plane SLRSets and Reps: 3 x 15-20 (progress to 30)

Weight-bearing exercises:4" One-legged step-upsWall squatsLeg pressMini-squats with physioball between knees to increase EMG output from the VMO*Sets and Reps: 2 x 10 each (progress to 3 x 15)ROM: 0º-45º*NOTE: The VMO takes its origin from the adductor longus and magnus.12 Weight-bearing exercises should beperformed in a pain-free ROM and without crepitus. At the same time, the patella should at not go anterior to the toes.

• Weight-bearing Proprioception:Device: Biodex Balance SystemStance: Bilateral (Both feet)Level: Level 6 progressing to level 4Sets and Duration: 3 x 30 seconds (progress to 3 min continual)Eyes: open (progress to closed)Training method: Trace circles on screen (A-D), color in circles (A-B)Recommendations: Have patient progress to using no hands

• Non-weight-bearing Proprioception:Device: Biodex Multi-Joint SystemPassive and Active position sensePattern: Knee EXT/FLEXMode: Passive and IsokineticSets and Reps: 3 x 10 each target angleHold: 10 secondsTarget angles: 90º/60º/30º

2-12 PHASE II: RANGE OF MOTION AND INITIAL STRENGTHENING

Page 15: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

SUPERVISED PROGRAM:

(Frequencies prescribed on individual basis)

• Reduce swelling and manage pain:P.R.I.C.E.

• Patellofemoral bracing/strapping

• Muscle re-education for disuse atrophyBiofeedback Electrical Stimulation (EMS)

• Cardiovascular Training:

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticSeat height: normalPedal length: normalDuration: 15 minSpeed: 120 deg/secIntensity: 65-80% MHR

Device: Biodex Upper Body CycleMode: IsokineticDuration: 7-10 minSpeed: 90 deg/secIntensity: 65-80% MHR

Device: Biodex Rehabilitation TreadmillDirection: RetroambulationSpeed: 2.0 mphIncline: 12%Position: Straight ahead walkingTime: 10 minIntensity: 65-70% MHR

• Muscle Re-education and strengthening:Leg raises with ankle weightsSets and Reps: 3 x 15 each directionHold from initiating abduction

Seated Isometrics90º knee flexion up to greatest extended position without pain or crepitusSets and Reps: 3 x 15 each angle

Wall squats with ball between kneesSets and Duration: 2 x 20 seconds (progress to 5 sets)

Calf raisesSets and Reps: 3 x 10 (progress to 20)Instruct patient to perform raise with both feet. Initial raises should be done from flat surface and progress to 4" step.(Frequencies prescribed on individual basis)

• Flexibility:Hamstrings seatedIT bandSupine over table rectus femoris/quadsGastrocnemius/SoleusHold each stretch for 20 sec repeat 5-6 times

© BIODEX MEDICAL SYSTEMS, INC. 2-13

Page 16: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

HOME PROGRAM:

• Control pain and edema:P.R.I.C.E.Modalities/Medications as prescribed

• Electro Neuromuscular Stimulation (ENS) as directed

• Range of Motion (ROM) exercises:PROM knee EXT/FLEX with contralateral limbSets and Reps: 3 x 10Repeat: 4x/day

• Strengthening"Quad sets" at 0º and 90º of knee flexionSets and Reps: 1x 10Hold contraction: 10 secondsRepeat: 2x/day

Mini squatsSets and Reps: 3 x 10Repeat: 2x/dayRecommendations: Stand between two chairs, feet shoulder width apart, keeping the patellaover the second metatarsal. Squat down to 30º knee flexion and slowly return to standing.

3-way SLRSets and Reps: 3 x 10Repeat: 2x/dayResistance: begin with none and progress to 3-5 poundsRecommendations: Continue to hold abductor leg raises.

• Flexibility training: (static stretch only)QuadricepsHamstringsIT bandGastrocnemius/soleusSets and duration: 5-6 x 20 secondsRepeat: 2x/day

• Cardiovascular training30 min at 65-80% MHR 3-4x /week

REPORTS:

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60º

• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec (as tolerated)

• Biodex Gait Trainer Exercise Summary

• Biodex Stability Index

2-14 PHASE II: RANGE OF MOTION AND INITIAL STRENGTHENING

Page 17: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

PHASE III

GOALS:

• Decrease pain and inflammation

• Increase flexibility with pain-free PROM and AROM

• No pain with ADL’s

• Restore full AROM

• Restore normal patellar mobility

• Increase cardiovascular conditioning

• Restore normal VMO:VL firing sequence

• Increase VMO:VL ratio to 100%

• Isometric QUAD/HAM strength = bilaterally or WNL

• Isokinetic QUAD/HAM strength < 15% deficit

• OKC Proprioception < 15% deficit

• Stability Index: Bilateral stance < 15% deficit from normative goal

© BIODEX MEDICAL SYSTEMS, INC. 2-15

initial weight-bearing &intermediate strengthening

Page 18: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL EVALUATION:

• Evaluate muscle hypertrophy

• Pain scale:Severity, location, duration, quality, radiation

• Edema:Degree and character of swelling

• Goniometry:Knee FLEX/EXT (0-135º knee flexion) active and passive

• Biofeedback evaluation: VMO:VL ratioNOTE: Current research trends point to VMO/VL ratios in time-based evaluations. However, this was notedthrough fine wire electrode EMG. Clinically the most applicable means is through surface EMG VMO/VL ratio.

