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REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. H SELCUK KUCUKOGLU ULUDAG UNIVERSITY SCHOOL OF MEDICINE DEPARTMENT OF PM&R AND SPORTS MEDICINE. EPİDEMİOLOGY. Yearly incidence of ACL injuries has been reported to be 3/10,000 inhabitants in Denmark (Nielsen, 1991), - PowerPoint PPT Presentation
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REHABILITATION AFTER ANTERIOR CRUCIATE
LIGAMENT RECONSTRUCTION
H SELCUK KUCUKOGLUULUDAG UNIVERSITY
SCHOOL OF MEDICINEDEPARTMENT OF PM&R AND SPORTS MEDICINE
EPİDEMİOLOGY
• Yearly incidence of ACL injuries has been reported to be 3/10,000 inhabitants in Denmark (Nielsen, 1991),
• In Sweden, ACL injuries comprise 43% of all soccer related injuries (Roos,1995),…
Type of
graft
Age(Year)
Weight(kg)
Operation time after the injury (months)
SexLevel of Sportive Activity
Injury level Injured extremity
M F Sp Sed Ak Sub Kr Right Left
PT 25.66.9
75.19.4 21.732.6
53 2 36 19 2 9 44 29 26
SG 26.35.6
75.910.8
14.719.1
24 1 5 20 1 4 20 13 12
GOAL• The goal of ACL
reconstruction is to improve the patients level of function, with in the hope of allowing them to return to an active life style, with minimal disability, while protecting them from further injury to the knee.
why treat
• After an ACL lesion, knee instability is common and may produce progressive functional changes and damage to other joint structures (meniscal damage,articular cartilage damage,and degenerative arthritis) which may also affect daily life activities.
why TREAT• The ACL has poor
potential for spontaneous healing after complete rupture,and therefore conservative treatment aims to develop joint motion patterns that help control abnormal knee motions which can arise in the absence of functional ACL.
why TREAT
• In the years following an ACL injury additional meniscus ruptures frequently occur. 80% of ACL deficient patients were found to have a torn meniscus within 2 years of ACL injury.
» Gillquist-Messner (Sports Med. March 1999)
why REHABILITATION
• Optimal healing of an ACL graft and the knee is dependent on rehabilitation,
• The strains applied to an ACL graft by body weight, muscle activity, and joint motion affect its healing response,
ACCELERATED REHABILITATION
• Investigations of ACL grafts that have been done in animals indicate that they lose their ultimate failure strength and undergo a decrease of stiffness and the knees have an increase in anterior laxity develop during healing.
Accelerated rehabilitation
• The exact cause of above mentioned changes and the application of this data to humans are unclear.Rougraff-Shelbourne reported that large proportion of the tendon survives and ACL graft healing in humans may not undergo the same complete necrotic stage that has been reported in animals.
» Knee Surg Sports Traumatol Arthrosc 1999
ACLRehabilitation
• Preoperative Phase:– Goals
• Diminish inflammation,swelling, and pain• Restore normal range of motion (extension)• Restore voluntary muscle activation• Provide patient education to prepare for surgery• Brace-elastic wrap or knee sleeve to reduce
swelling• Weight bearing-as tolerated with or without
crutches
ACL Rehabilitation2
• Preoperative phase– Exercises
• Ankle pumps• Passive knee extension to zero• Passive knee flexion to tolerance• Straight leg raises (3-way, flexion, abduction,
adduction• Quadriceps setting• Closed kinetic chain exercises: mini squats,
lunges, step-ups
ACL Rehabiltation3
• Preoperative Phase– Muscle stimulation-electrical muscle
stimulation to quadriceps during voluntary quadriceps exercises (4-6 hours/day)
– Cryotherapy/elevation-apply ice 20 minutes of every hour, elevate leg with knee in full extension
– Patient education- review postoperative rehabilitation program
BIOMECHANICS
• Isometric exercises that strain the ACL involve contraction of the dominant quadriceps muscle group with the knee between extension and 60° flexion, or involve isotonic contraction of the quadriceps between extension and 50° flexion,
Biomechanics2
• The largest ACL strain magnitudes that have been measured and produced by isometric and isotonic contraction of the quadriceps muscles with the knee near extension.
Biomechanics3
• Squatting, stationary bicycling,and closed kinetic chain exercises that involves body weight loading and substantial cocontraction of the muscles does not create an appreciable change in ACL strain values.
