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ACL Rehab: Traditional vs Accelerated Kathryn A. Koshansky, MS, ATC Athletic Training Program Chair Associate Professor School of Health Technology & Management Stony Brook University May 11, 2012 Background nCertified Athletic Trainer = 29 yrs nChair of SBU Athletic Training Program nState Education Board for Athletic Training nNATA D2 Advanced Education Committee nFormer SBU Assistant AD for Sports Medicine Objectives nIdentify examples of ACL RTP that are shared in the media. nDiscuss the common in ACL rehabilitation protocols used over the past 30 years. nProvide insight to the concept of being “patient driven”. The Injury Example 1 n Former NFL wide receiver Jerry Rice famously made a comeback 3 ½ months after undergoing ACL reconstruction in 1997; In his first game back, he fractured his kneecap (where the ACL graft was taken from). This new injury ended his season. Example 2 n 35-year-old forward player; isolated complete ACL tear; competitive 2001-2002 season; contention for a position on the Italian World Cup Team that was to be played 135 days after his injury, only if he demonstrated that he could return to play at the highest level before the team was selected. n ACL surgery 4 days after the injury. 8 days after surgery he began rehabilitation at a rate of 2 sessions a day, 5 days a week, plus 1 session every Saturday morning. Sessions involved pool (aquatic exercises), gymnasium (flexibility, coordination, & strength exercises), and soccer field (technical and tactical skills) n The surgical technique and the progressive rehabilitation program allowed the patient to play for 20 minutes in an official First Division soccer game 77 days after surgery and to play a full game 90 days after surgery. 18 months post surgery, the player had participated in 62 First Division matches, scoring 26 times, and had received no further treatment for his knee. Example 3 Three months removed from a torn ACL, Detroit Lions running back Kevin Smith says he’s on schedule in rehabbing his knee. But he also says that he’s not running yet and not sure how long it will be before he’s back to full speed: “My leg is feeling good and I think I’m right on schedule,” Smith wrote on his personal web site. “I’m just taking it day-by-day, doing my rehab every day and lifting. It’s time to get back into it. Football season is going to come back around real fast. There’s no timeline for my knee, I just know that I don’t want to waste a single day,” Smith wrote. “I rehab with a purpose, every day I find the focus to get myself right. My time is coming really soon.” March 2010 The Question n When is it safe to Return to Play? nIs it: 3 months? 6 months? 12 months? The Answer? nIf it were that easy… we all may be out of jobs, or have much less stress in our jobs! nThe patient (and their family, coaches, etc) have all the answers nEach patient is the perfect patient nNot going to happen! We’ve Heard it All… n “When’s the quickest I can get back to activity?” n “I have to be back by …” n “My friend so & so got back to activity …” n “At xyz college so & so got back to playing …” n “I’m committed to my rehab!” n “You don’t know me, I’m a quick healer!” n Etc… Where are we in 2012? nSurgical techniques nRehabilitation We are living in a world of INSTANT GRATIFICATION! ACL Rehab Timeline n“Surgical stability is easily reproducible, long-term patient satisfaction is difficult to guarantee.” Shelbourne, 2006 The Issues nDamaged structures in addition to ACL nGraft choices nAllograft nAutograft nBPTB nSemitendinosus/Gracilis tendons nPre-Injury Status nPatient Commitment The Biology nBone will have meaningful incorporation by 6-8 weeks nSoft tissue healing to bone with fibrous tissue or scar may take up to 12 weeks where it's relying on the screws alone before the fibers start growing into bone Goals of ACL Rehabilitation nReturn the patient back to activity as soon as possible but also as safely as possible nReach symmetry between knees: nRange of Motion nStrength nStability nOverall Function nSuccessfully pass RTP testing Traditional (early 1980’s) Accelerated (late 1980’s) Comparison Current Cascade of events outlines a systematic rehabilitation program that emphasizes the return to symmetrical knee motion that includes hyperextension. ROM, range of motion. Shelbourne & Klotz, 2006 Current Perioperative Phases of Rehabilitation. Shelbourne & Klotz, 2006 Experience nYou've lived it! nWhat works for you and your patient? Critical input from.. n Physician (surgeon) n Certified Athletic Trainer n Physical Therapist n Athlete (+/- parents) n +/- Coach Bottom Line nTo return earlier there is a higher failure rate nIt's the patient's call but they have to live with the consequences Summary nRehabilitation program is NOT going to follow the same timeline for each athlete nEvery athlete is different nRehabilitation should be “Patient Driven”! Take Home Message nProtocol should be built on criteria-based progression rather than time-based progression; with the knowledge of graft strength timelines nIf your athlete is not playing sports at 6 months… stop expecting that something is wrong! References n Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, Nichols CE. Accelerated versus nonaccelerated rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind investigation evaluating knee joint laxity using roentgen stereophotogrammetric analysis. Am J Sports Med. 2011 Dec;39(12):2536-48. Epub 2011 Sep 27. n Decarlo MS, Shelbourne KD, McCarroll JR, Rettig AC. Traditional versus Accelerated Rehabilitation following ACL Reconstruction: A One-Year Follow-Up. J Orthopaedic Sports Physical Therapy. 1992;15(6):309-16. n Roi GS, Creta D, Nanni G, Marcacci M, Zaffagnini S, Snyder-Mackler L. Return to Official Italian First Division Soccer Games Within 90 Days After Anterior Cruciate Ligament Reconstruction: A Case Report. Journal of Orthopaedic & Sports Physical Therapy. 2005;35(2): 52-66. n Pezzullo, David & Fadale P. Current Controversies in Rehabilitation After Anterior Cruciate Ligament Reconstruction. Sports Medicine and Arthroscopy Review. 2010; 18(1); 43-47. n Shaw T. Accelerated rehabilitation following anterior cruciate reconstruction. Physical Therapy in Sport. 2002; 3: 19-26. n Shah VM, Andrews JR, Flesig, GS, McMichael CS, Lemak LJ. Return to Play After Anterior Cruciate Reconstruction in National Football League Athletes. American Journal of Sports Medicine. 2010; 38(11):2233-2239. n Shelbourne KD & Klotz C. What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction. Journal of Orthopaedic Science. 2006;11:318-325. n ACL Protocols from: Dr. Stuart Cherney (All-Sport Orthopaedic Surgery) Dr. James Paci and Dr. James Penna (SBU Department of Orthopaedics) Thank you!
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