Thank You RTP-after ACL-R RTP-after ACL-R RTP-after ACL-R RTP-after ACL-R So, what else

29 Pages·2017·3.65 MB·English

4/15/2017
Thank You Clinical Decision-Making: Specific Parameters to
A Quantitative and return an athlete back to sports following a knee
injury
Thanks to OHSUfor the kind Qualitative Functional
invitation to present this What amazes me, is that many of us
information Testing Algorithm for need to make this decision on a
regular basis, however, there are:
clinical decision making
1) very few guidelines published
to return athletes back to
2) few objective tests documented to
support the clinical decision making
Sports following a Knee process
It is indeed an honor and privilege Injury 3) limited evidence to support this
to be invited to participate and process
share information.
RReettuurrnn ttoo PPllaayy--SSuummmmaarryy RRTTPP--aafftteerr AACCLL--RR RRTTPP--aafftteerr AACCLL--RR
So what are BFRar. bFearc-tWoress utisne, dS Dto, Noyes, ACL-R:
May fail
most clinicians determine return to
unrestricted sports Rates of either reinjuring
doing for criteria activities after ACL-R. an ACL-R knee or
sustaining an ACL
Arthroscopy. 27:1697-1705,
for RTP? 2011 rupture to contralateral
knee range from 3-49%
(Systematic Review)
RRTTPP--aafftteerr AACCLL--RR RRTTPP--aafftteerr AACCLL--RR CClliinniiccaall DDeecciissiioonn--
Systematic review: Systematic review: MMaakkiinngg
264 studies: 264 studies:
105 (40%) failed to provide any 35 (13%) objective criteria So, what else
criteria for RTP 9 %-muscle strength criteria 80-90%
84 (32%) amount of time post-op was of Q & H can we do???
only criteria 6 % -effusion/ROM
40 (15%) time and subjective criteria 4% -single leg hop
35 (13%) objective criteria 1 study –stability
Muscle strength, stability, 1 study –validated questionnaires
neuromuscular control, function
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CClleeaarraannccee ttoo RReettuurrnn ttoo So how do we do it ??? Return To Sports
SSppoorrttss
One way is to perform a task analysis of
the specific sport Need to perform
One method is to have Try to establish a performance metric
baseline pre- Check epidemiology testing in non-
participation information, information for MOI fatigued state as well
and have the athlete Then determine if there are appropriate as “fatigued” state
return back to “normal” testswith good psychometric properties
for all the parameters to test and evaluate the specific “tasks”
for the sport
CClleeaarraannccee ttoo RReettuurrnn ttoo RReettuurrnn ttoo PPllaayy CLINICAL ARTICLE
SSppoorrttss
Functional
progression of a
If a physician, physical therapist or patient through a
arethtulernti ct ot rsapinoertrs a, ltlhoewys mana ya tbhel eletge atloly Literature rperhoagbrailmitation
held responsible if the athlete
encounters a reinjury. Review Davies, GJ, et.al.
OrthopPhys Ther
Clinics North
Creighton, DW, et.al. Return-to-play in sport: a America, 9:103-
decision-based model. 118, 2000
ClinJ Sports Med. 20(5):379-385, 2010
HOT TOPIC Kreetyu rtna kteo hspomoret (mReTsSs)ages regarding definitions for The evidence emerging from this study
The minimum information required to define RTS is: suggests that the majority of patients
1) the sport and the level of participation the athlete who are 6 months after ACLR require
2017 aims to return to. additional rehabilitation to pass
2) RTS is a continuum comprising three elements:
return to participation, RTS criteria.
return to sport
Literature return to performance. The RTS battery described in this study
3) In certain situations the RTS decision may be may serve as a framework for future
reversed to a removal from sport decision. studies to implement multivariate models
4) The RTS decision should be shared among all
State of the stakeholders in order to optimize the decision-making
(except in the case of health risk to the athlete). regarding RTS after ACLR with the aim to
reduce incidence of second ACL injuries.
