Predictors of Outcome from the MARS Cohort: Physical Therapy, Rehabilitation and Bracing Factors

A Neuromuscular Warm Up Program May Help Prevent ACL Injuries

An old study, but still true. A neuromuscular based warm up program may help prevent ACL injuries. Read details HERE . Unfortunately, we don't know the exact dose, frequency etc. It is apparent that almost any program helps. Now we have to determine the easiest applied correct program. The Young Athlete's Center will be trialing programs locally with soccer teams. Stay tuned for results and recommendations

MARS (Multicenter ACL Revision Study) Rehabilitation Predictors of Surgical Outcomes

ACL Reconstruction Rehabilitation Part 3

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 based the protocol on a series of Systematic Reviews we performed to establish the evidence for best practice ACL rehabilitation. Previously we discussed the first 2 reviews. Here we will review the findings in our 3rd review which was an update of the original 2. It can be found HERE. In this study we discussed an additional study evaluating the use of Continuous Passive Motion machines which once again showed no advantage. Several additional studies had been published evaluating bracing and none demonstrated any advantage in the postoperative rehabilitation period. Additional studies evaluated early ROM and quad strengthening without any increase in laxity. Eccentric strengthening was safe and showed improved strength gains compared to concentric strengthening when initiated at 3 weeks and continuing for 12 weeks. Accelerated rehab shortening to 5 months the recovery did not result in worse outcomes  or safety issues. Additional electrical stimulation studies showed safety, but no significant efficacy in ACL rehabilitation.

Most additional studies performed since our last review reiterated our additional findings. I will be presenting specific findings for revision ACL reconstruction rehabilitation at the July 2016 American Orthopaedic Society for Sports Medicine and we will blog those results when available next week.

ACL Reconstruction Rehabilitation Part 2

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 systematic review evidence we based the protocol on in 3 separate studies. in Part 1 I reviewed the findings in our first publication. The second publication can be found HERE. Findings in this study included a review of open (isokinetic) vs. closed chain exercises. Closed chain exercises occur when the foot is planted on the floor or on a firm surface such as a leg press machine. These type of exercises may be more protective for the healing ACL graft,  but it appears open chain exercises are safe 6 weeks after ACL reconstruction.

Neuromuscular stimulation has been extensively studied utilizing a variety of parameters and has not been shown to be critically important. It is safe and can be utilized at the therapist's discretion most commonly when the patient is struggling to recruit the quadriceps muscle for strengthening.

Accelerated rehabilitation has gained much attention, but there remains little evidence that it can be truly lowered below the 4 month time frame safely. One randomized study looked at 8 vs. 5 months and found no problems with this length of rehabilitation, but to many of us this doesn't represent significant acceleration. Future research will be necessary to address this further.

Water exercise may decrease swelling and appears to be safe. Slide board exercises can be incorporated at 6 weeks without harm. Stair climber is as safe as stationary cycling at 4 weeks.

Additional principles will be reviewed in Part 3 reviewing our 3rd study evaluating ACL rehab PT

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.