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UNRAVELING THE CURRENT EVIDENCE TO MANAGING ANTERIOR CRUCIATE LIGAMENT
(ACL) INJURIES
Linda Truong, PTPhD Trainee, Faculty of Rehabilitation Medicine, University of AlbertaPhysical Therapist, Glen Sather Sport Medicine Clinic, University of AlbertaArthritis Research Canada
@LKTphysio
Oct 20, 2019Connect+Learn ConferenceCanmore, Alberta
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CASE SCENARIO #1
Video
16 year old female1st time ACL surgery (also known as ACL reconstruction or ACLR)
Goal: 6 months to return to full training to secure ascholarship
Is this realistic? What would you say?
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CASE SCENARIO #2
30 year old male2010 First ACL surgery2017 Re-tear of ACL on same knee
Goal: return to indoor/outdoor soccer and taekwondo
What management option would you recommend?
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OBJECTIVES
Evidence-Based Management for ACL Tears 01
02
03Clinical Strategies to improve ACLRecovery
Criteria-Based ACL Rehabilitation
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BACKGROUND
• Provide stability during twisting movements (side stepping, pivoting and landing from a jump)
• It is usually not required during normal daily living activities
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BACKGROUNDEpidemiology
• 15-20% of reported sport injuries are kneeinjuries!
• Types of acute knee injuries:• Tibiofemoral ligaments (40%)• Patella (25%)• Meniscus (11%)• Other – tendon ruptures, bone bruises,
contusions, bursitis, etc. (25%) ACL, 46%MCL, 29%
ACL/MCL, 13%
PCL, 4%LCL, 2%
Complex Multilig,
6%
Emery et al. (2006); Emery et al. (2009); Bollen et al. (2000); Majewski et al. (2006)
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• 250,000 ACL injuries per year in USA• Common injury mechanisms for ACL:• non-contact (70%)• indirect non-contact• direct contact
Hewett et al. (2006); Montalvo et al (2018); Majewski et al. (2006)
• Females more at risk • Age range:• 43% were 20-29 • 20% were 30-39• 17% were 10-19
BACKGROUNDEpidemiology
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1 65% return to sport (RTS) within 2 years
Ardern et al (2014); Filbay et al (2016); Wiggins et al (2016); Øiestad et al (2009)
2 Reduced quality of life 5-20 years after injury
3 ~20% risk of re-injury to either knee after ACLR if RTS
4 ~50% will develop post-traumatic osteoarthritis (PTOA) 10 years after injury
BACKGROUNDConsequences of ACL Tears
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Management of ACL TearsFrom Prevention to Osteoarthritis
01
Improve Function
INTE
RVEN
TIO
N
Joint injury to PTOA
TIM
ELIN
E
Prevent ACL Injuries
Optimize rehabilitation
Tertiary Prevention
Primary Prevention
Secondary Prevention
After PTOA diagnosis
Prior to joint injury
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Evidence-Based Recommendations for ACL Rehabilitation01
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Trial exercise rehabilitation for at least 3 months
Re-evaluate after 3 months of compliance with exercise:
Will this individual benefit from ACLR?
Exercises: progressively load quadriceps muscle
and contains neuromuscular training
Discuss surgical management
No instability?
Discussion of non-surgical
management
Continued instability?
A shared decision-making approach is needed in order to properly inform the patient of their options while
considering their goals and preferences
Surgical vs. Non-Surgical Management Who Should have surgery?
01
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Surgical vs. Non-Surgical Management Who Should have surgery?
01
Frobell et al (2010); Frobell et al (2013)
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Surgical vs. Non-Surgical Management Who Should have surgery?
01
Frobell et al (2010); Frobell et al (2013)
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Surgical vs. Non-Surgical Management Should I have surgery?
01
Frobell et al (2010); Frobell et al (2013)
CHOOSING NON-SURGICAL MANAGEMENT IS NOT AN INFERIOR AND NEEDS TO BE PRESENTED AS AN OPTION
• Early ACLR is not superior than the option of delayed ACLR
• Surgical ACLR was avoided 61% of the time without compromising short and long term outcomes
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Evidence-Based Recommendations for ACL RehabilitationResources
01
Open kinetic chain vs.
