knee positioned between 60° to 85° of knee flexion position. This position is used to prevent overloading the new harvested graft tissue as an activation of the quadriceps muscle between 0° and 30° of knee extension induces an anterior displacement of the tibia (Figure 6; Delitto et al., 1988; Snyder-Mackler et al., 1995). NMES training can be incorporated in the first few days after injury or surgery in conjunction with a progressive quadriceps strengthening program to avoid quadriceps strength deficits and activation failure (Rebai et al., 2002). Patients with patellar tendon autograft may experience donor site pain during forceful quad- riceps contractions with the knee is positioned at a high angle of flexion. If a dynamometer is unavailable, a modified NMES protocol can be used to produce similar results (Fitzgerald et al., 2003). The modified NMES protocol places the patient in a supine position with the knee in full extension. The NMES stimulus is the same as previously described. The intensity is set to maximum patient tolerance once a full, sustained, tetanic contraction (sus - tained muscle contraction without an interval of relaxation) of the quadriceps is achieved. One advantage of NMES is that it does not require delaying the training program until impairments have been resolved and can be used regardless of the presence of joint effusion or ROM limi- tation to restore normal quadriceps activation (Lynch et al., 2012). Once quadriceps muscle strength of the injured limb is greater than 80% of the uninjured limb, NMES can be discontinued and patients may continue with their progressive strengthening pro- gram without NMES (Adams et al., 2012). All patients are recom- mended to participate in a progressive strengthening program to maximize quadriceps strength and restore normal limb symme- try in quadriceps strength. Applying NMES in combination with high-intensity progressive quadriceps strengthening exercises re- sults in greater strength improvement in ACL-deficient and ACL- reconstructed patients when compared with standard exercise alone (Kim et al., 2010). A systemic review indicated that electrical stimulation can be added to the conventional postoperative reha- bilitation training as it improves quadriceps muscle strength (van Melick et al., 2016). Electrical stimulation be effective in improv- ing quadriceps muscle strength up to 2 months after surgery with long-term effect on knee function performance after surgery is inclusive (Imoto, Peccin, Almeida, Saconato, & Atallah, 2011; Kim et al., 2010; van Melick et al., 2016; Wright et al., 2008).
Figure 6: Neuromuscular Electrical Stimulation to Quadriceps Muscles Using a Portable Device
Note . From Western Schools, © 2018. Weightbearing and non-weightbearing exercises Weightbearing (WB) and non-weightbearing (NWB) exercises, also known a s closed kinetic chain and open kinetic chain exer- cises, respectively, are used in rehabilitation programs for patients following ACL injury and ACL reconstruction surgery to improve quadriceps strength and dynamic knee stability (Escamilla et al., 2009; Escamilla, MacLeod, Wilk, Paulos, & Andrews, 2012a; Flem- ing, Oksendahl, & Beynnon, 2005). During the first few weeks af- ter ACL reconstruction surgery, patients begin loading their oper- ated knee as tolerated to manage pain and to protect the healing tissue. Biological incorporation of soft tissue grafts such as STG requires more time (typically 8 to 12 weeks) when compared to grafts incorporating bone plugs (Buckwalter, Grodzinsky, Hunter, & Thomas, 1999). Therefore, rehabilitation following ACL recon- struction may be modified according to the time frame of biologi- cal healing and graft remodeling (Kvist, 2006). Exposing the new graft tissues – which are undergoing remodeling and maturation processes – too early to an excessive and uncontrolled load may cause graft rupture or graft failure (Mikkelsen, Werner, & Eriksson, 2000). Although overloading the reconstructed graft may cause graft rupture or failure, unloading the graft may delay recovery and weaken the graft strength (Buckwalter et al., 1999). Thus, early resumption of activities that place controlled load onto the healing tissue enhances graft tissue strength and function (Buck- walter et al., 1999).
Figure 7: Examples of Weightbearing Exercises (Closed Kinetic Chain Exercises)
Note . From Western Schools, © 2018.
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Book Code: PTCA2624
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