TEST: Bilateral Isometric knee EXT/FLEX evaluationDevice: Biodex Multi-Joint SystemPad Placement: NormalSetup: 30º/60º/90º of knee flexionMode: IsometricSets and Duration: 1 x 10 reps x 5 seconds eachRecommendations: Must be performed pain free and without crepitis

TEST: Bilateral Isokinetic knee FLEX/EXT evaluationDevice: Biodex Multi-Joint SystemPad Placement: normalSetup: pain free ROMMode: IsokineticSets and Reps: 1 x 5 @ 180 deg/sec, 1 x 15 @ 300 deg/secRecommendations: ROM should be limited to avoid crepitis and allow for safe speed training.

TEST: Stability IndexDevice: Biodex Balance SystemStability level: Level 6Trials and Duration: 3 x 30 secondsEyes: openRecommendation: Prepare to support patient during test. Instruct patient to use handrails as needed.

TEST: Bilateral OKC Proprioception testDevice: Biodex Multi-Joint SystemPassive and Active position sensePattern: Knee EXT/FLEXMode: Passive and IsokineticSets and Reps: 1 x 3 each target angleTarget angles: 90º/60º/30º/15º

2-16 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING

Page 19: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS:

• Reduce pain and edemaP.R.I.C.E.Electro Neuromuscular Stimulation (ENS)

• Continue with patellofemoral bracing/strapping

• Strengthening:Device: Biodex Multi-Joint SystemPattern: knee EXT/FLEX concentric/concentricMode: IsokineticPad placement: normalSetup: Pain-free ROM and no crepitusSpeeds: 180-500 deg/sec in both directionsSets and Reps: 5 x 10 (progress to 10 x 10)Recommendations: Have patient perform velocity spectrum

Device: Biodex Multi-Joint SystemPattern: knee EXT/FLEX concentric/eccentricMode: PassivePad placement: normalSetup: Full extension to 60º of flexionSpeeds: 60 deg/secSets and Reps: 2 x 10 (progress to 3 x 15)Resistance: Initial torque levels should be based on concentric and isometric test results.Recommendations: Instruct patient to contract quadriceps into extension and to resist movement into flexion.There should be no pain or crepitus with this movement.

Weight-bearing strengthening exercises:Mini-squats with physioball between knees to increase EMG output from the VMO*.Sets and Reps: 3x15 eachROM: 0º-90º (secondary to joint reaction forces)

8" One-legged step-ups and step-downsLeg pressesSingle leg calf raisesSets and Reps: 3 x 10 each

Wall squats with physioball behind backSets and Duration: 2 x 30 seconds

Isotonic strengthening:

Device: Recumbent SquatFoot position: tibia parallel to the groundSets and Reps: 3 x 12

*NOTE: This exercise should be performed in a pain-free ROM and with no crepitus. Also, the patella should at no timego anterior to the toes.

© BIODEX MEDICAL SYSTEMS, INC. 2-17

Page 20: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS (CONT):

Isotonic strengthening (Cont):PNF patterns on Cable Column to increase resistance

• Weight-bearing proprioception:

Device: Biodex Balance SystemStance: UnilateralLevel: Level 4 progressing to level 2Sets and Duration: 3 x 30 seconds (progress to 3 min continual)Eyes: ClosedTraining method: Trace circles on screen (A-D), color in circles (A-B)Recommendations: Have patient progress to using no hands

• Non-weight-bearing proprioception:Device: Biodex Multi-Joint SystemPassive and Active position sensePattern: Knee FLEX/EXTMode: Passive and IsokineticSets and Reps: 3 x 5 each target angleHold: 10 secondsTarget angles: 90º/75º/60º/45º/30º/15º/0ºRecommendations: There should be no incidence of pain or inhibition with movement.

• Cardiovascular training:

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticDuration: 15 minSpeed: 100 deg/secIntensity: 65-80% MHR

Device: Biodex Upper Body CycleMode: IsokineticDuration: 10 minSpeed: 80 deg/secIntensity: 65-80% MHR

Device:Biodex Rehabilitation TreadmillDirection: Forward Jogging onSpeed: 4.5 mphIncline: 0%Duration: 5-10 min

Aquatic Therapy15-20 min

• Flexibility training:QuadricepsHamstringsIT bandGastrocnemius/SoleusSets and duration: 5-6 x 20 seconds

2-18 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING

Page 21: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

SUPERVISED PROGRAM:

(Frequencies prescribed on an individual basis)

• Reduce swelling and manage pain:P.R.I.C.E.