Art-RTS Arden, CL, et.al. 2016 Consensus statement on return to
Sport from the First World Congress in Sports Physical Gokeler, A, et.al. Development of a test battery to enhance safe return to
Therapy. BJSM. May, 2016 Sports after ACL reconstruction. Knee SurgSports TraumatolArthrosc.
July, 2016
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Patients who return to level I sports Those who failed RTS criteria: Functional Testing
had a 4.32 times higher injury rate 38.2% re-injury rate
Algorithm for
than those who did not
Those who passed RTS criteria:
Re-injury rate was reduced by 51% 5.6% clinical decision
for each month RTS was delayed
making
until 9 months after surgery More symmetrical quadriceps
strength prior to RTS For Return to Sports
After 9 months, no further
risk reduction was observed significantly reduced the knee following a
re-injury rate
Knee Injury
Grindem, H, et.al . Simple decision rules can reduce reinjuryrisk by Grindem, H, et.al . Simple decision rules can reduce reinjuryrisk by
84% after ACL-R: the Delaware-Oslo ACL cohort study. 84% after ACL-R: the Delaware-Oslo ACL cohort study.
BJSM. 1-16, 2016. BJSM. 1-16, 2016.
Functional Testing Algorithm – FTA Specific Guidelines Functional Testing Algorithm-
Knee -1980-2017
LEFT –M-1:30; F-2:00 minutes Sports Specific Tests
SLToepwsotrestr S Epxetcriefmic iTtye sFtuinngctional CoAmthpleettietisve HNJUOoMrPmP -s -</<v 1a 10ri5%o%uHs/ th.H;o t<p.;s 1N 0o%rm bsilat. Comp.; LFouwncetri oEnxatlr eHmopit yT eFsutnsc t i o n a l T e s t s
Functional Hop Tests OcoKmCp Iasroiksoinne/toictsh e-r< c r2it5e%ria bilateral Functional Jump Tests
Functional Jump Tests Recreational CKC Isokinetics -< 30% bilateral OKC Isokinetic Tests (MMT,HHD)
OKC Isokinetic testing Athletes comparison CKC Isokinetic Tests (Wall
SBCeaKnlCasn oIcrseiom/kPoirtnooeprt rSiiocy csTeteepmstitv iTnee gsting: OrGtheonpeareadlic KcKoiTnm e1ps0th0e0t -ic</B 3a lmanmc eb iTlaetsetrinagl c–omBiplaatrison sliBdaelsa/nsccea lTeess)ts (Stork Stand Test)
Testing Patients Basic Measurements -< 10% bilateral KT 1000 Tests (“Good hands”)
KT 1000/2000 comparison Basic Measurements
Basic Measurements
Functional Testing Algorithm Functional Testing Algorithm –
–Knee Knee -1980-2017
Sport Specific Testing Competitive
Pofr otgesretisnsgio dni ftfoic tuhlety n ies xptr ehdigichaetre lde vel LToewstesr Extremity Functional Athletes
upon passing the prior test in the Functional Hop Tests
series… Functional Jump Tests Recreational
OKC Isokinetic testing Athletes
Each successive test and its CKC Isokinetic Testing
ainscsroecaiasitnegd sttrraeinssinogn r ethgeim peanti epnlat ces SBeanlasnocreim/Portoopr rSioycsetepmtiv Tee sting: OrGtheonpeareadlic
while at the same time decreasing Testing Patients
clinical control KT 1000/2000
Basic Measurements P & S M, 1978
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BBaassiicc MMeeaassuurreemmeennttss Treatments BBaassiicc MMeeaassuurreemmeennttss
Time/soft tissue healing MD Clearance & Approval
VAS (0-10 scale) Time/soft tissue healing
Anthropometric VAS (0-10 scale)
measurements Anthropometric measurements
AROM, PROM Example – AROM, PROM
Special Tests Hypomobility SQpueacliitaal tTivees t&s Quantitative
Qualitative & Quantitative Movement Assessment
Movement Assessment
Knee Rating scales: IKDC, etc.
