PROGRESSION
Before returning to participation in high-demand activity levels, patients should demonstrate pain-free performance of loading activities and tolerate these activities without experiencing ad- verse joint reactivity such as joint pain, joint effusion, or muscle soreness. These adverse responses, sometimes experienced by patients progressing to a higher level of therapeutic exercise, can cause muscle inhibition, joint deterioration, and an increase in the number of treatment sessions required to achieve rehabilitation goals (Chmielewski et al., 2006). pain or joint swelling are experienced after exercising, but the symptoms resolve before the next rehabilitation visit or after the next warm- up, then the program should not be progressed but rather maintained at the same level and monitored for reoccur - rence of symptoms. Chmielewski and colleagues (2006) suggest that a patient should tolerate two to three sessions at a specific intensity without any adverse responses before the intensity of the program is progressed. Table 4: Running Progression Stage 1 • Track : Jogs straights and walks curves for more than 2 miles. • Treadmill : Walks 0.1 mile and then jogs 0.1 mile; repeats 10 times. Stage 2 • Track : Jogs straights and then jogs more than 1 curve every other lap for 2 miles. • Treadmill : Alternates between walking 0.1 mile and jogging 0.2 mile for more than 2-mile distance. Stage 3 • Track : Jogs straights and then jogs more than 1 curve every lap for 2 miles. • Treadmill : Alternates between walking 0.1 mile and jogging 0.3 mile for more than 2-mile distance. Stage 4 • Track : Jogs 1.75 laps and then walks more than 1 curve for 2 miles. • Treadmill : Alternates between walking 0.1 mile and jogging 0.4 mile for more than 2-mile distance. Stage 5 • Track or Treadmill : Jogs for full 2 miles. Stage 6 • Track or Treadmill : Increases jogging to 2.5 miles. Stage 7 • Track or Treadmill : Increases jogging to 3 miles. Stage 8 • Track : Begins running straights and jogging curves. • Treadmill : Alternates between running and jogging every 0.25 mile. Note . Reprinted with permission. © 2013, Zakariya Nawasreh.
Patients may progress through the rehabilitation process at dif- ferent rates, depending on individual characteristics, the number and severity of impairments, and concomitant pathologies. The development and implementation of rehabilitation should reflect a criteria-based approach based on scientific research of tissue- healing constraints, knee complex biomechanics, neuromuscular physiology, and activity-specific tasks. Thus, systematic progres- sion should be criteria-based and time-based, and not solely on fixed timetables. Soreness rules ACL rehabilitation programs should use effusion grades and soreness rules to monitor the therapeutic exercise progression of patients following ACL injury and reconstruction. The use of soreness rules depends on the timing of adverse effects experi- enced during performance of the exercises. (See Table 3.) When an adverse response is encountered, the recovery period will be prolonged until the impairment has completely resolved. In addi- tion, the intensity of the next exercise session should be reduced to a lower level to avoid recurrence of soreness or effusion. If joint Running, agility, and return-to-sport training After ACL injury or ACL reconstruction, patients may develop car- diovascular deconditioning because of the lack of aerobic train- ing. Patients with an ACL-deficient or an ACL-reconstructed knee who wish to return to sport or recreational activities are encour - aged to initiate a gradual running progression to promote cardio- vascular endurance, improve oxygen consumption, increase lower extremity muscle strength, and increase force generation from the dynamic nature of the running (Adams et al., 2012). A running pro- gression is incorporated into the rehabilitation program when pa- tients are at least 12 weeks out from ACL reconstruction and have met the criterion of 80% quadriceps strength index and have trace or less effusion. Patients are instructed to begin a graded running program that includes jogging and walking intervals for 2 miles (3.2 km) on level surfaces (either a running track or a treadmill). The program is progressed by increasing the jogging-to-walking- time ratio. At the beginning of the program, the ratio of jogging to walking distance is small (1:1). The ratio of jogging to walking distance, as well as the distance and pace, is gradually increased if the patient tolerates the previous stage without muscle sore- ness, joint pain, or effusion (see Table 4). For patients with an ACL injury who pursue nonoperative treatment, running progression may begin once they meet the criteria of no pain; effusion of less than trace grade; full-knee ROM; 70% quadriceps strength index; and pain-free, unilateral hopping on the injured limb (Fitzgerald, Axe, & Snyder-Mackler, 2000c). Upon successful completion of a running program, patients may progress to agility training. This program is similar to the agil- ity program listed for nonoperative treatment. Agility training should consist of cutting and pivoting exercises of increasing in- tensity that simulate the demands of the patient’s sport. Agility exercises are incorporated into the ACL reconstruction rehabilita- tion program to improve the neuromuscular coordination of the lower extremity muscles and to increase patients’ ability to quickly change running directions (Fitzgerald, Axe, & Snyder- Mackler, 2000c). As running and agility programs are progressed toward return-to-sport training, a systematic approach for sport participa- tion is recommended that accounts for pain and apprehension (see Table 5; Adams et al., 2012).
Table 5: Progression to Sport-Specific Activities Activity
Criteria for Progression
Action for Failing the Criteria Continue practicing agility training.
Stage 1
Agility training
Patients tolerate maximum effort of agility training with no pain or apprehension. Patients tolerate unopposed sport-specific activity with no pain or apprehension.
Stage 2
Unopposed sport activity
Continue unopposed sport-specific activity.
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Book Code: PTCA2624
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