Commentary and Historical Perspective of Anterior Cruciate Ligament Rehabilitation

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Commentary and Historical Perspective of Anterior Cruciate Ligament Rehabilitation Terry R. Malone, EdD, PT, ATC' William E. Garrett, )r., MD, Php Terry R. Malone William E. Garrett T he article entitled
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Commentary and Historical Perspective of Anterior Cruciate Ligament Rehabilitation Terry R. Malone, EdD, PT, ATC' William E. Garrett, )r., MD, Php Terry R. Malone William E. Garrett T he article entitled Accelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction by K. Donald Shelbourne and Paul Nitz (21) describes the clinical experiences and observations of two groups of patients who underwent anterior cruciate ligament (ACL) reconstruction and were provided different postoperative rehabilitation sequences. The surgical procedure was an arthroscopically aided, modified Jones intra-articular reconstruction using a 10-mm central patella tendon graft with bone fixation provided by a suture over button technique. Since 1982, Shelbourne has performed more than 800 of these procedures. Although the authors report on two groups, three groups of patients actually existed in their review. The first group consisted of patients treated with a lengthy rehabilitation and immobilization sequence that did not permit full weight bearing for 6-8 weeks. In 1983, a more progressive program was implemented This article serves as the introduction and historical perspective of anterior cruciate ligament surgery and rehabiliation. Several physician-therapist teams have been invited to share their state of the art techniques and to contrast their programs to that espoused by Shelbourne and Nitz in Our commentarylreview of Accelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction (Shelbourne KD, Nitz P, Am I Sports Med 18: , 1990) is provided to contextualize the reader to what most clinicians would recognize as an extremely aggressive rehabilitation approach that is being popularized in the 1990s. A comparison is then presented of the rehabilitation sequence used in the Maclntosh procedures, demonstrating how early motion/functional rehabilitation was the hallmark of this type of extraarticular rehabilitation sequence and how today's pattern has evolved to follow that philosophy. Each of the teamed authors has attempted to present his surgery and rehabilitationltechniques and highlight differences between his program and that of Shelbourne and Nitz. We hope that the readers find this glimpse of the past and present helpful in formulating their rehabilitation sequences and that the future will be predicated on excellent basic science and clinical judgment. Key Words: anterior cruciate ligament reconstruction, rehabilitation, clinical catcome 'Executive director of sports medicine, associate professor of physical therapy, assistant professor of surgery, Duke University Medical Center, Durham, NC kssociate professor of surgery, Division of Orthopaedics, Duke University Medical Center, Durham, NC utilizing CPM without rigid immobilization. The surgeons closely monitored this sequence over the next 2 years. Through observation of positive results in noncompliant patients, they became convinced that a more aggressive rehabilitation program could be safely implemented. This led to the introduction of the accelerated rehabilitation protocol after The advantages of the accelerated rehabilitation protocol were: 1) increased patient cooperation and compliance, 2) earlier return to normal function and athletic activities, 3) decrease in the incidence of patellofemoral joint symptoms, and 4) marked decrease in the number of procedures required to obtain full knee extension. The patient popula- tion for the study consisted of 138 patients who underwent surgery in 1984 and 1985 (Group 1) and 247 patients who underwent surgery in 1987 and 1988 (Group 2). Group 1 data included complete 2-year follow-up on 127 patients (92%). and Group 2 data included 73 patients with 2-year follow-up (30%) and 174 patients with greater than I-year follow-up (70%). The rehabilitation sequence followed by Group 1 is shown in Table 1. The rehabilitation sequence for Group 2 is presented in Table 2. The best descriptors for these rehabilitation programs would be criterion referencing and successful completion of specific functional tasks. Table 2 illustrates greater emphasis on functional task achieve- JOSPT * Volume 15 * Number 6 * June Time After Reconstruction 6 weeks 8-10 weeks 4 months 5 months 6 months 7-8 months Rehabilitation Program Day 1 Leg splinted at 10 flexion, continuous passive motion (CPM) begun 2-3 days Abladduction straight leg raises (SLR), extension SLR, passive range of motion (ROM) 0'-9O0, gluteal sets, ambulation (nonweightbearing), crutches 5-6 days Discharge from hospital, CPM & exercises continued at home, rigid knee immobilizer (set at 10 ) used except during passive knee ROM exercises, hamstring curls, abladduction & extension SLR, toe