Neuromuscular training Rehabilitation programs that focus only on restoring joint motion, increasing quadriceps muscle strength, and improving agility skills do not optimize return to all previous activity levels. Rehabilitation programs should emphasize treatment techniques that facilitate appropriate neuromuscular strategies for participation in high- level activities that involve jumping, cutting, and pivoting maneu- vers. Patients with ACL deficiency or ACL reconstruction exhibit poor proprioception resulting from damage to the mechanore- ceptors that are embedded in the articular structures of the knee and the ACL (Lephart, Pincivero, Giraido, & Fu, 1997). Neuromus- cular training increases neuromuscular awareness and improves dynamic stability of the knee joint (Cooper, Taylor, & Feller, 2005; Fitzgerald, Axe, & Snyder-Mackler, 2000b; Fitzgerald, Axe, & Sny- der- Mackler, 2000c; Fu et al., 2013; Gerber et al., 2009; Gerber et al., 2007; Risberg, Holm, Myklebust, & Engebretsen., 2007). Therefore, neuromuscular training should be integrated into the ACL rehabilitation to improve patients’ outcomes (Gokeler et al., 2014; Kruse et al., 2012; Logerstedt et al., 2017). Neuromuscular training programs include balance exercises, dy- namic stabilization exercises, plyometrics, agility drills, and per- turbation training. The therapist progresses the exercise difficulty from low-intensity to high-intensity maneuvers and decreases pa- tients’ base of support by progressing from two-limb support to one-limb support. As balance improves, squatting or sport-spe- cific activities – such as dribbling a basketball, kicking a football, or throwing a baseball – may be implemented during balance training. Examples of dynamic knee-stability exercises include the Star Excursion Balance training and single-limb squat. In the Star Excursion Balance training, patients stand on single-limb support in the center of an eight-line grid (Figure 9). Patients are asked to reach with the free foot as far as possible along each of the eight lines. Although balance exercises have been shown to improve patients’ functional outcomes and are often used in rehabilitation programs, the guidelines for the balance exercises are not well established (Herrington et al., 2009).
Perturbation training, described earlier, may be incorporated into the postoperative rehabilitation program as soon as patients are pain free, knee joint effusion is trace or less, and full knee ROM is restored. A randomized clinical trial investigated the effect of a progressive quadriceps strengthening training augmented with perturbation training compared to only progressive strengthen- ing training administered preoperatively (Hartigan et al., 2010). The results of that randomized clinical trial revealed that func- tional outcomes were not different between the two treatment programs, except that more patients who received perturbation training achieved a higher score on a global rating scale that al- lowed them to pass the return-to-sport criteria at 6 and 12 months postoperatively (Hartigan et al., 2010). Other studies shown that perturbation training was effective to mitigate abnormal gait pattern prior to the reconstruction surgery (Di Stasi & Snyder- Mackler, 2012), and preoperative perturbation training was effec- tive to restore normal limb-to-limb biomechanical symmetry at 6 months after surgery (Hartigan et al., 2009). Resolving the abnor- mal movement pattern is of high importance, because this was found to predict a second ACL injury after reconstructive surgery (Paterno et al., 2010). Another randomized clinical trial found no difference in clinical, functional, or biomechanical outcome mea- sures or second injury rates between an extended, postoperative ACL rehabilitation program that included strengthening, agility, plyometrics, and secondary prevention exercises compared to a rehabilitation program that included the same training plus per- turbation training in men or women immediately after program completion and at both 1 and 2 years after the ACL reconstruc- tion (Arundale et al., 2017; Arundale et al., 2018a; Arundale et al., 2018b; Capin, Khandha, Zarzycki, Arundale, et al., 2018; Capin, Zarzycki, et al., 2017, Capin, Zarzycki, et al., 2019; Johnson et al., 2020). However, female athletes after ACL reconstruction and rehabilitation who engage in 10 additional sessions of strength, plyometric, agility, and secondary prevention exercises (with and without perturbation training) may achieve superior outcomes compared to those who engage in criterion-based rehabilitation.
Figure 9: Star Excursion Balance Training
Note . From Western Schools, © 2018.
Plyometric exercises Plyometric training refers to quick and powerful movements that involve quickly stretching the muscle-tendon unit during an eccen- tric maneuver to produce a subsequently stronger muscle contrac- tion during a concentric maneuver (Chmielewski, Myer, Kauffman, & Tillman, 2006). These types of exercises are widely designed to resolve postinjury neuromuscular impairments, increase muscle strength and power production, and prepare patients for rapid movements and high-force production needed during high-level activities (Myer, Ford, McLean, & Hewett, 2006). Plyometric ma- neuvers constitute a natural part of most sport movements and involve double- and single-limb jumping, hopping, and skipping activities (Paterno et al., 2004). In clinical practice, plyometric ex- ercises are integrated into rehabilitation programs to bridge the
gap between traditional rehabilitation exercises and sport-specif- ic activities that include explosive movements (Cordasco, Wolfe, Wootten, & Bigliani, 1996). One example of plyometric exercise typically incorporated into postoperative rehabilitation is hopping. Hopping exercises prog- ress from double- legged support (i.e., jumping) to single-legged hopping as the patient gains strength, control, and confidence. Single-legged hopping can include hopping up and down on a step (Figure 10), lateral hopping, and skating, where a patient stands on one leg and hops sideways with a soft, deep, and steady landing on one leg, and then hops back on the other leg (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010).
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