WEEKS 1 2 3 4 5 6 7 8 9 10
11
12
13
14
15
16
MOTIONCPMIntermittant passive motionEXERCISESPatellar mobilizationStraight leg raises (4-way)IsometricsStationary bike (if ROM>110º)RunningClosed chainIsokinetic Quadriseps (0º-40º not permitted)Isokinetic Quadriseps (0º-20º not permitted)Isokinetic HamstringPROPRIOCEPTIVE TRAININGBalance activities (eyes open-closedı, bilaterally)Balance activities (eyes open-closedı,unilaterally)Functional skill activites (low to high speed)WEIGHT BEARING/BRACERigid-hinged braceFull weight bearingMODALITIESElectrical muscle stimulationCold (4-6 times/day)Cold (after exercises)
ACL Rehabilitation
• Immediate postoperative Phase (1-7 days)– Goals
• Restore full passive knee extension• Diminish joint swelling and pain• Restore patellar mobility• Gradually improve knee flexion• Reestablish quadriceps control• Restore independent ambulation
ACL Rehabilitation
• Early Rehabilitation Phase (2-4 weeks)– Criteria to progress to phase 2
• Quad control (ability to perform good quad set and straight leg raises
• Full passive knee extension• Passive ROM 0° -90°• Good patellar mobility• Minimal joint inflammation• Independent ambulation
ACL Rehabilitation
• Early Rehabilitation Phase– Goals
• Maintain full passive knee extension• Gradually increase knee flexion• Diminish swelling and pain• Muscle training• Restore proprioception• Patellar mobility
ACL Rehabilitation
• Controlled ambulation Phase (weeks 4-10)– Criteria to enter phase 3
• Active ROM 0° to 115°• Quadriceps strength 60%>contralateral side
(isometric test at 60° knee flexion)• Minimal to no joint inflammation• No joint line or patellofemoral pain
ACL Rehabilitation
• Controlled Ambulation Phase(2)– Goals
• Restore full knee ROM (0° -125°)• Improve lower extremity strength• Enhance proprioception,balance and
neuromuscular control• Improve muscular endurance• Restore limb confidence and function• No brace or immobilizer, may use knee sleeve
ACL Rehabilitation• Advanced Activity Phase (10-16 weeks)
– Criteria to enter Phase 4• Active ROM 0°-125°• Quad strength 80% of contralateral side• Knee flexor:extensor ratio 70%-75%• No pain or effusion• *Satisfactory clinical exam• *Satisfactory isokinetic test (values at 60°/sec, 180°/sec and 300°/sec)• *Hop Test (80% of contralateral leg) (4test)• *Subjective knee scoring 80 points or better (Noyes)
ACL Rehabilitation
• Advanced activity phase (2)– Goals
• Normalize lower extremity strength• Enhance muscular power and endurance• Improve neuromuscular control• Perform selected sport-specific drills
ACL Rehabilitation
• Return to activity phase– Criteria to enter phase 5
• Full ROM• Isokinetic test that fulfills criteria• Quad bil comparison (80% or greater)• Hams Bil comparison (110% or greater)• Proprioceptive test (100% of contralateral leg)• Hamstring/quadriceps ratio (70% or greater)• Functional test(85%or greater of contralateral side)• Satisfactory clinical exam• Subjective knee scoring (Noyes) 90 points or better
ACL Rehabilitation
• Return to activity phase (2)– Goals
• Gradual return to full unrestricted sports• Achieve maximal strength and endurance• Normalize neuromuscular control• Progress skill training
Complications
• Hemarthrosis; Operative trauma and repeated operations
• Pretension of the substitute ligament• Septic arthritis• Postoperative arthrofibrosis• Patellafemoral pain
– All may lead to gonarthrosis in the long run
ROLE of PMR
• Check for the goals and the criterias to upgrade the patient
• Evaluate the results of isometric and isokinetic tests
• Evaluate the results of four HOP tests• Examine the patient when appropriate for
the stability• Examine the patient for the complications
and progress
PROPRIOCEPTION AND BALANCE AFTER ACL RECONSTRUCTION
Ufuk Şekir , Bedrettin Akova , Hakan Gür
Medical School of Uludag University, Department of Sports Medicine , BURSA
THE AIM OF THE STUDY
To observe the changes in the proprioception and balance after ACL reconstruction.