• Patellofemoral bracing/strapping

• Cardiovascular Training:

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticDuration: 15 minSpeed: 100 deg/secIntensity: 65-80% MHR

Device: Biodex Upper Body CycleMode: IsokineticDuration: 10 minSpeed: 80 deg/secIntensity: 65-80% MHR

Device: Biodex Rehabilitation TreadmillDirection: RetroambulationSpeed: 2.5 mphIncline: 12%Position: Straight ahead walkingTime: 15 minIntensity: 65-85% MHR

Device: Biodex Rehabilitation TreadmillDirection: Forward joggingSpeed: 3-5 mphIncline: 0%Duration: 5-15 min

• Strength training:Leg raisesSets and Reps: 3 x 15 each direction

Knee extension (concentric/eccentric quadriceps)Sets and Reps: 3 x 12-15Recommendations: Perform the exercise in pain free ROM

Wall squats with ball between kneesSets and Duration: 2 x 20 seconds (progress to 5 sets)

Single-leg calf raisesSets and Reps: 3 x 10 (progress to 20)

(Frequencies prescribed on an individual basis)

© BIODEX MEDICAL SYSTEMS, INC. 2-19

Page 22: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

SUPERVISED PROGRAM (cont):

• Strength training (Cont):Device: Recumbent SquatFoot position: tibia parallel to the groundWeight: begin with 3-4 plates and progress as toleratedSets and Reps: 3 x 12NOTE: This exercise should be performed in a pain-free ROM and with no crepitus. It is imperative that the patella doesnot travel medially and /or laterally during the motion. Also, the patella should at no time go anterior to the toes.

• Flexibility training: (static stretch only)QuadricepsHamstringsIT bandGastrocnemius/SoleusSets and duration: 5-6 x 20 seconds

2-20 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING

Page 23: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

HOME PROGRAM:

• Control pain and edema:P.R.I.C.E.Modalities/Medications as prescribed

• StrengtheningActive knee extensionSets and Reps: 3 x 10-12Resistance: Start with a 5 pound cuff weight and progress to 10 poundsRepeat: 2x/dayRecommendations: Pain-free ROM and with no crepitis

Mini squatsSets and Reps: 3 x 15 -20Repeat: 2x/dayRecommendations: Stand between two chairs, feet shoulder width apart, keeping the patella over the secondmetatarsal. Squat down to 45º knee flexion and slowly return to standing.

3-way SLRSets and Reps: 3 x 10Repeat: 2x/dayResistance: 3-5 poundsRecommendations: Continue to hold abductor leg raises if lateral structures remain inflexible or VMO is deficient.

Wall SitSets and Duration: 2 x 30 secRepeat: 3x/dayPosition: 45º

Heel raisesPosition: Both feet (progress to single)Sets and Reps: 3 x 15Repeat: 2x/day

• Flexibility training: (static stretch only)QuadricepsHamstringsIT bandGastrocnemius/soleusSets and duration: 5-6 x 20 secondsRepeat: 2x/day

• Cardiovascular training30 min at 65-80% MHR 3-4x/week

© BIODEX MEDICAL SYSTEMS, INC. 2-21

Page 24: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

REPORTS:

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60º

• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec (as tolerated)

• Biodex Gait Trainer Exercise Summaries

• Biodex Stability Index

2-22 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING

Page 25: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

PHASE IV

GOALS:

• Decrease pain and inflammation

• Maintain flexibility with pain-free PROM and AROM

• Maintain pain-free with all activities

• Maintain full AROM

• Maintain normal patellar mobility

• Increase cardiovascular conditioning

• Maintain normal VMO:VL firing sequence

• Maintain VMO:VL ratio at 1:1

• Isokinetic QUAD/HAM strength < 10% deficit

• Isokinetic QUAD concentric/eccentric strength < 85% bilaterally

• OKC Proprioception < 10% deficit

• Stability Index: Bilateral stance < 10% deficit from normative goal

• Single leg hop, 6 meter timed hop and crossover hop < 15% deficit lower extremity 19

© BIODEX MEDICAL SYSTEMS, INC. 2-23

return to activity

Page 26: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL EVALUATION:

• Evaluate muscle hypertrophy

• Pain scale:Severity, location, duration, quality, radiation

• Edema:Degree and character of swelling

• Goniometry:Knee FLEX/EXT (0º-135º knee flexion) active and passive

• Biofeedback evaluation: Vastus medialis:lateralis (VMO:VL) ratio 16

TEST: Bilateral Isokinetic knee FLEX/EXT evaluationDevice: Biodex Multi-Joint SystemPad Placement: normalSetup: Full pain-free ROMMode: IsokineticSets and Reps: 1 x 5 @ 180 deg/sec1 x 15 @ 300 deg/secRecommendations: ROM should be limited to avoid crepitis and allow for safe speed training.