touch weightbearing 3 weeks Quadriceps exercises, active ROM 60' to 90e, gradual light resistance. NOTE: Patients should have at- tained passive ROM of 0'-90' assisted by CPM or the well leg. Continue Dobi splint when up. May discontinue for sleep Passive ROM 0' to 100', full weightbearing as tolerated, wear IKO (functional knee brace) 10 stops, full time when walking Full weightbearing as tolerated, active ROM 0 to 1 lo , passive stretching to increase ROM, SLR with increased weights, eccentric knee extensions, short arc knee extension 90 to 45', hamstring curls, swimming, stationary bicycling when patient able to walk without crutches. NOTE: If patient has not attained full extension, regimen includes lying prone with 1 pound weight on ankle weeks ROM to 120, full weightbearing, previously described exercises continued, knee bends, step-ups (well leg first; step-down, operated leg first), calf raises ROM 0' to 130 (goal), brace discontinued for activities of daily living (ADL) if patient's quadriceps tone is good, exercises increased in intensity with higher weights and more sets and repeats, fast speed isokinetics Jumping rope Cybex at 180 and 240e/sec with a 20' block, KT- 1000, lateral shuffles, walking up to 2 miles per day, short arc knee extensions to full knee extensions, squats, use of brace for activities other than AC L Cybex, KT-1000, walking, progressive running & jogging; weight lifting continued to strengthen quadriceps, hamstrings, & calf muscles; jogging followed by progressive running program, including backward running and hill running; agility drills including large (gentle) figure of eights; lateral shuffles; slow & fast speed isokinetic strengthening exercises 9-12 months Return to normal activity levels if strength greater than 8O0/0 of the nonoperated knee, full ROM, no pain or swelling, successful completion of functional progression TABLE 1. Croup I, rehabilitation protocol, 1984 through 1985 (From Shelbourne and Nitz (2 1 ), with permission). ment but also remains criterion ref- In Group 1 patients, Shelbourne erenced since it includes specific and Nitz noted difficulty in returnevaluations via isokinetic assessment ing to functional activities at 9 as well as clinical assessment of range months, with most patients expressof motion, effusion, and knee stabil- ing dissatisfaction with their perity. formance ability at that point. In Group 2 patients, full competitive return was not recommended until 4-6 months after surgery, which is in line with the Cybex isokinetic assessment demonstrating a 75 percent functional output at the 4-6-month time frame. It is important to note that in Group 2, isokinetic assessment numbers at 4-6 months and 7-10 months were significantly better than the quadriceps results in Group 1. Range of motion values were significantly better for Group 2 throughout the study. There were no significant differences in KT measurements. Postoperative subjective ratings of the involved knee were significantly better for Group 2 than Group 1 at all assessment times. Sixteen patients in Group 1 (12%) underwent a scar resection, while 11 patients (4%) in Group 2 required a similar procedure. Shelbourne and Nitz's follow-up of Group 1 and Group 2 has convinced them to use the accelerated rehabilitation program following their particular ACL reconstructive procedure. They do not feel it will cause graft weakening or subsequent failure. Shelbourne and Nitz recommend using closed kinetic chain exercises as soon as unsupported weight bearing of the involved extremity is possible. They feel that the accelerated program helps decrease postoperative anterior knee pain and increase subjective stability of the involved knee. They also noted quicker return of quadriceps strength in Group 2. It is important to note that the return of quadriceps strength appears to be somewhat motivationally related as well as interacting with pain tolerance and knee effusion. Shelbourne and Nitz recommend that patients achieve greater than 80 percent of quadriceps function as well as complete other functional tasks prior to return to full activity. They noted that some competitive athletes in Group 2 re- 266 Volume 15 Number 6 June 1992 JOSPT Time After Reconstrudion Day days 2-4 days 7-10 days 2-3 weeks 5-6 weeks 10 weeks 16 weeks 4-6 months Rehabilitation Program Continuous passive motion (CPM), rigid knee immobilizer in full extension for walking, weightbearing as tolerated without crutches CPM, passive range of motion (ROM) 0 to 90Yemphasis on full extension), weightbearing as tolerated without crutches Discharge from hospital; CPM at home. NOTE: Prerequisite to discharge is 1) satisfactory pain management, 2) full extension symmetrical to nonoperated knee, 3) able to do SLR for leg control, 4) full weightbearing with or without crutches ROM terminal extension, prone hangs (2 Ibs) if patient has not achieved full extension, towel extensions, wall slides, heel slides, active-assisted flexion, strengthening-knee bends, step-ups, calf raises; weightbearing-partial to full weightbearing; gradual