Thursday, May 12, 2016

ACL Reconstruction Rehabilitation Part 1

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the principles that it was based upon in a series of evidence based systematic reviews. The study can be found HERE  I will summarize our findings in this and subsequent blogs. Continuous passive motion CPM has been anecdotally advocated as a way to improve range of motion (ROM) following ACL reconstruction. It has become increasingly difficult to get insurance to pay for this and fortunately 6 randomized controlled trials demonstrated no advantage for the use of CPM. Based on this we did not utilize or advocate for its use in our protocol.

Immediate weight bearing and early ROM has been shown to improve outcome with less patellofemoral pain postoperatively. More than 15 randomized trials have evaluated using braces during the recovery phase following ACL reconstruction. No study demonstrated an advantage for safety, swelling, graft function or ROM with the use of the brace. Given the cost and inconvenience of braces we do not require or advocate bracing after ACL reconstruction.

Home based vs. outpatient rehabilitation has been evaluated in several studies. In the motivated patient appropriate outcomes can be achieved with minimal outpatient therapist guidance. This should be individualized for each patient.

Read future blogs for a review of further studies guiding our protocol’s development.

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