Strengthening programs should include single-limb exercise for the injured limb, including knee extension, knee flexion (leg curl), and leg press exercises. Patients may also perform single-limb squats, two-limb support squats with weights, and lateral and for- ward step-downs using different step heights. The American College of Sports Medicine (ACSM) guidelines for the resistance training progression to induce muscle hypertrophy in healthy individuals recommend that loads corresponding to 1 to 12 repetition maximums (RM) be used (with emphasis on the 6 to 12 RM zone) in a periodized fashion using 1- to 2-minute rest periods between sets at a moderate velocity (Kraemer et al., 2002). Resistance progression follows a “+2 principle,” which dic- tates that if the patient is able to perform an extra two repetitions above the target repetition, then the load will be increased in the next training session (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010). For patients who fail to restore quadriceps strength to the injured limb within 80% of the uninjured limb, strength train- ing may be augmented with neuromuscular electrical stimula- tion (NMES) training (Fitzgerald, Axe, & Snyder-Mackler, 2000c; Snyder-Mackler et al., 1995). The therapist must consider the pa- tient’s sport and occupational needs and individualize strengthen- ing programs for each patient accordingly. Additionally, patients are encouraged to start a fitness strengthening program once they finish their rehabilitation program. The aims of the fitness strengthening program are to maintain muscular strength and to minimize quadriceps strength asymmetry between limbs. Agility training Agility drills are being used as part of the nonoperative ACL re- habilitation program for patients who are planning to return, for short or long term, to the preinjury activities (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000b; Fitzgerald, Axe, & Snyder- Mackler, 2000c). Agility training is used to improve neuromuscular coordination of the lower extremities muscles and to increase patients’ ability to quickly accelerate, decelerate, and change in running directions while maintaining dynamic knee stability (Fitzgerald, Axe, & Snyder-Mackler, 2000c; Risberg & Holm, 2009). This training should be initiated following successful completion of perturbation training and in the absence of patient-reported knee instability. It is also suggested that ef- fusion and ROM limitations be minimized prior to initiation of an agility program. Agility techniques include forward and backward running with quick start and stop, side-to-side shuffling, carioca, figure-eight running, and 45° cutting and sprinting. Agility train- ing should be initiated with simple unidirectional activities (e.g., forward and backward running with quick start and stop, side- to-side shuffling) and then progressed to multidirectional activi- ties (e.g., carioca, figure-eight running, and 45° cutting). Patients should start performing agility training at 35% to 50% of their maximum effort and progress to full-effort training. Agility pro- gression is based on the patient’s tolerance for activity and the presence or absence of knee pain and effusion. Sport-specific skills (basketball dribbling, ball throwing, ball kick- ing) may also be integrated into agility training when the patient is able to tolerate full-effort training without pain or swelling. Be- fore adding sport-specific skills, therapists should supervise their patients to provide feedback and ensure a proper activity perfor- mance. Agility training has been shown to decrease the time to peak muscle torque in healthy individuals (Wojtys, Huston, Taylor, & Bastian, 1996). It might be beneficial for patients with ACL in- jury who exhibit dynamic knee instability, because muscles that cross the knee join can provide enough force within a short time to control the knee stability during dynamic activities. tient functional recovery and outcomes after ACL reconstruction surgery, so preoperative rehabilitation programs should focus on resolving the common knee impairments as a result of the ACL in- jury. It is suggested that the patient should demonstrate full knee ROM, no or minimum joint effusion, no knee extension lag dur- ing a straight leg raise, and isometric quadriceps strength index
Table 2: Perturbation Training Program and Progression Guidelines
Number of Sets/ Duration
Perturbation Movement
Setup
Roller board/ stationary platform
Begin with anterior- posterior and medial- lateral movements, and then progress to diagonal and rotation movements.
Patient stands with one foot on the roller board and the other foot on the platform. Patient is instructed to maintain the roller board in a steady position while the therapist moves the roller board. Begin with two- legged support, progressing to single-legged support on the injured limb. Begin with two- legged support, progressing to single-legged support on the injured limb.
• 2-3 sets • Each set for 1 minute
Roller board • 2-3 sets • Each set for 1 minute
Begin with anterior- posterior and medial- lateral movements, and then progress to diagonal and rotation movements. Begin with anterior- posterior and medial-lateral movements. After the third session, anterior-posterior movements are replaced by diagonal movements.
Tilt board
• 2-3 sets • Each set for 1 minute
Instructions 1. The therapist moves the board in a block or random pattern and at different magnitudes and speeds according to the patient’s responses. 2. The patient is instructed to maintain his or her balance. 3. During sessions 1 through 4, unidirectional (anterior-posteri- or and medial-lateral) perturbation stimuli are provided with verbal cues about the movement directions at small ampli- tude and low speed. 4. During sessions 5 through 7, multidirectional (anterior-pos- terior, medial-lateral, diagonal, and rotational) perturbation stimuli are provided randomly at medium amplitude and moderate speed. 5. During sessions 8 through 10, multidirectional (anterior-pos- terior, medial-lateral, diagonal, and rotational) perturbation stimuli are provided randomly at large amplitude and high speed. In addition, activity-specific tasks should be added to the training sessions. Note. Reprinted with permission. © 2013, Zakariya Nawasreh. Muscle strengthening Patients receive a progressive exercise program to restore muscle strength that is required for participation in high-level activities (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010). The goal of the strengthening program is to maximize the quadriceps force production by using high-intensity and low-repetition principles. Operative management Patients who experience multiple episodes of knee instability and impaired knee function following conservative rehabilitation are ideal candidates for ACL reconstruction. The goals of ACL recon- struction surgery are to restore mechanical knee stability, protect against further knee joint damage, and increase the likelihood of returning to preinjury sport levels (E. H. Hartigan et al., 2010; Myklebust & Bahr, 2005). Preoperative knee status influences pa-
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