PATIENTS AND METHODS• 31 patients, mean age 24±7 (17-44)• Patellar tendon autograft• Time period between injury and the operation: 12
months ( 1-96)• Follow-up : At 1th, 2nd, 3rd, 4th, 6th, and 12th
months after operation• Accelerated rehabilitation program, includes
proprioceptive exercises (which began in the first month): – Single-leg stance on hard surface (eyes open-closed)– Single-leg stance on soft surface (eyes open-closed ) – Balance board exercises (eyes open-closed )
Joint Position Sense (JPS)
•Eyes closed•Index angles: 200,450 and 700
•Angular velocity: 10/s• Before matching an index angle, the examiner extends the knee passively to the index angle for 3 s.• Three repetitions for each index angle was made. • The mean of absolute error score (AES) for each index angle was calculated• Mean AES= Sum of means of index angles /3
JPS active
JPS passive
Cybex 6000Cybex 6000
Single-limb Balance
• On a soft surface.• Eyes open-closed.• First on the uninjured and then on the
injured side.• Arms crossed, contralateral leg flexed.• The subjects were required to stand 60s.• Two repetition were made.• Mean number of touchdowns and mean
time to first touchdown were recorded.
STATISTICS
To compare injured-uninjured leg results;
– Wilcoxon test
The results at the follow-up of the Single-limb
Balance Test (Mean number of touchdowns)
0
1
2
3
4
5
6
1 2 3 4 6 12
Months
Mea
n to
uchd
owns
Eyes-openinjuredEyes-openuninjuredEyes-clodesinjuredEyes-closeduninjured
**
** p<0,01, *p<0,05** p<0,01, *p<0,05
The results at the follow-up of the Single-limb Balance Test (Mean time to first touchdown)
0
10
20
30
40
50
60
70
1 2 3 4 6 12
Months
Mea
n tim
e
Eyes-openinjuredEyes-openuninjuredEyes-clodesinjuredEyes-closeduninjured
** **
** ** ***
** p<0,01, *p<0,05** p<0,01, *p<0,05
Joint Position Sense at 200 of Flexion
0
2
4
6
8
10
12
14
1 2 3 4 6 12
Months
AE
S
injured-activeuninjured-activeinjured-passiveuninjured-passive
*
*p<0,05*p<0,05
Joint Position Sense at 450 of Flexion
0123456789
1 2 3 4 6 12
Months
AE
S
injured-activeuninjured-activeinjured-passiveuninjured-passive
**
**
** p<0,01, *p<0,05** p<0,01, *p<0,05
Joint Position Sense at 700 of Flexion
0
1
2
3
4
5
6
1 2 3 4 6 12
Months
AE
S
injured-activeuninjured-activeinjured-passiveuninjured-passive
Joint Position Sense (Mean)
0123456789
1 2 3 4 6 12
Months
Mea
n A
ES
injured-activeuninjured-activeinjured-passiveuninjured-passive
CONCLUSION
The results of this study indicates that the proprioceptive capabilities of the ACL reconstructed knee can improved to the same level of the uninjured knee at 2 months after operation, with a rehabilitation program including proprioceptive exercises in early phase.
FUNCTIONAL CAPACITY AFTER ACL RECONSTRUCTION: RELATIONSHIPS WITH KNEE EXTENSOR AND FLEXOR
MUSCLE STRENGTH
1 Bedrettin Akova ,1 Hakan Gür, 1 Ufuk Şekir, 2 Sefa Müezzinoğlu1Medical School of Uludag University,Department of Sports Medicine , BURSA 2 Medical School of Kocaeli University, Department of Orthopaedic Surgery, KOCAELİ
THE AIM OF THIS STUDY;
To determine 1) the functional capacity and 2) the relationships between the functional capacity and knee extensor, and flexor peak torque after ACL reconstruction.