TEST: Stability IndexDevice: Biodex Balance SystemReport: Stability IndexStability level: Level 4Trials and Duration: 3 x 30 secondsEyes: openRecommendation: Prepare to support patient during test. Instruct patient to use handrails as needed.

TEST: Bilateral OKC Proprioception testDevice: Biodex Multi-Joint SystemPassive and Active position sensePattern: Knee FLEX/EXTMode: Passive and IsokineticSets and Reps: 1 x 3 each target angleTarget angles: 90º/60º/30º/15ºRecommendations: There should be no incidence of pain or inhibition with movement.

TEST: Hop testsSingle leg hop, 6 meter hop and crossover hop testsTrials: Average of threeTake off: On the involved extremityLanding: On the involved extremity

2-24 PHASE IV: RETURN TO ACTIVITY

Page 27: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS:

• Reduce pain and edemaP.R.I.C.E.

• Continue with patellofemoral bracing/strapping PRN

• Flexibility training:QuadricepsHamstringsIT bandGastrocnemius/SoleusSets and duration: 5-6 x 20 seconds

• Cardiovascular training

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticDuration: 20 minSpeed: 100 deg/secIntensity: 80-85% MHR

Device: Biodex Upper Body CycleMode: IsokineticDuration: 20 minSpeed: 80 deg/secIntensity: 80-85% MHR

Device: Biodex Rehabilitation TreadmillDirection: forward jogging/runningSpeed: 5.0 mph as toleratedIncline: 0% as toleratedDuration: 10-15 min

Device: FitterDuration: 10-12 min

• Proprioceptive Neuromuscular Facilitation (PNF) patterns for the Lower Extremity:Device: Cable ColumnSets and Reps: 3 x 10-15Recommendations: Perform hip adduction only if VMO:VL ratio is 1:1 and has no complaints of increased signs or symptoms.NOTE: Should perform exercises on involved and uninvolved side

• Weight-bearing ProprioceptionDevice: Biodex Balance SystemStance: UnilateralLevel: Level 2 progressing to Level 1Sets and Duration: 3 x 30 seconds (progress to 3 min continual)Eyes: ClosedTraining method: Trace circles on screen (A-D), color in circles (A-B)Recommendations: Have patient progress to using no hands

© BIODEX MEDICAL SYSTEMS, INC. 2-25

Page 28: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS (cont):

• Weight-bearing/Partial weight-bearing isotonic strengthening:Device: Functional Squat System or Isotonic SquatFoot position: tibia parallel to the groundWeight: use weight as toleratedSets and Reps: 3 x 12NOTE: This exercise should be performed in a pain/crepitus free ROM. It is imperative that theclinician ensures that the patient’s patella should at no time go anterior to the toes.

Device: Mini-squats with physioballPattern: 60º/75º/90º of knee flexionSets and Reps: 3 x 12 each

Device: Cable ColumnPattern: Single leg mini squatsSets and Reps: 3 x 12

Device: Recumbent SquatPattern: PlyometricsFoot position: Begin in center of platform (progress to various positions throughout)Weight: 3 plates to begin, progress as toleratedSets and Reps: 3 x 12NOTE: This is an alternative to standing plyometrics. The clinician may want to utilize the squat system for increasedcontrol of patient movement. Assure proper foot position as well as the foot slipping off the edge of the platform.

Lateral step-downSets and Reps: 3 x 12Recommendations: Perform step-down from 4" height and progress to 8"

Wall Seats with ball between kneesSets and Reps: 3 x 12 with 10 sec holdRecommendations: Instruct patient to push heels into ground and to pull toes up while performing this exercise.

Heel raises (Seated and Standing)Sets and Reps: 3 x 20-25

2-26 PHASE IV: RETURN TO ACTIVITY

Page 29: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

CLINICAL TREATMENT OPTIONS (cont):

• Isokinetic Strengthening:Device: Biodex Multi-Joint SystemPattern: Knee flexion/extension Concentric/Concentric trainingPad placement: normalSetup: crepitus/pain free ROMMode: IsokineticSpeeds: 180-450 deg/sec in both directionsSets and Reps: 3 x 10Recommendations: Progress to 30 seconds at each speed instead of reps.

Device: Biodex Multi-Joint SystemPattern: Knee extension Concentric/Eccentric trainingPad placement: normalSetup: 60- 0º of knee flexionMode: PassiveSpeeds: 60 deg/secSets and Reps: 3 x 8-10Recommendations: Instruct patient to actively contract quadriceps into extension and to resist movement into flexion.Once patient has understanding of eccentric muscle contractions, change mode to Reactive Eccentric and set torquelimits based on test values.

