improve during the course of rehabilitation. It is important to dis- cuss self-efficacy with patients throughout rehabilitation because poor self-efficacy can negatively affect progress toward achieving rehabilitation goals. Preoperative K-SES scores have been found to predict knee-related quality of life and return to intensity and frequency of preinjury activity levels 1 year following ACL recon- struction (P. Thomeé et al., 2008). Emotional factors such as de- pression may also affect patient progress following ACL injury; patients with ACL injury score higher on depression scales com- pared with uninjured controls (Mainwaring, Hutchison, Bisschop, Comper, & Richards, 2010). cal for matching the intervention strategy that is most likely to provide the optimal outcome for a patient’s clinical findings. 3. Physical therapy can address these impairments with cryotherapy (knee pain), heel slides (knee flexion range of motion), slow revolutions on stationary cycle (knee flexion range of motion), prone hangs (knee extension range of motion), “quad sets” (knee extension range of motion and quadriceps muscle activation), and quadriceps activation with neuromuscular electrical stimulation. A donut and elastic bandage may also help manage effusion and swelling. It is important for clinicians to understand that the impairment pattern and that the most relevant impairments of body function and the associated intervention strategies often change during the patient’s episode of care. Thus, continual re-evaluation of the patient’s response to treatment and the patient’s emerging clinical findings is important for providing the optimal interventions throughout the patient’s episode of care. Discussion The client is 1-week post ACL reconstruction. She will exhibit dif- ficulty with ambulating on level and unlevel surfaces, ambulating up and down stairs, and rising up and sitting down in a chair. She is not able to run or jump at this time. These activities are limited because of postsurgical knee pain and effusion, decreased knee ROM, and reduced quadriceps and hamstrings activation and strength. Additionally, these knee impairments may be substan- tially depressed because the patient did not have preoperative physical therapy to resolve the initial physical impairments. A cli - nician should assess the previous impairments using physical im- pairment measures, such as a visual analogue pain scale (for pain), modified stroke test (for knee joint effusion), goniometry (knee ROM, and “quadriceps lag” during the straight leg raise (quad- riceps strength and activation). Furthermore, the clinician should assess the patient’s perceived knee function using patient-report- ed outcomes measures. These outcome measures can identify baseline pain, function and disability, assess global knee function, determine readiness to return to activities, and monitor changes in status throughout treatment. Impairment-based classification is critical for matching the intervention strategy that is most likely to provide the optimal outcome for a patient’s clinical findings. Physical therapy can address these impairments with cryotherapy (knee pain), heel slides (knee flexion ROM), slow revolutions on a stationary cycle (knee flexion ROM), prone hangs (knee exten- sion ROM), “quad sets” (knee extension ROM and quadriceps muscle activation), and quadriceps activation with neuromuscu- lar electrical stimulation. A donut and elastic bandage may also help manage effusion and swelling. It is important for clinicians to understand that the impairment pattern and that the most rel - evant impairments of body function and the associated interven- tion strategies often change during the patient’s episode of care. Thus, continual re-evaluation of the patient’s response to treat- ment and the patient’s emerging clinical findings is essential for providing the optimal interventions throughout the patient’s epi- sode of care.
following ACL reconstruction demonstrate greater fear of reinjury (Kvist et al., 2005). In fact, 46% of patients had returned to pre- injury activity levels, whereas 54% did not return. In those who did not return, 68% reported persistent knee symptoms, and 52% reported fear of reinjury as factors for not returning to sport (Ever- hart et al., 2013). Furthermore, athletes after ACL reconstruction who do not return to sports are more likely to have poor quality of life outcomes (Filbay, Crossley, & Ackerman, 2016). Self-efficacy is the judgment of one’s potential ability to carry out a task regardless of ability to perform the task or actual perfor- mance of the task (Bandura, 1977). Levels of self-efficacy are of- ten low following ACL injury and ACL reconstruction but typically Case study A 25-year-old woman is referred to physical therapy 1 week after left ACL reconstruction with a semitendinosus and gracilis tendon autograft. Five weeks ago, the client was injured during a soccer match when she planted her left foot during a change of direction as a defender. She heard an audible “pop” and had immediate sharp pain inside her left knee. As she attempted to walk off the field unassisted, her knee buckled and gave way. She was then carried off the field by the athletic trainer. While on the sidelines, she noted that her left knee was swelling substantially. The cli- ent was referred by the athletic trainer to an orthopedic surgeon for consultation. The surgeon’s examination revealed gross and painful limitations in knee flexion ROM (100° of left knee flexion) and modest limitations in knee extension (5° short of 0° of left knee extension). Joint effusion was graded at a 3+. The Lachman test revealed an absent end feel with greater than 5 mm of ante- rior translation. The pivot shift test revealed a positive shift with a clunk. Magnetic resonance imaging revealed a full-thickness mid- substance tear of the ACL with associated bony contusions to the posterolateral tibia and lateral femoral condyle. The medial and lateral menisci were intact. The client did not receive any preop- erative physical therapy to address the existing impairments. The client had reconstructive surgery 4 weeks after the initial in- jury. The client entered the clinic wearing an upright knee immo- bilizer and ambulating with bilateral axillary crutches. Her pain is rated at 3/10 at rest on the visual analogue scale and 6/10 while performing ROM activities. Her past medical and surgical history are unremarkable. She wants to return to playing Questions 1. What do you anticipate to be the likely activity limitations and contributing impairments? 2. What are the most appropriate physical impairment measures or tests? 3. What are the most appropriate rehabilitation interventions? Responses 1. She will exhibit difficulty with ambulating on level and unlevel surfaces, ambulating up and down stairs, and rising up and sit- ting down in a chair; she is not able to run or jump at this time. These activities are limited due to impairments including post- surgical knee pain and effusion, decreased knee range of mo- tion, and reduced quadriceps and hamstrings activation and strength. Additionally, these knee impairments may be sub- stantially depressed as the patient did not have pre-operative physical therapy to resolve the initial physical impairments. 2. A clinician should assess the previous impairments using phys- ical impairment measures, such as a visual analog pain scale (for pain), modified stroke test (for knee joint effusion), goni- ometry (knee range of motion), and “quadriceps lag” during the straight leg raise (quadriceps strength and activation). Fur- thermore, the clinician should assess the patient’s perceived knee function using patient-reported outcomes measures. These outcome measures can identify baseline pain, func- tion, and disability; assess global knee function; determine readiness to return to activities; and monitor changes in status throughout treatment. Impairment-based classification is criti-
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