Knee Rating scales: IKDC, etc.
Functional Testing Algorithm ACL Quad Tendon We still have not
TIME: TDeanrdkOo nQp uParde - Graft Healing answered this Question?
Soft tissue healing
Biologics and “mother nature”
and the:
from the injury or
from a Neoangiogenesis
Maturation
post-surgical condition Time Zero 1 month PO 6 months PO Ligamentization
ACL Quad Tendon KKnneeee RReehhaabbiilliittaattiioonn:: PPhhaassee II Limitations of Rehabilitation
TDeanrdko nQ uParde - Graft Healing Biopsychosocial Approach
Op Bio-Psycho-Social Rehabilitation
1. Fear
9 Months 2. Pain catastrophizing
3. Kinesiophobia
4. PROs
Time Zero 1 month PO 6 months PO 1 year PO
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Functional Testing Algorithm – Biodex BiodexBalance Stabilometer
Knee -2017 Balance
Sport Specific Testing Competitive Stabilometer
Lower Extremity Functional Athletes
Tests
Functional Hop Tests
Functional Jump Tests Recreational
OKC Isokinetic testing Athletes
CKC Isokinetic Testing
Sensorimotor System Testing: General
Balance/Proprioceptive Orthopaedic
Testing Patients
KT 1000/2000
Basic Measurements
ACL-R
Clinical
It has been my clinical Biomechanics •More flexion - WB on ACL-R side
observation (performance 17:525010-2554, •More external weight - WB on ACL-R side
motion assessment) that
after a LE injury, individuals 3 months: unweightedACL-R side
do not bear weight equally 6 months: unweightedACL-R side
during double-leg exercises, 12 months: normalized WB -ACL-R side
especially on the
Majority of patients felt like they were
injured leg performing equal WB on both legs
Balance/Proprioceptive Testing TTrreeaattmmeenntt IInntteerrvveennttiioonnss BBaallaannccee//
When prescribing squat exercises, it should be
rteencodg tnoi zuendl otahda tt hinei taiafflelyc,t epda tkiennetes. with ACLR So what do we do if PPrroopprriioocceeppttiivvee//
More symmetrical loading patterns may be the patient cannot
achieved by inducing bilateral fatigue. “pass” this part of KKiinneesstthheettiicc
When fatigued, loading symmetry was similar
between this patient group and controls. the Functional
This is relevant information for those who TTrraaiinniinngg
implement rehabilitation training programs. Testing Algorithm
(FTA)
Webster KE1, et.al. Symmetry of squatting and the ““LLaabb””
effect of fatigue following ACL-R.