elimination of required use of knee immobilizer ROM (0 to 1 lo ), unilateral knee bends, step-ups, calf raises, StairMaster 4000, weight room activities: leg press, quarter squats and cali raises in the squat rack, stationary bicycling, swimming, custom-made functional knee brace with no preset limits (to be used at all times out of the home for the next 4 weeks) ROM (0' to 1307, isokinetic evaluation with 20 block at 180 and 240 deglsec. When strength is 70% or greater than the opposite unoperated knee, the patient can begin lateral shuffles, cariocas, light jogging, jumping rope, agility drills, weight room activities, stationary bicycling, and swimming. NOTE: Functional brace discontinued (except for sports activities) when muscle tone and strength are sufficient Full ROM; isokinetic evaluation at 60, 180, and 240 deg/ sec, KT-1000, increased agility workouts, sport-speciiic activities lsokinetic evaluation, KT-1000, increased agility workouts Return to full sports participation (if patient has met criteria of full ROM, no effusion, good knee stability, and has completed the running program) TABLE 2. Croup 2, accelerated rehabilitation program, 1987 through (From Shelbourne and Nitz (21). with permission). gained percent of quadriceps function as early as 10 weeks postop eratively. As an aside, Shelbourne and Nitz have performed a series of biop sies and histological analyses on patients undergoing additional surgical procedures in both Groups 1 and 2. They have been unable to demonstrate significant differences between any of the analyses in these groups and, thus, feel comfortable in recommending the accelerated rehabilitation program without fear of deleterious effects. COMMENTARY As with any retrospective analysis, some problems are beyond the author's control. Although one could be critical of the number of patients in follow-up more than 2 years in Group 2 (73 of 247), it should be noted that 174 of the 247 had been followed for more than 1 year. Of 134 patients, 127 had been followed throughout the course of study in Group 1. Shelbourne and Nitz should be applauded for the significant level of follow-up. However, they should still be aware that some patients lost to follow-up possibly represent specific patients who might have changed the reported results. Shelbourne and Nitz have done an excellent job of specifying that these results are specific to their surgical technique and may not be appropriate for other surgical procedures. Their rehabilitation sequence attempts to minimize the complications seen previously with intra-articular ACL reconstructions through an emphasis on prevention (2, 3, 7). Maintaining extension is the hallmark of this concept, and it is stressed throughout the early portions of the Shelbourne and Nitz sequence. It is interesting to note that following the accelerated program, patients still demonstrate quadriceps weakness of approximately percent at 6 months. This is very much in agreement with our data (79-83%) (12). The level of isokinetic output required for safe function has never been scientifically determined, but the percent value has been used frequently in the functional progression of patients toward more aggressive cutting demands (7-9, 1 1). In our experience, this level is required to safely proceed through that portion of the functional progression. Closed kinetic chain concepts are not new but, rather, reflect what was termed functional progression during the 1970s (8, 9). The ability to quantify closed kinetic chain function is difficult and requires multiple measures (18, 19, 24, 25). We are aware that graft strength is somewhat compromised at 6 months, and, thus, we emphasize the need for normal proprioceptive and functional patterns in musculature and coordination before exposure to potentially dangerous joint loads (2, 5, 6, 10, 17, 19, 20, 22). It is extremely interesting to note the similarities between the accelerated rehabilitation program and the extra-articular rehabilitation se- JOSPT Volume 15 Number 6 June l9!e quences used with the MacIntosh procedures in the early 1970s (1 1). The following outline is provided for comparison, and the similarities should be noted. Macintosh Procedures Postoperative Management Postoperative management included maintenance of the externally rotated and posteriorly placed tibia for 6-8 weeks. This was performed with a postoperative cast for 7 days, followed by an additional 5-7 weeks of hinge casting or hinge orthosis, allowing a protected range of motion. The early range of motion at weeks 2-4 was 90-60 ; at weeks 4-6, it was 30-90 . During hinge casting, patients were allowed to work actively using both isotonic and isometric exercises. They were encouraged to work very aggressively on their hamstrings and low in the range of motion (90-40 ) on isometric and isotonic quadriceps. Patients were instructed to remain nonweight bearing until cast removal at 7-8 weeks. Early Rehabilitation-Cast Removal to Full Weight Bearing Patients were urged to not attempt to bear full weight until they had active control of