• Functional Program:Plyometric program 11

Return to sport progression

SUPERVISED PROGRAM:

(Frequencies prescribes on an individual basis)

• Patellofemoral brace/strap to facilitate pain free exercise

• Strengthening program:Isotonic Progressive Resistance Exercises (PREs)Hip adduction, abduction, flexion and extensionSets and Reps: 3 x 12-15Resistance: 10-12 IbRecommendations: Perform on both involved and uninvolved lower extremities

Knee extension (concentric/eccentric quadriceps)Sets and Reps: 3 x 12-15Resistance: 10-12 IbRecommendations: Should have full pain free ROM

Knee flexion (concentric/eccentric hamstrings)Sets and Reps: 3 x 12-15Resistance: 10-12 IbRecommendations: Should have full pain free ROM

Device: Recumbent SquatFoot position: tibia parallel to the groundSets and Reps: 3 x 12Weight: as toleratedNOTE: This exercise should be performed pain-free and with no crepitis. At the same time, the patella should at no timego anterior to the toes.

© BIODEX MEDICAL SYSTEMS, INC. 2-27

Page 30: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

SUPERVISED PROGRAM (cont):

• Cardiovascular training:

Device: Biodex BioStep® Semi-Recumbent EllipticalMode: IsokineticSeat height: normalPedal length: normalDuration: 20 minSpeed: 100 deg/secIntensity: 80% MHR

Device: Biodex Upper Body CycleMode: IsokineticDuration: 20 minSpeed: 80 deg/secIntensity: 80% MHR

Device: Biodex Rehabilitation TreadmillDirection: ForwardSpeed: 4-8 mphIncline: as neededDuration: Vary depending on sport/activityNote: Perform exercises as per athletic competition as well as different patterns (i.e., cross-over steps, side-steps)

Slide BoardDuration: 10-12 min

FitterDuration: 8-12 min

Aquatic therapySport/activity specific exercises and conditioning techniques

2-28 PHASE IV: RETURN TO ACTIVITY

Page 31: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

HOME PROGRAM:

• Reduce pain and edema:P.R.I.C.E.

• Strengthening:Active knee FLEX/EXTSets and Reps: 3 x 15Resistance: Start with a 10 pound cuff weight and progress to 15 poundsRecommendations: Pain-free ROM and with no crepitis

Mini squatsSets and Reps: 3 x 15 -20Repeat: 2x/dayRecommendations: Stand between two chairs, feet shoulder width apart, keeping the patellaover the second metatarsal. Squat down to 45º knee flexion and slowly return to standing.

3-way SLRSets and Reps: 3 x 15Repeat: 2x/dayResistance: 3-5 poundsRecommendations: Continue to hold abductor leg raises if lateral structures remain inflexible or VMO is deficient.

Wall SitSets and Duration: 2 x 45 secRepeat: 2x/dayPosition: 45º

Heel raisesPosition: Both feet (progress to single)Sets and Reps: 3 x 20-25Repeat: 2x/day

• Flexibility training: (static stretch only)QuadricepsHamstringsIT bandGastrocnemius/soleusSets and duration: 5-6 x 20 secondsRepeat: 2x/day

• Cardiovascular training30 min at 65-80% MHR 3-4x /weekSport specific drills and conditioning techniques

• Functional progression: 5

15 heel raisesWalking at fast paceJumping on both legsHopping on the involved legJog straight and curvesRun straight at 1/2 speed, 3/4 speed, and then full speedRun large figure - 8's (20 yards) at 1/2, 3/4, and full speedRun small figure - 8's (10 yards) at 1/2, 3/4, and full speedCross-over run in both directionsRun on uneven terrainRun up, down, and sideways on hillsCutting (wearing athletic shoes on asphalt) at 1/2, 3/4, and full speedNOTE: Patients can progress through each step only if asymptomatic

© BIODEX MEDICAL SYSTEMS, INC. 2-29

Page 32: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

REPORTS:

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60º

• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec

• Biodex isokinetic bilateral comparison QUAD/HAM Concentric/Eccentric comparison

• Biodex Gait Trainer evaluation

• Biodex Bilateral and Unilateral Stability Index

2-30 PHASE IV: RETURN TO ACTIVITY

Page 33: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

BIODEX BALANCE SYSTEM

NORMATIVE VALUES:

Age (yrs) Stability Index Standard Deviation (+/–)

17-35 1.54 .72

36-53 2.13 .90

54-71 2.57 .78

72-89 2.70 .80

Females are more stable than males:

All ages Stability Index Standard Deviation

Females 1.94 .80

Males 2.70 .08

Values were collected by J.A. Finn, et al, Stability Performance Assessment among Subjects of Disparate Balancing Abilities.Southern Connecticut State University.