Closed kinetic chain
Predictors forPost Operative
success
Strengthand
Neuromuscular Training
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The Evolution of ACL RehabilitationFrom Cast to Crutch to Criterion
02
De Carlo et al (1992);
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Time-Based RehabilitationTime dictates progression
6 months
12 weeks
surgery
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The Evolution of ACL RehabilitationFrom Cast to Crutch to Criterion
02
POST SURGERY OR ACUTE ACL INJURY1PHASE
STRENGTHTRAINING
PHAS
E2
DYNAMICTRAINING PH
ASE 3
@satherclinic @LKTphysio @yegphysio
SPORT SPECIFIC TRAINING4PHASE
RETURN TO ACTIVITY OR SPORTPH
ASE 5
PHAS
E
INJURY PREVENTION6
ACL REHAB
GSSMC ACL PROTOCOL
0-6 weeks
6 wks - 2 yr
> 3-4 months
> 6 months
> 9 months
> 1 year
Edited April.10.2017
A CRITERION AND GOAL BASED APPROACH TO KNEE REHAB
“ELEVATING ACL REHAB THROUGH RESEARCH AND CLINICAL EXPERTISE”REHAB IS DRIVEN BY CRITERIA AND GOALS
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Criterion and Goal-Based ACL RehabilitationGlen Sather Sports Medicine ACL Protocol
02
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02 Criterion and Goal-Based ACL RehabilitationGlen Sather Sports Medicine ACL Protocol
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02 Criterion and Goal-Based ACL RehabilitationGlen Sather Sports Medicine ACL Protocol
IN ORDER TO PRESCRIBE THE RIGHT EXERCISES, YOU NEED TO KNOW THE END GOAL
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Quadriceps is a Key Criterion 02
van Melick et al (2016)
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Quadriceps is a Key Criterion 02
Grindem et al (2016)
1%
TRAINING QUADRICEPS IS ESSENTIAL FOR SHORT AND LONG TERM RECOVERY
3% Quad
Symmetry Reinjury
Rate to the knee
=
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Physical Criteria: Functional Testing02
Single Leg Squat Test 3 Rep Max Testing Strength
5-10-5 direction change test, T-testTimed Change of directionAgility
Functional hops: Single leg hops, triple single leg hops, lateral hops, single leg tuck jumps Power
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Addressing the Non-Physical Side of Recovery02
Slide Adapted from Clare Ardern; Ardern et al (2013)
HOPPING
LOW FEAROF
REINJURY CONFIDENCE
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Addressing the Non-Physical Side of RecoveryPsychological, Social, Contextual Factors
02
Truong et al (2019) submitted;
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Addressing the Non-Physical Side of RecoveryPsychological, Social, Contextual Factors
02
Truong et al (2019) submitted
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How to Assess Psychological Factors Using Patient Reported Outcome Measures
02
Tampa Scale for Kinesiophobia (TSK)Re-injury Anxiety Scale Fear
ACL Return to Sport after Injury Scale (ACL-RSI)
Psychological Readiness
Knee Injury and Osteoarthritis Outcome Score (KOOS)ACL-QoL HRQoL
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Is Using a Criteria-Based Rehabilitation Really Effective?02
LESS KNEERE-INJURIES
38% 6%
Adapted from Clare Ardern; Grindem et al (2016)
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Is Using a Criteria-Based Rehabilitation Really Effective?02
LESS KNEERE-INJURIES
38% 6%
Adapted from Clare Ardern; Grindem et al (2016)
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Is Using a Criteria-Based Rehabilitation Really Effective?02
LESS ACL GRAFT RUPTURES
33% 10%
Adapted from Clare Ardern; Kyritis et al (2016)
PASSING RTS CRITERIA = 4x less risk of re-tearing ACL graft
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Is Using a Criteria-Based Rehabilitation Really Effective?02
LESS ACL GRAFT RUPTURES
33% 10%
Adapted from Clare Ardern; Kyritis et al (2016)
PASSING RTS CRITERIA = 4x less risk of re-tearing ACL graft
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What is Realistic Expectations for Criterion-Based Rehabilitation? 02
Welling et al (2019)
66% ~10 monthsMet 90%
Quadriceps Symmetry
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02
Grindem et al (2016)
14% 6 mo.
55% 12 mo.
CRITERIA BASED HAS PUSHED TIME LINES LONGER
0% 5 mo.
What is Realistic Expectations for Passing Criteria?
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02
Lai et al (2010)
8-13 mo.
11-12 mo.
6-12 mo.
What is Realistic Expectations for Return to Sport?
8-10 mo.
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LEVEL 1• Learn to lift with good form (e.g., front squat, traditional deadlift)• Develop lower body strength
3
LEVEL 2• Continue strength training (e.g., 3RM front squat >80% body weight)• Introduce dynamic movement
LEVEL 4• Introduce and develop sport-specific movements (e.g., 1v1 shadow)• Continue injury prevention
LEVEL 3• Introduce power exercises• Introduce and develop dynamic movement (e.g., plant and cut)
Getting Creative with Rehabilitation03More info: uab.ca/FAST
Functional Agility Strength Training (FAST) Knee Program
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Our Role as Therapists 03
Truong et al (2019) submitted; Podlog (2011)
Acknowledge both physical and non-physical barriers
Establish social support &shared-decision making
Ensure individual is ready to and support their decision
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03
FOUNDATION: STRENGTH(EVERYONE will benefit from getting stronger)
DYNAMIC MOVEMENT(how does the patient need to move?)
SPORT-SPECIFIC TRAINING(situations the patient needs to move)
GUIDE BACK TO SPORT/ACTIVITY
(support the athlete)
LONG TERM MANAGEMENT
(reduce injuries)
What Should your ACL Rehabilitation Program Look Like?
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03 Criterion and Goal-Based ACL Rehabilitation
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03 Criterion and Goal-Based ACL Rehabilitation
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03 Criterion and Goal-Based ACL Rehabilitation
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Where can I go for more informationResources
03
RESEARCHRELATED
ACLPROTOCOLS
GSSMCRandall Cooper
Mick Hughes
PODCASTS
@PTInQuest@BJSM
Clinical Edge
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Take Home MessagesClinical Strategies
03
NOT EVERYONE NEEDS ACL SURGERY TO RETURN TO ACTIVITIES
1
USE CRITERIA AND GOALS TO PROGRESS REHABILITATION
2
TREAT BOTH PHYSICAL AND NON-PHYSICAL ASPECTS FOLLOWING ACL INJURY3