REHABILITATION CONSIDERATIONS
Once a patient has a diagnosis of an ACL tear and has been clas- sified based on dynamic stability of the knee, the patient may choose to undergo ACL reconstruction to restore the passive re- straints of the knee or may choose a nonoperative management Nonoperative rehabilitation programs The effectiveness of nonoperative management depends largely on the decision-making criteria used for selecting appropriate candidates and the incorporation of perturbation training tech- niques into the nonoperative rehabilitation program (Fitzgerald, Axe, & Snyder-Mackler, 2000a; 2000b; 2000c). Regardless of clas- sification, all patients with acute ACL injury should be advised to go through 10 sessions of an exercise therapy program (including progressive strengthening training augmented with perturbation training) for 5 to 6 weeks after initial impairments are resolved and before the final decision for either ACL reconstruction or nonop- erative management is made (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010; Magnussen et al., 2010). Currently, operative management is recommended for young patients who experi- ence episodes of knee instability during simple activities and who intend to return to activities that involve jumping, cutting, and pivoting movements. The focus of nonoperative treatment is on perturbation training, strengthening, and neuromuscular and agil- ity training. Perturbation training Rehabilitation programs that include perturbation training, com- pared to standardized rehabilitation without perturbation train- ing, result in higher rates of return to preinjury activity levels, with fewer episodes of giving way for patients classified as potential copers (Fitzgerald, Axe, & Snyder- Mackler, 2000c). Perturbation training that includes purposeful destabilization stimuli applied to movable surfaces is incorporated into the rehabilitation program. Perturbation training can consist of three techniques: a tilt board, a roller board with a stationary platform, and a roller board (Figure 3). Perturbation training progresses in a similar manner for each technique, with each training session consisting of all three tech- niques. Early in the training, the patient stands on the movable surfaces with two-limb support and the therapist provides verbal cues of the direction of the perturbation stimulus so the patient can become familiar with the training. Patients are progressed to single-limb support on the injured limb in the first training session. During sessions 1 through 4, unidirectional perturbation stimuli should be administered at small amplitude and low frequency to allow the patient to become familiar with the training (Fitzgerald, Axe, & Snyder-Mackler, 2000c). Once the patient feels comfortable with the training, the therapist begins to progress the training by removing verbal cues and administering the perturbation stimuli in random directions at mild to moderate amplitude and higher frequency. In addition, unidirectional destabilizing stimuli are re- placed with two-directional and multidirectional stimuli, depend- ing on the patient’s tolerance (Fitzgerald, Axe, & Snyder-Mackler, 2000c). Sport-specific activities are incorporated during the last four perturbation sessions to develop neuromuscular responses that might be carried over to activity (Fitzgerald, Axe, & Snyder- Mackler, 2000c). Sport-specific activities can be initiated when pa- tients demonstrate minimal balance disturbance on the tilt board and minimal co-contraction responses on the roller board/station- ary platform (Fitzgerald, Axe, & Snyder-Mackler, 2000c). During sport-specific performance, sport activities are incor- porated according to the patient’s sport practice. For example, basketball players may receive and throw the ball to the thera- pist, whereas soccer players might kick the ball. During the last three training sessions (as appropriate), the destabilizing stimuli are administered at large amplitudes and multiple directions that include rotations and high frequency so that the subjects may elicit specific muscular co-contraction in the lower extremity (Eit- zen, Moksnes, Snyder-Mackler, & Risberg, 2010; Fitzgerald, Axe, & Snyder-Mackler, 2000c).
approach. Considerations for either approach should be a shared decision between the patient, the surgeon, and the physical ther- apist.
Figure 3: Perturbation Training
Note . From Western Schools, © 2018. Perturbation training with a roller board and platform is gener- ally initiated first because this technique provides a more stable base of support. With this technique, the patient stands with one foot on the roller board and the other foot on the platform. The therapist asks the patient to stand with the knee flexed and to place equal weight on each foot during the training. During roller board/platform exercises, the patient is instructed to maintain the roller board in a steady position once the therapist starts moving it. While the therapist provides destabilizing force to the roller board, the patient is encouraged to develop muscle force that counteracts the destabilizing force. Patients are discouraged from overcoming the applied force and from co-contracting the thigh and leg muscles to maintain the roller board in one place. The therapist observes the patient’s thigh and leg muscles to ensure that the selective muscle contractions occur during training. Clini- cians use their clinical reasoning skills to make decisions concern- ing the progression in difficulty throughout the perturbation train- ing. The progression is guided by the patient’s tolerance to the activity and the presence of adverse responses, such as muscle soreness and joint effusion (Table 2). To provide a more unstable surface, the stationary platform may be removed. During the roller-board-only perturbation training, the patient stands with single-limb support on the injured limb and the therapist moves the roller board in multiple directions to disturb the patient’s standing balance. The therapist moves the board in a random pattern and at different magnitudes according to the patient’s responses, with small displacement amplitudes for patients with poor balance responses and large amplitudes for patients demonstrating a minimal loss of balance. The therapist instructs the patient on the roller board to maintain his or her balance. The final technique is tilt board training. During the first three training sessions, the patient stands on a tilt board and the thera- pist applies anterior-posterior and medial-lateral oriented pertur- bation stimuli at random to challenge the patient’s balance. After the third training session, anterior-posterior perturbation stimuli are replaced with diagonal stimuli by moving the tilt board into a diagonal position. During tilt board exercises, the therapist in- structs the patient to maintain balance during each of the desta- bilizing stimuli.
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Book Code: PTCA2624
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