© BIODEX MEDICAL SYSTEMS, INC. 2-31

stability index

Page 34: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

EVIDENCE-BASED CLINICALPROTOCOL FOR

REHABILITATION OFPATELLOFEMORAL DYSFUNCTION

1. Brownstein. VMO EMG activity was highest between 90°-60°, lowest between 0°-30° (hip adduction therapy may helpenhance the VMO of attachment to adductor magus. JOSPT, 1985.

2. Conway A, Malone TR, and Conway P. Patella Alignment/Tracking Alteration: Effect on Force Output and perceived pain.Isokinetics and Exercise Science: (2) No. 1, 1992.

3. D'Amico JC, Rubin M. The Influence of Foot Orthoses on the Quadriceps Angle, J.A.P.A.: 76(6) 337-340, 1986.

4. DeAndrade JR., et al. Joint distention and reflex muscle inhibition in the knee. JBKJS (AM): 47:313-322, 1965.

5. DeMaio M, Mangine RE, Noyes FR, and Barber SD. Advanced Muscle Training After ACL Reconstruction: Weeks 6 to 52.Sport Medicine Rehabilitation Series: 757-767. 1993.

6. Draper V, Ballard L. Electrical stimulation versus electromyographic biofeedback in the recovery of quadriceps femoris musclefunction following anterior cruciate ligament surgery. Physical Therapy, Vol. 71 p. 455-461. 1991.

7. Eifert-Mangine M, Mangine R, Vasquez A. Overuse Syndrome of the Patellafemoral Joint. Orthopedics, 1991.

8. Flynn TT, Soutas-Little RW. Mechanical Power and Muscle Action During Forward and Backward Running.JOSPT: (17)2: 108-112. 1993.

9. Hanten WP, Schulties SS. Exercise effect on EMG activity of the VMO and VL muscle. Physical Therapy: 70:561-565

10. Hodges PW, Richardson CA. The influence of isometric hip adduction on quadriceps femoris activity. Journal of RehabilitationMedicine: 25:57-62, 1995.

11. Hollonshead WH, Jenkins DB. Functional anatomy of the limbs and back. Philadelphia, Saunders. 1981.

12. Hoppenfeld S. Physical Examination of the Spine and Extremities. Appleton-Century--Crofts. p.187, 1976.

13. Insall JN, Salvati. Patella Position in the Normal Knee Joint. Radiology 101:101-104, 1971.

14. Kiernan, H. Physical Exam and Differential Diagnosis p.31.

15. Kip. McConnell tape increased VMO/VL ratio at 90° of knee flexion no effect at 15°-30° of flexion. Medicine Science Sport andExercise. 1992.

16. Lephart SM, Kocher MS, Fu FH, Borsa PA, and Horner CD. Proprioception Following Anterior Cruciate LigamentReconstruction. Journal of Sport Rehabilitation: Vol 1: 188-196. 1992.

17. Mangine R. Physical Therapy of the Knee. Clinics in Physical Therapy. Vol. 19, Churchill Livingstone, 1988.

18. McConnell J. The Management of Chondromalacia Patella: A Long Term Solution. The Australian Journal of Physiotherapy,Vol 31(4):214-223, 1986.

19. Noyes FR, Barber SD, Moorar LA. Abnormal lower limb symmetry determined by function hop test after anterior cruciateligament rupture. American Journal of Sport Medicine:19(5):513-518, 1991.

20. Puniello MS. Iliotibial band tightness and medial patella glide in patients with patellofemoral dysfunction.JOSPT: 17(3): 144-148, 1993.

21. Reynolds. EMG data in normal VMO/VL ratio 1:1. EMG data in patellofemoral patients VMO/VL ratio greater than 1:1.American Journal of Physical Medicine.

22. Sczepanski T, Gross M, Duncan P, Chandler J. Effect of Contraction Type, Angular Velocity, and Arc of Motion on VMO:VLEMG ratio. JOSPT. (14) 6, 1991.

23. Smith CA. The Warm-Up Procedure: To Stretch or Not to Stretch. A Brief Review. JOSPT (19)1-12, 1994.

© BIODEX MEDICAL SYSTEMS, INC. 2-33

references

Page 35: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

24. Voight ML, Blackburn TA, Soffer SS, Bowman J. Single Leg Stance: Development of Reliable Testing Procedures. Submitted asabstract: 1995 Combined Sections.

25. Voight, Ml, Weider D. Comparative reflex response times of VMO and VL in normal subjects with exterior mechanism dysfunc-tion. American Journal of Sports Medicine, 19: 131-137, 1991.

26. Wilk KE, Andrews JR. The Effect of Pad Placement and Angular Velocity on Tibial Displacement During Isokinetic Exercise.JOSPT: (17)1: 24-30. 1993.