extension. It was not unusual for a patient to achieve full extension within 5-8 days of cast removal. Patients were allowed to work on active range of motion and whirlpool activities to achieve greater range, but they were urged to achieve active extension through muscular control. We normally saw these patients achieve full extension at 10 days after cast removal and become weight bearing to tolerance and then full weight bearing typically within 2 weeks of cast removal. We allowed full extension on an active mode since external rotation of the tibia in a open chain concept allowed protection of this particular surgical procedure. An additional point of emphasis was that we allowed abductor and adductor strengthening in these patients. Intermediate Phase: 2-5 Weeks Postcast Removal Most patients had achieved full extension and, essentially, full range of motion through the first 2 weeks of mobilization. They were fully weight bearing and were beginning what we termed a protected strengthening environment. Patients worked on terminal extension but not into heavy PRE terminal extension. They worked on isokinetic exercises, pushing toward higher velocities as quickly as possible. We utilized lower speed isokinetics only on a submaximal level and advanced to moderate and higher speeds as quickly as possible. This allowed us to minimize compression and shear forces on the articular surfaces. Cycling and step ups were two of the activities we used extensively during the intermediate phase. Proprioceptive activities were vital to allow functional enhancement. The Advanced Phase At 3-4 months postsurgery, the advanced phase of rehabilitation was begun. Strength was approximately 80 percent, and endurance was 80 percent, as assessed isokinetically. The patients were well into a functional progression as dictated by their chosen activities. Running was begun at 3-4 months postsurgery, and a return to full competitive athletics was allowed between 6-8 months. In our experience, it required 2-3 months of a particular activity before full competition was advisable. We felt that this time frame was required for normalization of muscular responses through neural enhancement. The ability to perform terminal extension activities safely was unique in the rehabilitation of these patients. External rotation was a desired positioning, as seen in its maintenance during cast immobilization. A second important factor was allowing early range of motion through hinge casting, providing movement at 7-10 days. A third hallmark was permitting exercises with a ham- string emphasis and allowing active quadriceps work to start during the hinge cast immobilization phase. Early strength activities included biking, stepups, partial squats, and leg presses, along with propriocep tive work. Finally, these patients were allowed to return to full activity at approximately 6-8 months and were involved in an advanced rehabilitation phase at 3-4 months. Lastly, the rehabilitation was designed around functional progression as dictated by the demands of the individual patient. Although the early treatment of the MacIntosh patient was nonweight bearing exercise and hinge casting, range of motion and strength activities were allowed and encouraged. The weight bearing progression was extremely rapid, as was the encouragement to regain full extension. The functional progression involved cycling, stepups, and other aggressive, closed kinetic activities. Patients returned to full activity at approximately 6 months postsurgery. Malone and Garrett Approach to Intra-articular Surgery and Rehabilitation At our clinic, we use a similar protocol to Shelbourne and Nitz. However, we are very careful to avoid uncontrolled full extension stresses early in our rehabilitation program ( ). We allow weight bearing to tolerance in an extended position using a locked hinge orthosis and find that most patients are able to become full weight bearing at 3-5 weeks. We believe that middle of the range of motion weight bearing activities are better tolerated during exercise activities and are safer than their open chain counterparts, but acknowledge that the greatest stresses on the graft are still seen in an extended position (2, 10, 17). Thus, we emphasize the redevelopment of normal protective Volume 15 Number 6 June 1992 JOSPT responses prior to exposing the patient to potentially dangerous joint stresses. We also emphasize care in implementing functional patterns that may alter neuromuscular responses (1, 4, 23). We do not believe that it is essential to allow very early aggressive actions since we do not allow a full return until approximately 6 months postsurgery. We prefer to describe our sequence as controlled physiologic rehabilitation. Although progression criteria are used, patients must be provided flexible time windows to allow individualization of the rehabilitation process. Functional progression is the best means of providing this in an integrated format. It has been our experience that athletes require 2-3
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