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 anterior 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 preoperative physical therapy to address the existing impairments. The client had reconstructive surgery 4 weeks after the initial injury. The client entered the clinic wearing an upright knee immobilizer 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 sitting 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 motion, and reduced quadriceps and hamstrings activation and strength. Additionally, these knee impairments may be substantially 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 physical impairment measures, such as a visual analog pain scale (for pain), modified stroke test (for knee joint effusion), goniometry (knee range of motion), and “quadriceps lag” during the straight leg raise (quadriceps strength and activation). Furthermore, the clinician should assess the patient’s perceived knee function using patient-reported 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. 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 Conclusion The goal of this course is to provide the reader with the latest information concerning ACL injuries, management options, therapeutic techniques, criterion-based progression of activities, and outcome measures commonly used in the process of managing patients after ACL injury. The findings of evidence-based practice research have contributed significantly to improving the rehabilitation protocols for patients with ACL deficiency and ACL reconstructions. Both operative and nonoperative treatment options are viable for managing patients with ACL injury. Currently, rehabilitation programs emphasize early resolution of impairments related to knee joint pain, joint effusion, ROM deficits, and muscle strength deficits that are commonly present in patients with ACL deficiency and ACL reconstruction. Additionally, earlier initiation of quadriceps strengthening training, neuromuscular training, and dynamic activities are highly recommended to improve the patient’s outcome (Wilk, Macrina, Cain, Dugas, & Andrews, 2012). The current suggested clinical practice guidelines for patients pursuing a nonoperative
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 difficulty 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 substantially depressed because the patient did not have preoperative physical therapy to resolve the initial physical impairments. A clinician should assess the previous impairments using physical impairment 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 (quadriceps strength and activation). Furthermore, the clinician should assess the patient’s perceived knee function using patient-reported 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 extension ROM), “quad sets” (knee extension ROM 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 essential for providing the optimal interventions throughout the patient’s episode of care. ACL management are to administer a progressive strength training augmented with neuromuscular perturbation training. In patients who are managed operatively, the postoperative rehabilitation program is recommended to include three criterion-based phases: impairment-based, functional-based, and return-to-activity phase. Integration of neuromuscular control of the lower extremity to ACL rehabilitation is a key factor to improving knee joint dynamic stability, correcting gait pattern, and improving knee functional performance (Chmielewski, Hurd, Rudolph, et al., 2005). Decisions for progressing through the rehabilitation program depend on meeting clinical milestones, the absence of adverse responses and muscle soreness, and patients’ ability to perform the activity. Incorporating a testing battery of objective measures to determine the patients’ readiness may warrant successful outcomes after reconstruction. With advanced surgical techniques and rehabilitation guidelines reaffirmed by the latest evidence-based practice, therapists can provide patients with the best outcomes after the ACL injury and reconstruction surgery. Investigators continue to
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