PATIENTS AND METHODS
• Between January, 2000 and June, 2002• 21 male patients, mean age 24±7 (17-
44)• Patellar tendon autograft• Time period between injury and the
surgery: 7 months ( 1-48)• The follow-up was performed at 2nd, 3rd,
4th, 6th, and 12th months after operation
FUNCTIONAL TESTSTo
tal d
ista
nce
Tota
l dis
tanc
e
6 meters6 meters
Tota
l dis
tanc
eTo
tal d
ista
nce
Tota
l dis
tanc
eTo
tal d
ista
nce
Single Hop For DistanceSingle Hop For Distance Triple Hop For DistanceTriple Hop For Distance Cross-over Hop For DistanceCross-over Hop For DistanceTimed HopTimed Hop
ISOKINETIC TEST
• Cybex 6000 • Concentric test for knee
flexors and extensors at the angular velocity of 600 and 1800/seconds
• Peak torques (Pt) • Both legs
STATISTICS
• To compare injured-uninjured leg results; – Wilcoxon test
• Relationships between functional capacity and isokinetic test results;
– Pearson correlation coefficient test
The results of the Single Hop test
*** p<0.001,** p<0.01 compared with uninjured leg at same month *** p<0.001,** p<0.01 compared with uninjured leg at same month ++++ p<0.01 compared with uninjured leg at 2p<0.01 compared with uninjured leg at 2nd nd monthmonth
020406080
100120140160180200
2 3 4 6 12months
dist
ance
(cm
)
InjuredUninjured
******+++
***++ *** **
The results of the Timed Hop test
0
50
100
150
200
250
300
2 3 4 6 12months
time
(mse
c)
InjuredUninjured
*** ***++
***** *
*** p<0.001,** p<0.01, *p<0.05 compared with uninjured leg at same month *** p<0.001,** p<0.01, *p<0.05 compared with uninjured leg at same month ++++ p<0.01 compared with uninjured leg at 2 p<0.01 compared with uninjured leg at 2nd nd monthmonth
The results of the Triple Hop test
0100200300400500600700
2 3 4 6 12months
dist
ance
(cm
) InjuredUninjured
***
***+++
***++
*** **
*** p<0.001,** p<0.01 compared with uninjured leg at same month *** p<0.001,** p<0.01 compared with uninjured leg at same month ++
++++p<0.001,p<0.001, ++ ++ p<0.01 compared with uninjured leg at 2 p<0.01 compared with uninjured leg at 2nd nd monthmonth
The results of Cross-over Hop test
0
100
200
300
400
500
600
700
2 3 4 6 12months
dist
ance
(cm
)
InjuredUninjured
******+++
***+++
***+ **
*** p<0.001,** p<0.01 compared with uninjured leg at same month *** p<0.001,** p<0.01 compared with uninjured leg at same month ++
++++ p<0.001, p<0.001, ++ p<0.05 p<0.05 compared with uninjured leg at 2 compared with uninjured leg at 2nd nd monthmonth
ResultsLimb Symmetry Index
05
10152025303540
2 3 4 6 12Months
Defi
cite
(%)
single hop for distance
triple hop for distance
Cross-over for distance
Timed hop
RESULTS
05
1015202530354045
2 3 4 6 12Months
Defi
cite
(%)
Quadriseps (60º/sn)
Quadriseps (180º/sn)
Hamstring (60º/sn)
Hamstring (180º/sn)
CONCLUSION
It is concluded that, the functional capacity can improve with a rehabilitation program used in this study up to four months after ACL surgery, and this improvement is significantly correlated by knee strength.
TIME
2nd week 1st month
2nd month
3rd month
4th month
6th month
12th month
TOTAL SCORE 2,81,2 3,6 1,1 5,4 1,6 6,8 1,3 7,7 1,4 8,7 1,1 8,9 1,1
DAILY ACTIVITY
14,1 9,1
22,7 7,5
32,0 6,6
36,0 3,7
38,3 2,5
38,9 2,6
38,6 2,6
SPORTS ACTIVITY
40,4 2,0
41,5 4,0
52,5 10,8
63,3 11,2
71,7 12,3
83,3 10,4
88,6 9,1
Outcome Measures – Patellar Tendon
TIME
2nd week 1st month
2nd month
3rd month
4th month
6th month
12th month
TOTAL SCORE 3,21,2 3,9 1,0 5,1 1,2 6,0 1,3 7,2 1,3 7,5 0,8 8,7 0,9
DAILY ACTIVITY
14,7 11,2
22,8 6,8
33,2 4,6
35,8 3,7
37,8 3,5
38,7 2,9
38,7 1,8
SPORTS ACTIVITY
41,4 5,6
41,7 5,7
49,2 10,0
55,1 9,1
64,5 13,9
74,9 9,9
85,3 15,2
Outcome Measures – SG
IKDC - Final Score(Patellar Tendon)
%POINT
A B C D
TIME
2nd week - - 4 96
1st month - 2 27 71
2nd month - 13 65 22
3rd month - 51 43 6
4th month 6 65 29 -
6th month 23 56 21 -
12th month 29 54 17 -
IKDC - Final Score(SG)
%POINT
A B C D
TIME
2nd week - - 29 71
1st month - 12 38 50
2nd month - 33 46 21
3rd month - 32 58 10
4th month 6 76 18 -
6th month 8 92 - -
12th month 20 80 - -
THANK YOU FOR YOURKIND ATTENTION