Knee SurgSports TraumatolArthrosc., 2014
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BBaallaannccee EExxeerrcciissee PPrrooggrreessssiioonn ffoorr LLoowweerr BBaallaannccee EExxeerrcciissee PPrrooggrreessssiioonn ffoorr LLoowweerr BBaallaannccee EExxeerrcciissee PPrrooggrreessssiioonn ffoorr LLoowweerr
EExxttrreemmiittyy IInnjjuurriieess((WWiitthhoouutt aannyy eeqquuiippmmeenntt)) EExxttrreemmiittyy IInnjjuurriieess((WWiitthhoouutt aannyy eeqquuiippmmeenntt)) EExxttrreemmiittyy IInnjjuurriieess((WWiitthhoouutt aannyy eeqquuiippmmeenntt))
22--lleeggggeedd ssttaannddiinngg 11--lleeggggeedd ssttaannddiinngg
22--lleeggggeedd ttooee wwaallkkiinngg 22--lleeggggeedd ssttaannddiinngg --eeyyeess cclloosseedd 11--lleeggggeedd ssttaannddiinngg --eeyyeess cclloosseedd
22--lleeggggeedd ssttaannddiinngg --ttaannddeemm --eeyyeess 11--lleeggggeedd ssttaannddiinngg --ppeerrttuurrbbaattiioonnss
22--lleeggggeedd hheeeell wwaallkkiinngg cclloosseedd 11--lleeggggeedd ssttaannddiinngg --ppeerrttuurrbbaattiioonnss --
22--lleeggggeedd ssttaannddiinngg --ttaannddeemm 22--lleeggggeedd ssttaannddiinngg --ppeerrttuurrbbaattiioonnss -- eeyyeess cclloosseedd
22--lleeggggeedd ssttaannddiinngg –– eeyyeess cclloosseedd 11--lleeggggeedd hhoopp aanndd ssttiicckk
ppeerrttuurrbbaattiioonnss 22--lleeggggeedd ssttaannddiinngg --ttaannddeemm -- 11--lleeggggeedd hhoopp aanndd ssttiicckk ––ppeerrttuurrbbaattiioonnss
ppeerrttuurrbbaattiioonnss --eeyyeess cclloosseedd oonn llaannddiinngg
22--lleeggggeedd ssttaannddiinngg --ttaannddeemm -- 22--lleeggggeedd ssttaannddiinngg --ttaannddeemm -- 11--lleeggggeedd hhoopp aanndd ssttiicckk ––ppeerrttuurrbbaattiioonnss
ppeerrttuurrbbaattiioonnss ppeerrttuurrbbaattiioonnss --eeyyeess cclloosseedd iinn aaiirr
Functional Testing Algorithm – TTrreeaattmmeenntt IInntteerrvveennttiioonnss
Knee -2017
Coovnetrilnaup ooufs SLopworetr S Epxetcriefmic iTtye sFtuinngctional CoAmthpleettietisve So what do we do if
Rehab Continuous Tests the patient cannot
interventions overlap of Functional Hop Tests
Rehab Continuous Functional Jump Tests Recreational “pass” this part of
interventions ovRerelhaapb of OCKKCC IIssookkiinneettiicc Tteessttiinngg Athletes the Functional
interventions Sensorimotor System Testing: General Testing Algorithm
Balance/Proprioceptive Orthopaedic
Testing Patients (FTA)
KT 1000/2000
Basic Measurements
WWaallll SSlliiddeess
The Forgotten Exercise TTrreeaattmmeenntt IInntteerrvveennttiioonnss
Can progress
to single leg
wall slides and
single leg
squats
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Knee Flexion-
BBiillaatteerraall GGoobblleett SSqquuaattss The Other Forgotten Exercise
Nordic/Russian/Etc.
Hams
Knee Flexion-Hams-Functional
Specificity (Davies Adaptation)
Lengthened position
Faster Velocities (Manual force)
TLS-Forward Lunges TLS-Monster Walks
FWB-
Advanced Squat
Exercise
Progression
“Lab”
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KKnneeee RReehhaabbiilliittaattiioonn
KKnneeee RReehhaabbiilliittaattiioonn
Squat

Sequence
KKnneeee RReehhaabbiilliittaattiioonn KKnneeee RReehhaabbiilliittaattiioonn KKnneeee RReehhaabbiilliittaattiioonn
Squats – Bodyweight Tuck Squats - BW Toe Touch Squat
Exercise
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Squats – BW- Overhead Face the Wall Squats -BW Hindu Squat - BW
Sissy Squats Squats – Smith Rack Box Squats - BB
Back Squats-BB Front Squats - BB Zercher Squats – BB
(BB held with elbows)
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Trap Bar Squats Hack (heel) Squats - BB
Overhead Squats - BB
Belt Squats Goblet Squats
(weight is attached to hip belt)
Cossack Squats KKnneeee RReehhaabbiilliittaattiioonn Side to Side Squats
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