27. Wise HH., et al. EMG biofeedback as treatment for patellofemoral pain syndrome. JOSPT 6:95-103, 1984.

2-34 REFERENCES

Page 36: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

EVIDENCE BASED CLINICAL PROTOCOL FORTHE MANAGEMENT OF:

patellofemoral dysfunction

post Injury: phase I:Reduction of Acute Symptoms

phase II:Range of Motion and Initial Strengthening

• Mentally prepare patient for rehabilitation• Education of Pt to understand the problems of

PF dysfunction• Identify specific needs of patient and

potential problems• Decrease pain and edema• Maintain ankle ROM and strength• Full knee PROM• Increase VMO:VL strength ratio to 50%• OKC Proprioception < 40% deficit of uninvolved side• Isometric strength QUAD/HAM < 30% deficit• Normalize gait deviations and correct

biomechanical faults• Identify contributory factors• Stability Index

• Rehabilitation process education• Patellar bracing or strapping• Reduce pain and edema• Patellar mobilization• Correct biomechanical dysfunction/

ambulation training• Flexibility training• Muscle re-education of QUADS• Strengthening: Multi-angle isometrics• WB Proprioception: Biodex Balance System

bilateral stance• Cardiovascular training: Biodex UBC, SRC

• General patient history and observation• Pain scale: location, quality and duration• Degree and type of edema• Range of motion: active and passive• Goniometry (0-135 degrees)• Patella assessment (radiographs, palpation, physical)• Neurological assessment: myotomes, dermatomes

and reflexes• TEST: Biodex bilateral isometric test 3 position

QUAD/HAM (30, 60,90) OR• TEST: Biodex bilateral isokinetic test

QUAD/HAM @ 300 deg/sec• TEST: Biodex OKC proprioception test• TEST: Biodex Balance System bilateral stance• TEST: Biodex Gait Trainer assessment

• Control edema and manage pain• Patellofemoral bracing/strapping• Muscle re-education

-EMS, isometrics• Flexibility training• Cardiovascular training: Biodex UBC or LBC

• Control pain and edema• ROM exercises• Flexibility training• EMS• Non-WB strengthening exercises• Cardiovascular training

• Range of motion• Pain scale• Cardiovascular fitness level• Biodex bilateral OKC proprioception test• Biodex isometric OR isokinetic bilateral comparison• Biodex Balance System bilateral stance test

• Decrease pain and inflammation• Increase flexibility with pain free PROM and AROM• Restore normal patellar mobility• Increase cardiovascular conditioning• Increase VMO: VL ratio to > 75%• OKC Proprioception < 25% deficit• Isometric QUAD/HAM strength < 10% deficit• Isokinetic QUAD/HAM strength < 30% deficit• Stability index: Bilateral stance < 25% deficit

• Reduce edema / inflammation• Reduce spasm / pain• Patellar mobilizations• Patellofemoral bracing/strapping• ROM: AAROM QUAD/HAM• Postural control• Strengthening exercises:

- Biodex multi-angle isometric QUAD/HAM- Biodex isokinetic QUAD/HAM@180/300 deg/sec

• Non-WB Proprioception: Biodex MJS• WB Proprioception:

Biodex Balance System bilateral stance• WB and partial WB Exercises:

- Wall squats, step-ups- Biodex CC Attachment

• Cardiovascular training: Biodex UBC,LBC or Treadmill

• Verify home program compliance• Degree and character of edema• Pain scale: location, quality and duration• ROM testing: AROM and PROM (0-135 degrees)• TEST: Biodex bilateral isometric

QUAD/HAM @ 30, 60, 90 deg• TEST: Biodex bilateral isokinetic

QUAD/HAM @ 180/300 deg/sec• TEST: Biodex bilateral proprioception QUAD/HAM• TEST: Biodex Balance System bilateral stance

• Control pain and edema• Muscle re-education• Strengthening: Hip, knee, lower leg & ankle*• Flexibility: Hip, knee, lower leg and ankle• Cardiovascular training: Biodex UBC, LBC or Treadmill

*NOTE: No hip adduction with knee exercises

• Control pain and edema• Flexibility: Hip, knee, lower leg and ankle• Non-WB strengthening: Hip, knee, lower leg & ankle*• Cardiovascular training: 20-30 min. 3-4 x/wk

*NOTE: No hip adduction with knee exercises

• Range of motion• Pain scale• Cardiovascular fitness level• Biodex bilateral OKC proprioception test• Biodex isometric AND isokinetic bilateral comparison• Biodex Balance System bilateral stance test• Biodex Gait Trainer Evaluation

goals:

clinicaltreatment

options:

clinicalevaluations:

supervisedprogram:

homeprogram:

reports:

