one episode of the knee giving way since initial injury, a KOS- ADLS score of 80% or higher, and a GRS score of 60% or higher (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000c). Individuals who do not meet any one of these criteria are classified as potential noncopers. Descriptive statistics from studies comparing potential copers to potential noncopers demonstrate no differences in quadriceps strength or anterior knee joint laxity outcome measures between groups (Hurd, Axe, & Snyder-Mackler, 2008a). Also, a larger percentage of patients are classified as potential noncopers than as potential copers, and these individuals are more likely to be women, middle-aged adults, and patients with a noncontact mechanism of ACL injury (Hurd, Axe, & Snyder-Mackler, 2008b). Patients classified as potential copers may be successful in returning to a short period of preinjury activity levels following nonoperative rehabilitation to finish out an athletic or work season without further meniscus or articular cartilage damage or episodes of the knee giving way (Fitzgerald, Axe, & Snyder- Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000b; Fitzgerald, Axe, & Snyder-Mackler, 2000c; Moksnes, Snyder- Mackler, & Risberg, 2008). Individuals who are able to return to preinjury sport levels without giving way for at least 1 year
are defined as true copers; true noncopers are those unable to return to preinjury activity levels without multiple episodes of giving way (Snyder-Mackler et al., 1997). Interestingly, recent evidence from Thoma et al. suggests that even potential non- copers who undergo extended preoperative rehabilitation (or ‘pre-habilitation’) may be able to become true copers (Thoma et al., 2019), as discussed further below. Table 1: Potential Coper and Noncoper Classification System Classification Criteria Classification Status
• Giving way < 1 episode. • 6-meter timed hop > 80% LSI. • KOS-ADLS > 80%. • GRS > 60%.
• Potential coper : Meets all criteria. • Potential noncoper : Fails at least one of the criteria.
GRS = Global Rating Scale of Perceived Function; LSI = limb symmetry index. Note. From Western Schools, ©2018.
REHABILITATION CONSIDERATIONS
Once a patient has a diagnosis of an ACL tear and has been classified based on dynamic stability of the knee, the patient may choose to undergo ACL reconstruction to restore the passive restraints of the knee or may choose a nonoperative Nonoperative rehabilitation programs The effectiveness of nonoperative management depends largely on the decision-making criteria used for selecting appropriate candidates and the incorporation of perturbation training techniques into the nonoperative rehabilitation program (Fitzgerald, Axe, & Snyder-Mackler, 2000a; 2000b; 2000c). Regardless of classification, all patients with acute ACL injury should be advised to go through 10 sessions of an exercise therapy program (including progressive strengthening training augmented with perturbation training) for 5 to 6 weeks after initial impairments are resolved and before the final decision for either ACL reconstruction or nonoperative management is made (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010; Magnussen et al., 2010). Currently, operative management is recommended for young patients who experience episodes of knee instability during simple activities and who intend to return to activities that involve jumping, cutting, and pivoting movements. The focus of nonoperative treatment is on perturbation training, strengthening, and neuromuscular and agility training. Perturbation training Rehabilitation programs that include perturbation training, compared to standardized rehabilitation without perturbation training, result in higher rates of return to preinjury activity levels, with fewer episodes of giving way for patients classified as potential copers (Fitzgerald, Axe, & Snyder- Mackler, 2000c). Perturbation training that includes purposeful destabilization stimuli applied to movable surfaces is incorporated into the rehabilitation program. Perturbation training can consist of three techniques: a tilt board, a roller board with a stationary platform, and a roller board (Figure 3). Perturbation training progresses in a similar manner for each technique, with each training session consisting of all three techniques. Early in the training, the patient stands on the movable surfaces with two-limb support and the therapist provides verbal cues of the direction of the perturbation stimulus so the patient can become familiar with the training. Patients are progressed to single-limb support on the injured limb in the first training session. During sessions 1 through 4, unidirectional perturbation stimuli should be administered at small amplitude and low frequency to allow the patient to become familiar with the training (Fitzgerald, Axe, & Snyder-Mackler, 2000c). Once
management approach. Considerations for either approach should be a shared decision between the patient, the surgeon, and the physical therapist.
the patient feels comfortable with the training, the therapist begins to progress the training by removing verbal cues and administering the perturbation stimuli in random directions at mild to moderate amplitude and higher frequency. In addition, unidirectional destabilizing stimuli are replaced with two-directional and multidirectional stimuli, depending on the patient’s tolerance (Fitzgerald, Axe, & Snyder-Mackler, 2000c). Sport-specific activities are incorporated during the last four perturbation sessions to develop neuromuscular responses that might be carried over to activity (Fitzgerald, Axe, & Snyder- Mackler, 2000c). Sport-specific activities can be initiated when patients demonstrate minimal balance disturbance on the tilt board and minimal co-contraction responses on the roller board/ stationary platform (Fitzgerald, Axe, & Snyder-Mackler, 2000c). Figure 3: Perturbation Training
Note . From Western Schools, ©2018. During sport-specific performance, sport activities are incorporated according to the patient’s sport practice. For example, basketball players may receive and throw the ball to the therapist, whereas soccer players might kick the ball. During the last three training sessions (as appropriate), the destabilizing stimuli are administered at large amplitudes and multiple directions that include rotations and high frequency so that the subjects may elicit specific muscular co-contraction in the lower extremity (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010; Fitzgerald, Axe, & Snyder-Mackler, 2000c).
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Book Code: PTNJ0824
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