Page 37: Evidence-based ClinicalProtocols - Biodex · Evidence-based ClinicalProtocols 2) ... is based on research and case studies involving very specif- ... Medical/lateral tilt Inferior/superior

EVIDENCE BASED CLINICAL PROTOCOL FORTHE MANAGEMENT OF:

patellofemoral dysfunction

phase III:Initial Weight-bearing andIntermediate Strengthening

phase IV:Return to Activity

• Pain-free with activity• No effusion and full ROM• Maintain normal patellar mobility• Activity specific tests WNL• Increase cardiovascular conditioning• Isokinetic strength QUAD/HAM < 10% deficit• Isokinetic strength con/ecc (quads only)

< 85% deficit• Functional hop test < 15% deficit• OKC Proprioception < 10% deficit• Stability index: unilateral stance < 10% deficit• Maintain VMO:VL ratio• Maintain VMO:VL firing sequence

• Reduce pain and edema• ROM exercises• Strengthening:

- Biodex isokinetic QUAD/HAM @(60, 180, 300)

- Isotonics WB and Non-WB- Isotonics for lower extremity (no hip AD)- Biodex isokinetic con/eccQUAD @ 60/180 deg/sec

• Non-WB proprioception: Biodex M-JS• WB proprioception: Biodex Balance System

unilateral stance• Flexibility Training• Cardiovascular Training (UBC, TM)• Functional Program

• ROM: active and passive• Muscle hypertrophy• Pain scale• Edema• Goniometry (0-135 degrees)• TEST: Functional hop test• TEST: Biodex bilateral isokinetic

QUAD/HAM (60, 180, 300)• TEST: Biodex OKC proprioception

(passive, isokinetic)• TEST: Biodex Balance System unilateral stance• Functional activity evaluation

• Control pain and edema• Strengthening: Hip, knee, lower leg and ankle• Flexibility: Hip, knee, lower leg and ankle• Cardiovascular training: Biodex UBC,

LBC or Treadmill• Initiate interval sports program

• Control pain and edema• Flexibility: Hip, knee, lower leg and ankle• WB strengthening: Hip, knee, lower leg and ankle• Cardiovascular training: 20-30 min. 3-4 x/wk• Initiate interval sports program

• Range of motion• Cardiovascular fitness level• Biodex bilateral OKC proprioception test• Biodex isokinetic bilateral comparison

(60, 180, 300 deg/sec)• Biodex Balance System unilateral stance test• Biodex Gait Trainer Evaluation• Patellofemoral Outcome Report

• Full pain free ROM• No effusion• No complaints of palpable tenderness• Restore normal VMO: VL ratio• Restore normal patellar mobility• Increase flexibility• Isokinetic strength < 15% deficit• Isokinetic strength (con/ecc) < 15% deficit (quad only)• Isometric strength = bilaterally or WNL• OKC Proprioception < 15% deficit• Stability Index: Unilateral stance < 15% deficit

• Reduce pain and edema• Patellofemoral bracing/strapping - PRN• ROM: active, passive and static• Strengthening:

- Biodex isokineticQUAD/HAM (60, 180, 300)

- WB and Non-WB isotonics- Biodex isokinetic con/eccQUAD @ 60 deg/sec

- Hip and ankle isotonics (no hip AD)• OKC Proprioception training: Biodex M-JS• CKC Proprioception: Biodex Balance System

unilateral stance• Cardiovascular training: Biodex UBC, Treadmill• Flexibility training

• Muscle hypertrophy• Pain scale: location, quality and duration• ROM: full AROM and PROM (0-135 degrees)• Biofeedback of VMO: VL ratio• TEST: Biodex bilateral isokinetic test

QUAD/HAM (60, 180, 300)• TEST: Biodex OKC proprioception active and passive• TEST: Biodex Balance System unilateral stance• TEST: Biodex Bilateral isometric multi angle

(30, 60, 90)

• Control pain and edema• Strengthening: Hip, knee, lower leg and ankle*• Flexibility: Hip, knee, lower leg and ankle• Cardiovascular training: Biodex UBC, LBC or Treadmill

*NOTE: No hip adduction with knee exercises

• Control pain and edema• Flexibility: Hip, knee, lower leg and ankle• Non-WB and WB strengthening: Hip, knee,

lower leg and ankle*• Cardiovascular training: 20-30 min. 3-4 x/wk

*NOTE: No hip adduction with knee exercises

• Range of motion• Pain scale• Cardiovascular fitness level• Biodex bilateral OKC proprioception test• Biodex isometric (60 degrees) AND isokinetic

bilateral comparison (180 and 300 deg/sec)• Biodex Balance System unilateral stance test• Biodex Stability Index• Biodex Gait Trainer Evaluation

goals:

clinicaltreatment

options:

clinicalevaluations:

supervisedprogram:

homeprogram:

reports: