Robertson ACL Management
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  • Welcome to this lecture entitled,Non-Operative Management of the ACL-deficient Knee, focusing on conservative management after ACL injury. My name is Eric Robertson from Regis University. I invited you to Sit back, relax, and enjoy the lecture.
  • We’ve already described usual care for ACL injury. It’s surgery followed by rehab. As we go through the remainder of this lecture, I’d like you to be able to define the terms coper and non-coper, and describe characteristics that differentiate them from one another. We’ll review the evidence for outcomes related to non-operative managemetn and compare that to operative management, and look at what a non-operative rehab program should look like for our patients.
  • Well it looks like it’s been a bad day for our friend Buzz Lightyear, and if I were a surgeon, I’d say he requires surgery to re-attach that leg. Surgeons as a group, follow a similar approach to ACL injuries, opting for surgery on the vast majority of them. In fact, as you view this lecture, you may not realize that repair of an ACL is an elective, not a required procedure. It’s become almost standard of care to rush into surgery following an ACL injury. This lecture exists to tell you the other side of the story.
  • Make no mistake about it, ACL repair is an industry, accounting for direct costs of over $3 billion annually. Clearly, physical therapists are also part of this economic pie, as almost all of the ACL’s operated on go to some degree of post-operative rehabilitation program.
  • But here’s the kicker: there is no definitive evidence that supports the use of ACL repair over non-surgical treatment. That’s right, even though ACL is a widely performed operation, and costs for the surgery are ell covered by third-party payers, we’re lacking that piece of evidence that says, ACL repair produced better outcomes than not operating at all. Given the risks inherent with such an invasive surgical procedure, the issue bears looking at a little more closely.
  • As a fan of the New York Giants, I know this fact well. This is a picture of star cornerback Terrel Thomas who injured his ACL late in the preseason in 2011. He missed that season as he had the ligament repaired. This was his second repair of that particular ACL, having injured it 6 years earlier when in college. Unfortunately for the Giants secondary and for Mr. Thomas, his return from injury was cut short, as his re-tore the ACL in a non-contact event early in the 2012 training camp. The surgical procedure did not allow him to return to his previous activity, although by any standard definition, his first procedure did. In this man alone, the surgical success rate is running at 50%. Well, he did the only thing available to him, he got it operated on for a third time! Let’s firgure out if we could have helped this guy figure out the best course of treatment for this injury.
  • Make no mistake about it, ACL repair is an industry, accounting for direct costs of over $3 billion annually. Clearly, physical therapists are also part of this economic pie, as almost all of the ACL’s operated on go to some degree of post-operative rehabilitation program.
  • This story begins with asking why orthopaedic surgeons recommend repair of the ACL so frequently. Well, evidence for outcomes aside, repair of the ACL theoretically will provide restoration of knee stability, leading to improved joint protection, less meniscal damage, and reduced degenerative changes. For these reasons, surgeons recommend repair to everyone from high-level athletes, where the recommendation makes a lot of sense, to low level middle-aged folks, where the surgery becomes more questionable. The logical question then becomes, is there a way we can figure out who actually benefits from ACL repair and who may be able to cope without it?
  • But here’s the kicker: there is no definitive evidence that supports the use of ACL repair over non-surgical treatment. That’s right, even though ACL is a widely performed operation, and costs for the surgery are ell covered by third-party payers, we’re lacking that piece of evidence that says, ACL repair produced better outcomes than not operating at all. Given the risks inherent with such an invasive surgical procedure, the issue bears looking at a little more closely.
  • When I think back to how I felt when I discovered that the rationale for ACL is based in theoretical concepts and not evidence, it’s kind of like this scene from the Matrix. The bottom line here with regards to OA, is that overall as a population, if you have an ACL injury, you have an increased risk for the development of knee OA. This may be slightly different for very young, active individuals, but we’ll discuss that subgroup later.
  • In this retrospective case series 80 patients divided in 40 matched pair groups with an arthroscopically proven ACL insufficiency were followed up for 15 years. One half was reconstructed using an autologous BTB patella graft, the other half was treated by a conservative physiotherapeutic based rehabilitation program. At follow-up the clinical scores (Lysholm, IKDC) showed no significant differences between subjects who had undergone ACL reconstruction and those who had not. Furthermore there was no detectable difference in the incidence of osteoarthritis between the cohorts. Patients having a negative pivot shift test showed significantly less signs of radiographic osteoarthritis and better functional assessment scores whether reconstructed or not. Based on these results and a review of the literature there is no clear evidence that ACL reconstruction reduces the rate of OA development or improves the long-term symptomatic outcome. Probably review of reconstruction by an anatomical approach will be more successful than operative techniques decades ago.Streich, Nikolaus A, David Zimmermann, Gerrit Bode, and Holger Schmitt. “Reconstructive versus Non-Reconstructive Treatment of Anterior Cruciate Ligament Insufficiency. A Retrospective Matched-Pair Long-Term Follow-Up.” International Orthopaedics 35, no. 4 (April 2011): 607–613. doi:10.1007/s00264-010-1174-6.
  • ACL-reconstruction aims to restore joint stability and prevent osteoarthritis; however, malfunction and osteoarthritis are often the sequelae. Our study asks whether ACL-reconstruction or conservative treatment lead to better long-term results. In this retrospective cohort study, 136 patients with isolated ACL-rupture who had been treated by bone-ligament-bone transplant or conservatively were identified. Twenty-seven of these were excluded because of a revision operation in the 11.1 years follow-up period, leaving 109 patients (60 reconstructions and 49 conservatively treated) for evaluation based on clinical, radiological and internationally accepted knee-scores (Tegner, IKDC, Kellgren and Lawrence). An individual cohort study is classified as EBM level 2b according to the Oxford Centre of EBM. We observed significantly better knee-stability (P = 0.008) but more osteoarthritis (Grade II or higher) after ACL-reconstruction (42% vs. 25%). Physical activity levels were similar in both groups during the follow-up period (P = 0.16). Eleven years after ACL-rupture the physical activity levels are similar for both groups. After ACL-reconstruction, stability is higher as is osteoarthritis, whereby the result is not necessarily perceived as better subjectively. Specifically, this retrospective study yielded a 24%incidence of oseoarthrits 11 years after conservative management of ACL-rupture in patients not needing secondary surgery. The risk of secondary meniscal tears is reduced after ACL reconstruction, which reduces the negative effects of OA after surgery. The ultimate objective would be to achieve a good subjective outcome by conservative treatment followed by a rehabilitation program designed to keep secondary meniscus tears at a low level. Kessler, M A, H Behrend, S Henz, G Stutz, A Rukavina, and M S Kuster. “Function, Osteoarthritis and Activity after ACL-Rupture: 11 Years Follow-up Results of Conservative versus Reconstructive Treatment.” Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA 16, no. 5 (May 2008): 442–448. doi:10.1007/s00167-008-0498-x.
  • A coper is defined as an individual who is able to sufficiently stabilize their ALCD knee. They do this to such a high degree that previous activity can be resumed, the have no episodes of giving way, and do not require surgery. Standard definitions used in research often require someone to maintain activity level for up to one year following injury to be classified as a coper.
  • A non-coper is the opposite. This person simply can’t devise a motor strategy that can dynamically stabilize their ACLD knee and will require surgery to resume function. They usually experience 1 or more episodes of giving way. If this concept of coping without an ACL seems odd to you, which it may given the thought paradigm that ACL repair is required, take a moment and recall how many of our joints are stabilized. Mechanical stability comes from bony congruency, and ligamentous support. Dynamic stability comes from muscle function coupled with a high level of nervous system input from the joint’s position sensors, including mechanoreceptors embedded within ligaments like the ACL. In the instance of an ACL tear, the repair can replace some level of mechanical stability, but the relative contribution of this seems to be variable across individuals. No surgical procedure can replace that nervous system input from the lost ACL mechano-receptors. At the end of the day, the simple fact is that some people can cope without an ACL, some cannot, and there may be a third subgroup that can adapt to no acl following rehabilitation programs.
  • If we look at outcomes, they are stable whether you are a coper or not. You can see the literature reports enormous ranges when looking at return to previous activity following an ACL injury. The important tale here is that 82% seems to be the top level reported and that as a population, a percentage of people who suffer ACL injury will not be able to return to previous activity.
  • The next several slides will compare the differences between copers and non-copers. Many researchers have devoted their careers to examining these two distinct groups and so we can look at a good amount of evidence in terms of kinematic difference, muscle activation patterns, functional differences and activity limitations.
  • If we look at kinematic differences, we see that neither group moves the way people with intact ACLs do, however there are some important differences. Copers are able to generate more stability around the joint and don’t have moments of gross instability. Non-copers seem to have more joint laxity overall, and knee motion is limited during activities that require quad control, such as jumping tasks. It’s as if the joint stays loose, and so to compensate for that, non-copers move it less.
  • When we look at muscle activation patterns, we see that both groups have some degree of reduced quad control, although this is much worse for the non-coper group. In fact the quad stays more active than it should in many instances. Interestingly, while non-copers use co-contractions very liberally, one study demonstrated that copers used a veruy specific patter of vastuslateralis and medial hamstring activition as part of a strategy to dynamically stabilize the knee.
  • Functionally,Copers have higher scores on measure of knee function and can outperform non-copers in single leg hop tests. Non-copers tend to demonstrate a relucatance to perform a task and have higher fear avoidance scores.
  • Now here’s the interesting part. If we look more broadly than specific functional tasks and look at activity participation, we see very few differences. Both have similar rates of resuming previous activities, both groups report about a 20% reduction in activity following injury, but the vast majority of both groups rate their knee function as good overall. We have a conundrum.
  • Let’s attempt to solve this conundrum by examining the evidence supporting identification of copers in a population of people with an ACLD.
  • Perhaps the best known, or most widely reported example of this from the University of Delaware group. They performed a screening examination, which consisted of a series of hopping tests, episodes of giving way, and functional outcome scores. You can see the components of this screening exam in the table here.
  • From this research, Fitzgerald et al reported that a coper may be someone who has no reported episodes of giving way, can perform hop tests at 80% of the ininvolved leg, and achieves a Global rating of knee function score of 60% or higher. You should note that this screening exam was administered an average of 60 days following injury.
  • It seems that using this screening exam, about 40% of people will be indentified as copers. However, a follow-up trial looked at this group of people initially identified as non-copers much later on. They examined the 63% of people who were non-copers at 1 year. What they found was that 70% of that group met the criteria for copers at one year. This means that overall at 1 year, 63%, not 37% of people were copers. The propotion of copers may be much higher if a rehab program is employed and the screening examination is performed later on down the line.
  • So what’s the best recommendation based on evidence for when to test for coper-ness if you will? It’s not perfectly spelled out anywhere yet, and the U of Delaware screening is just one of several projects to identify this group. That said, you’re looking at performing a coper screening more than 60 days and within 6 months to a year following injury, and perhaps after 10 sessions of a rehabilitation program. This is obviously a moving target, so working with your patient and individualizing when their impairments will allow testing that includes such rigourous events as a single leg hop is the best path. Keep in mind that more than just this functional testing goes into the determination for surgery. Patient goals, life factors such as scholarship need, etc, all play a part.
  • AbstractPURPOSE:Lack of return to sport following anterior cruciate ligament (ACL) reconstruction often occurs despite adequate restoration of knee function, and there is growing evidence that psychological difference among patients may play an important role in this discrepancy. The purpose of this review is to identify baseline psychological factors that are predictive of clinically relevant ACL reconstruction outcomes, including return to sport, rehab compliance, knee pain, and knee function.METHODS:A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SportDiscus, which identified 1,633 studies for potential inclusion. Inclusion criteria included (1) prospective design, (2) participants underwent ACL reconstruction, (3)psychological traits assessed at baseline, and (4) outcome measures such as return to sport, rehabilitation compliance, and knee symptoms assessed. Methodological quality was evaluated with a modified Coleman score with several item-specific revisions to improve relevance to injury risk assessment studies in sports medicine.RESULTS:Eight prospective studies were included (modified Coleman score 63 ± 4.9/90, range 55-72). Average study size was 83 ± 42 patients with median 9-month follow-up (range 3-60 months). Measures of self-efficacy, self-motivation, and optimism were predictive of rehabilitation compliance, return to sport, and self-rated knee symptoms. Pre-operative stress was negatively predictive, and measures of social support were positively predictive of knee symptoms and rehabilitation compliance. Kinesiophobia and pain catastrophizing at the first rehabilitation appointment did not predict knee symptoms throughout the early rehabilitation phase (n.s.).CONCLUSIONS:Patient psychological factors are predictive of ACL reconstruction outcomes. Self-confidence, optimism, and self-motivation are predictive of outcomes, which is consistent with the theory of self-efficacy. Stress, social support, and athletic self-identity are predictive of outcomes, which is consistent with the global relationship between stress, health, and the buffering hypothesis of social support.LEVEL OF EVIDENCE:Systematic review of prospective prognostic studies, Level II.Everhart, Joshua S, Thomas M Best, and David C Flanigan. “Psychological Predictors of Anterior Cruciate Ligament Reconstruction Outcomes: A Systematic Review.” Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, October 15, 2013. doi:10.1007/s00167-013-2699-1.
  • Rehab programs for people with ACLD who may or may not be copers look and feel somewhat similar to post-op ACL rehab, so we’re not reiventing the wheel here. After a period of rest to combat the injury response, the physical therapist should work to minimize edema, maximize ROM and quad function, and eventual include a large proportion of neuromuscular re-ed techniques.
  • Quadriceps activation failure a problem with PTB autograftReduced quad function can lead to patellofemoralarthrofibrosisRestoration of quad function correlates with ADL function in early stages of recovery
  • Though there are weeks here these are just approximate
  • Though there are weeks here these are just approximate
  • From this research, Fitzgerald et al reported that a coper may be someone who has no reported episodes of giving way, can perform hop tests at 80% of the ininvolved leg, and achieves a Global rating of knee function score of 60% or higher. You should note that this screening exam was administered an average of 60 days following injury.
  • Remember to include open chain exercises, which may preferentially activate the quad, but you should return to plenty of closed-chain exercises to help promote control of the joint. Several studies have reported that programs include perturbation training have superior outcomes to those that don’t. Remember, the ultimate goal here is to include specific functional training to help people get back to their activity. This may include various levels of conditioning depend on the demands of the individual.
  • Bracing is sometimes a topic of conversation, both after surgery, and as a substitute for mechanical stability if treating conservatively. The evidence doesn’t look too fondly on bracing for the general population. It doesn’t have an impact on proprioception, it may be associated with higher quad atrophy, and it doesn’t seem to actually impact joint stability, or your perception of joint stability. Bracing is an option, though perhaps not a great one.
  • I’d like to suggest one caveat to the wait and see how rehab goes approach. A trial by Frobel at el, published in a popular journal reported that rehab plus optional delayed reconstruction reduced the need for surgery significantly. Deeper into the data, however, was the fact that the delayed group had more incidence of meniscal injury. This was one trial, and didn’t screen for copers specifically, but it bears a warning. In those individuals who have a high demand and are healthy, ACL repair my still be the best route. Remember, however, that rates of Knee OA are similar if you opt for surgery or conservative treatment.
  • Ultimately, the choice for which management path for your patients with ACLD is a complex one. In one study, they examined folks who were part of a larger ongoing trial about operative and non-operative management, specifically looking at those who crossed over from the non-op to the operative group. Many of those individuals expressed a strong belief that surgery was the only way you could treat an ACL tear, or that rehab was not going to be effective. Interestingly, this belief supporting surgery did not translate into improved surgical outcomes for this group, making this one example of a failed placebo effect! Like many things in healthcare, the trick here is going to be matching evidence-based criteria with your patients goals and beliefs. The bottom line: it is possible to manage ACLD conservatively, and I hope that’s something you look for opportunities to do in your practice. This concludes the lecture, my references follow.
  • Well it looks like it’s been a bad day for our friend Buzz Lightyear, and if I were a surgeon, I’d say he requires surgery to re-attach that leg. Surgeons as a group, follow a similar approach to ACL injuries, opting for surgery on the vast majority of them. In fact, as you view this lecture, you may not realize that repair of an ACL is an elective, not a required procedure. It’s become almost standard of care to rush into surgery following an ACL injury. This lecture exists to tell you the other side of the story.

Robertson ACL Management Robertson ACL Management Presentation Transcript

  • Non-Operative Management of the ACL-Deficient Knee Conservative Management of ACL Lecturer: Eric Robertson, PT, DPT, Assistant Professor Regis University, Denver, CO University of Texas at El Paso, El Paso, TX
  • Objectives • Describe usual care following ACL injury • Define the terms Copers and Non-Copers • Describe the characteristics of Copers versus Non-copers • Explore the impact of psychological factors in prognosis and outcomes • Examine outcomes following conservative management of ACL injury • Review evidence-based interventions for non-operative management of the ACL-deficient knee
  • It’s a paradigm Currently, there are over 80,000 ACL injuries in the U.S. each year. Over 90% of those will be surgically repaired. Cochrane SR, 2005, Benjaminse, 2006
  • It’s a paradigm ACL reconstruction costs $3 billion each year.
  • It’s a paradigm It‘s not been demonstrated that operative management of ACL injury is superior to non-operative management.
  • It’s a paradigm It‘s not been demonstrated that operative management of ACL injury is superior to non-operative management.
  • It’s really true Surgical time correlated to $$ 23 min = $1000 = Bonsell, 2000
  • Why do orthopedic surgeons recommend ACL reconstruction following injury? • Restore knee stability • Prevent meniscal damage • Protect articular cartilage • Avoid degenerative changes • All these are theoretical concepts, with various levels of support in literature. • Who might be non- surgical candidates? • Seasonal, construction workers • Athletes with a need to compete (scholarship, perhaps?) • Low activity level • Is there a way we can figure out who can function without an intact ACL?
  • What do we think? Let‘s have a brief discussion. Is ACL repair a lemon?
  • Risk Factors for post-ACL OA? • ACL Injury • ACL Repair • Opting out of ACL Repair • Meniscal Injury • Meniscetomy at time of injury or before • Chondral Lesions
  • OA incidence is the same if you have surgery or if you don‘t.
  • Streich et al, 2011
  • “We observed significantly better knee-stability (P = 0.008) but more osteoarthritis (Grade II or higher) after ACL- reconstruction (42% vs. 25%)” Kessler et al, 2008 “Eleven years after ACL-rupture the physical activity levels are similar for both groups.”
  • Risk Factors for post ACL OA? • ACL Injury • ACL Repair • Opting out of ACL Repair • Meniscal Injury • Meniscetomy at time of injury or before • Chondral Lesions
  • Risk Factors for post ACL OA? •ACL Injury • ACL Repair • Opting out of ACL Repair • Meniscal Injury • Meniscetomy at time of injury or before • Chondral Lesions
  • Risk Factors for post ACL OA? •ACL Injury •Stability
  • Stability of the Knee • Dynamic • Kinestheic awareness • Proprioception • Muscle strength and control • Balance • Core Stabilility • Static • Ligamentous • Meniscii • Ability to achieve screw home mechanism (full extension)
  • Can some people cope without an ACL? Is there enough dynamic support to stabilize the knee sufficiently for function?
  • Coper Those individuals who can dynamically stabilize an ACLD knee. • Must resume previous activity • No episodes of giving way • Do not require surgery • Activity persists for up to one year, (perhaps)
  • Non-Coper Those individuals who can’t dynamically stabilize an ACLD knee. • Giving way • Unable to resume previous level of activity • Require surgery
  • Note… Being a coper or a non-coper does not seem to predict surgical outcomes. % of ACLR Achieve Full Return to Activity Copers Non-Copers 8-82% 19-82%
  • Comparing Copers vs Non-Copers • Kinematic Differences • EMG Differences • Functional Differences • Activity Differences
  • Kinematic Differences Copers • Joint stability • Fewer episodes of giving way • Somewhat normal knee ROM and forces during functional activities and gait Non-Copers • Increased joint laxity • Reduced knee ROM during hop tests • Reduced knee compression and shear forces during gait
  • EMG Differences Copers • Poor quadriceps control • Preferentially utilized a vastus lateralis and medial hamstring activation pattern during a cutting drill Non-Copers • Poor quadriceps control • Increased quadriceps activity during knee flexion activities • Increased co-contraction strategies
  • Functional Differences Copers • Increased IDKC scores • Increased fuctional scores • Improved single-limb hop tests Non-Copers • Reluctance to participate • Fear avoidance
  • Activity Differences Copers • Return to Activity: 82% • Return to activity is limited • Reduced activity scores ~21% • Self-reports: overall good knee function Non-Copers • Return to Activity: 82% • Return to activity is limited • Reduced activity scores ~21% • Self-reports: overall good knee function
  • IDENTIFICATION Who can cope with ACLD?
  • U of Delaware Screening Examination Moksnes H, Snyder-Mackler L, Risberg MA. Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation. J Orthop Sports Phys Ther. 2008;38(10):586-95.
  • Identifying Copers (Fitzgerald, 2000) Potential Copers: • 1. < 1 episode of giving way • 2. > 80% 6m timed hop test • 3. > 80% KOS ADL subscale • 4. > 60% Global Rating of Knee Function
  • Prevalence of True Copers True Copers Non Copers • Fitzgerald, 2000; Hurd 2008 • 42% • Moekses • 37% • True Copers can return to function without surgical reconstruction. • 63% but…maybe shouldn‘t classify them right away… • Of Non-copers, 70% were classified at Copers at 1- year follow-up • Summary: 63% of subjects were copers Moksnes H, Snyder-Mackler L, Risberg MA. Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation. J Orthop Sports Phys Ther. 2008;38(10):586-95.
  • When do I measure? Optimal Evidence-based Time Frame for Coper Determination: • After a period of rehabilitation, after 60 days, before 6 months • 10 sessions has been a reported treatment duration
  • Psychological Factors! ―Patient psychological factors are predictive of ACL reconstruction outcomes.‖ Everhart, 2013 Systematic Review
  • Psychological Model of Pain Perception (Linton and Shaw, 2011)
  • Specific Psychological Pain Models (Linton and Shaw, 2011) • Fear-avoidance • Acceptance and commitment • Misdirected problem solving • Self-efficacy • Stress-diathesis
  • Specific Psychological Pain Models (Linton and Shaw, 2011) • Fear-avoidance • Acceptance and commitment • Misdirected problem solving • Self-efficacy • Stress-diathesis
  • Fear-Avoidance Model (Linton and Shaw, 2011) • Attention • Fear/Injury keys attention to internal stimuli (hyper-vigilance) • Cognition • This is pain/event catastrophizing • Emotion • Fear, depression, and anxiety • Behavior • Activity avoidance is hallmark of the model
  • Fear-Avoidance Model (Leeuw et al, 2007)
  • Misdirected Problem Solving (Linton and Shaw, 2011) • Attention • Continuing pain/condition demands attention • Cognition • Beliefs that there is an identifiable cause of pain/circumstance • Emotion • Worry is the primary one here • Behavior • Attempts (continued) to solve the problem
  • Misdirected Problem Solving (Eccleston et al, 2007)
  • Self-Efficacy (Linton and Shaw, 2011) • Attention • Not emphasized much in this model • Cognition • Beliefs related to locus of control • Emotion • Not emphasized much in this model • Behavior • Coping skills
  • Self-Efficacy (Bandura, 1997) • Model summary • ―the belief in one‘s capabilities to organize and execute the courses of action required to produce given attainments‖ • Low self-efficacy accompanied by beliefs that pain/rehab is uncontrollable • High self-efficacy may be feature of self-management
  • Low Self-Efficacy Example • ―I hope the doctor knows what he‘s doing in surgery. I really need this to go right so I can return to my sport.‖
  • High Self-Efficacy Example • ―I‘m going to play football again, and quite frankly, I don‘t care what the doctors say.‖
  • Communication Keys • Physician research for effective patient communication (Maguire and Pitceathly, 2002) • Style and focus • Eye contact • Active listening • Facilitation of self-disclosure • Patient concerns • Explicit interest and consideration of psychosocial factors
  • Clinical Application • Be confident • Be positive • Clearly explain the problem in current framework for pain perception • Come to an agreement about the nature of the problem and the way to treat it.
  • Psychologically Informed Intervention (Nicholas and George, Phys Ther 2011) • Model of communication • Cognitive-behavioral methods
  • Cognitive Behavioral Methods (Nicholas and George, 2011) • Analysis • Observe when/where problem behaviors occur and consequences • Identify beliefs/expectations associated with problem behaviors • Develop a formulation of relationships between these domains
  • Cognitive Behavioral Methods (Nicholas and George, 2011) • Change plan (involves patient) • Identify goals the patient wants to achieve • Breakdown into specific sub-goals that can be up-graded • Especially important for quota or exposure approaches • Develop plan for dealing with obstacles • Plan for reinforcement when successful
  • Cognitive Behavioral Methods (Nicholas and George, 2011) • Implement plan • Explain to patient the formulation of problem behaviors (including pain) and obtain agreement • Ensure patients works on upgrading activities that were previously avoided • Help patient problem solve obstacles • Provide skills training as needed • Monitor and reinforce when successful • Terminate treatment when goals are met
  • Psychologically Informed Intervention (Nicholas and George, Phys Ther 2011) • Model of communication • Cognitive-behavioral methods • Treatment approaches
  • Psychosocial Pain Treatment (Jensen, 2011) • Clinical approaches • Hypnosis • Relaxation training • Mindfulness meditation training • Operant treatment (e.g. graded exercise) • Graded exposure • Motivational interviewing • Cognitive and cognitive behavioral therapies • Acceptance based cognitive therapy
  • Psychosocial Pain Treatment (Jensen, 2011) • Clinical approaches • Hypnosis • Relaxation training • Mindfulness meditation training • Operant treatment (e.g. graded exercise) • Graded exposure • Motivational interviewing • Cognitive and cognitive behavioral therapies • Acceptance based cognitive therapy
  • GRADED EXERCISE (ACTIVITY)
  • Fear-Avoidance Model (Leeuw et al, 2007)
  • Fear-Avoidance Beliefs Assessment • Fear-Avoidance Beliefs Questionnaire used to screen for elevated fear-avoidance beliefs (Waddell et al, Pain, 1993) • ―Physical activity might harm my knee‖ (0-6) • ―I should not do physical activities which (might) make my pain worse‖ (0-6) • ―I do not think I will be back to normal anytime soon‖ (0-6)
  • Kinesiophobia Assessment • Tampa Scale of Kinesiophobia (TSK) is also used to assess pain- related fear and fear of re-injury • Originally 17 items, now an 11 item scale (TSK-11) is recommended (Woby et al, 2005) • ―I‘m afraid I might injury myself if I exercise‖ (1 – 4) • ―Pain always means I have injured my body‖ (1 – 4)
  • Tampa Scale of Kinesiophobia (TSK-11) (Woby et al, 2005) SUM
  • Pain Catastrophizing Screening • Pain Catastastrophizing Scale (PCS) used to screen for elevated pain catastrophizing (Sullivan et al, 1995). • ―I worry all the time about whether the pain will end‖ (0-4) • ―I keep thinking about how much it hurts‖ (0-4) • ―There‘s nothing I can do to reduce the intensity of the pain‖ (0-4)
  • Pain Catastrophizing Screening SUM
  • Sport / ACL Specific Measures of Psychological Factors • ACL – Return to Sport After Injury scale • 11-item scale • ‗‗Are you fearful of reinjuring your knee by playing sport?‘‘ and ‗‗Are you confident you can perform at your previous level of sports participation?‘‘ • The Incredibly Short Profile of Mood States • Rate: anxiety, sadness/depression, energy, fatigue, anger on 5-point scale from ―nothing‖ to ―extreme‖ • TSK • Sport Rehabilitation Locus of Control • 5-point scale, ―agree‖ or ―disagree with statements • ‗I‘m in control of my rehabilitation and return to sport‘‘ and ‗‗If it‘s meant to be, I‘ll get back to sport‘‘ Arden et al, 2013 AJSM
  • Arden et al., 2013 • ―Clinical screening for maladaptive psychological responses in athletes before and soon after surgery may help clinicians identify athletes at risk of not returning to their pre-injury level of sport by 12 months.‖
  • Education Modifications ―…unambiguously educating the patient in a way such that the patient views his or her pain as a common condition, rather than as a serious disease that needs careful protection.‖ (Vlaeyan and Linton, Pain, 2000)
  • When to Intervene? Injury Return to Sport Early after Injury, pre-operatively, and early in rehab process seems more effective for influencing psychological barriers with ACL injury
  • Graded Exercise • Principles • Based on operant conditioning principles (Fordyce et al, Arch Phys Med Rehabil, 1973) • Primary intervention goal is increase in activity through quota attainment • Intervention does not focus on symptom abatement
  • Graded Exercise • Basic treatment flow • Include a variety of general exercises or activities • Determine exercise or activity tolerance • Set quota based on exercise or activity tolerance • Hold patient accountable to quota attainment • Reward quota attainment NOT pain behavior • Goals remain focused on functional gains • Repeat process
  • GRADED EXPOSURE
  • Fear-Avoidance Model (Leeuw et al, 2007)
  • Specific Fear • Vlaeyen et al suggests measurement of specific fears more relevant to patient • May be necessary for certain treatment protocols
  • Specific Fear • Beyond the FABQ or TSK or PCS • Need to measure fear of specific activities • PHODA-SeV (Leeuw et al, 2007) (Pictures) • 20 movements/activities presented to subjects • Rate fear of each one on VAS (electronically) • Consider highly rated movements/activities to intervention
  • Fear of Activities • Fear of Daily Activities Questionnaire (FDAQ) used to identify fear of specific activities (George et al, Phys Ther, 2009) • 10 movements/activities presented to subjects • Rate fear of each one on VAS • Average the first 10 items for FDAQ score • Consider highly rated movements/activities to intervention
  • Scan for highly rated activities to include for intervention AVERAGE (10 Items)
  • Graded Exposure • Vlaeyen et al suggests as a more effective alternative than quota driven approaches • What is the difference? • Graded activity = increase in generic functional capacity (operant conditioning model) • Graded exposure = increase in activities that are fearful (exposure/phobia model) • Differences have not been tested (much)
  • Graded Exposure • Basic treatment flow • Identified activities or exercises that are fearful • Determine initial exposure level • Gradually increase exposure based on decreased fear and anxiety • Hold patient accountable to increasing exposure • DO NOT reward pain behavior • Incorporate exposure as part of home program • Repeat process
  •  Outcome High fearPrognostic factor Treatment Moderator High fear Treatment A Treatment B ↑ Outcome  Outcome Low fear Treatment A Treatment B  Outcome ↑ Outcome Treatment Mediator Treatment Fear Outcome Outcome Decision Aides Treatment Monitoring Hill and Fritz, Phys Ther, 2011
  • Treatment Moderating Factor • Makes treatment effect greater in one group vs. another • When or among whom does an effect ―work‖? • Source of treatment effect heterogeneity • Decision Aide High fear Treatment A Treatment B ↑ Outcome  Outcome Low fear Treatment A Treatment B  Outcome ↑ Outcome
  • Treatment Mediating Factor • Mediator variables are part of the mechanism through which treatment impacts the outcome. • The effect of treatment on an outcome involves intervening changes in mediator variable • Treatment Monitoring Treatment Fear Outcome
  • How about Psychological Factors and Copers vs Non-Copers? • Kartigan et al., JOSPT 2013 Nov • ―Kinesiophobia after ACL Rupture and Reconstruction: Non-Copers Versus Potential Copers‖
  • Kartigan et al., JOSPT 2013 Nov • 50 copers • 61 non-copers • Examined functional outcomes and kinesiophobia after injury and 6 months post-surger • (all copers and non-copers had surgery)
  • Kinesiophobia: Non-copers Pre-Surgery Post-Op 70 10 *Graphical representation, not real scores
  • Kinesiophobia: Potential Copers Pre-Surgery Post-Op 30 10 *Graphical representation, not real scores
  • Key points • Non-copers had higher levels of kinesiophobia pre- operatively, but greater reductions when measured post- operatively compared to potential copers. • Kinesiophobia is higher pre-op than post-op, regardless of performance on functional measures. • Kinesiophobia should be measured throughout rehab. (plateaus at ~6 months?)
  • Components of Rehabilitation Program • Rehabilitation looks similar to post-operative rehabilitation and many of the same principles apply • Optimize quad function • Minimize swelling • Maximize ROM • Neuromuscular re-education
  • Restoring Quadriceps Function • Quad Sets • Straight Leg Raises • With and without Biofeedback • Active Knee Extension Against Gravity: No Added Resistance
  • Fitzgerald GK, Piva SR, Irrgang JJ. A modified neuromuscular electrical stimulation protocol for quadriceps strength training following ACL reconstruction. JOSPT 2003 33(9): 492-501 • 2500hz, 75 burst/sec • 10 contractions • 10 on/ 50 off • Stimulus produces full, sustained quad contraction with evidence of superior patellar glide NMES
  • Lower Extremity Strengthening • Initiate closed chain exercise with body weight when patient can fully weight bear without crutches. • Double and single leg squats (0- 45) • Lateral and forward step ups • Calf raises (up on toes) • Progress to leg press when tolerating 3 sets of 15 reps for two consecutive sessions without pain, swelling, instability • No significant difference in anterior knee laxity at 6 months • Significant increase in quadriceps torque in the CKC/OKC group • Significant higher number of patients returned to pre-injury sports level in the CKC/OKC group and did so 2 months earlier than the CKC group • Conclusion: Incorporate OKC exercises with CKC exercises in the protected ranges following ACL Reconstruction Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg, Sports Tramatol, Arthrosc. 2000; 8: 337-342.
  • Lower Extremity Strengthening • Begin leg press with double leg and eventually progress to single leg • Begin with 50 to 75% of body weight Arc of Motion = 0 to 45
  • Restore Balance and Proprioception • Altered proprioception and lower extremity muscular control has been associated with ACL Injury • Unclear if these deficits fully resolve after ACL reconstruction • Functional retraining programs for post-op ACL rehab may need to emphasize enhancement of lower extremity neuromuscular control strategies
  • Criterion Based Progression • Running • Pool Run (week 6) • Treadmill Run (week 8) • Normal gait pattern while walking • Quad strength = 70% of uninvolved limb • Minimal effusion with minimal pain Suggested Progression from Adams et al. JOSPT 2012
  • Criterion Based Progression • Agility Training • Track or Road Running for 1 to 2 miles without pain, swelling, instability • Quad Strength = 80% of uninvolved limb • Begin agility activities with 50% effort, progress to 75% then 100% effort provided no pain, swelling, instability
  • Criterion Based Progression • Sprinting • Tolerating all agility and low level sport specific training. • Quad strength 85 to 90% of uninvolved limb • Begin with form running at 50 and 75% effort, progress to 100% when tolerating these without pain, swelling, instability • Lower Level Sport Specific Training • Tolerating all agility training at 100% effort without pain, swellling, or instability • Quad function = 85% of uninvolved limb
  • Identifying Copers (Fitzgerald, 2000) Potential Copers: • 1. < 1 episode of giving way • 2. > 80% 6m timed hop test • 3. > 80% KOS ADL subscale • 4. > 60% Global Rating of Knee Function
  • Return to Sport • Tolerating 100% effort sprinting, agility drills, jumping, and hopping • No evidence of compensation or valgus collapse • No pain or reports of pain as progression continues • No reports of giving way • No effusion or signs of inflammation • Begin with opposed practice of sport specific skills (training partner) • Return to practice with team when tolerating opposed practice of skills. • Return to sport when no difficulty with all practice activities.
  • Components of Rehabilitation Program • Include Open-Chain Exercises • Taggesson, 2008 – no differences btwn OKC/CKC in observed dynamic tibial translation • OKC may significantly improve quad strength • NMES • Include kinesthetic awareness training • Include perturbation training • Enhance ability to protect joint • Neuromuscular component • Key Outcome: Resume previous level of activities, usually within <6 months to 1 year.
  • Bracing • Functional knee bracing does not seem to improve proprioception following ACL reconstruction even at 2 years after surgery. • Bracing produced significantly more thigh atrophy at 3 months after surgery than did non-bracing. • Bracing does not appear to influence either objective stability or subjective function. • Some researchers have concluded that functional braces may expose athletes to additional risk by imparting a false sense of confidence.
  • A note about joint health… • One study reported a reduced rate of surgery using conservative therapy and optional ACLR, however… • Increased rates of meniscal tear/damage noted • Rates of Knee OA increased with ACL injury regardless of management decision
  • Choosing Surgery • Remains gold standard for athletes, especially higher level, requiring pivoting skill • Complex and multifactorial for everyone else • Choosing surgery not correlated with better outcomes
  • It’s a paradigm Currently, there are over 80,000 ACL injuries in the U.S. each year. Over 90% of those will be surgically repaired. Cochrane SR, 2005, Benjaminse, 2006
  • References: • Eitzen, Ingrid, Havard Moksnes, Lynn Snyder-Mackler, Lars Engebretsen, and May Arna Risberg. ―Functional Tests Should Be Accentuated More in the Decision for ACL Reconstruction.‖ Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA (April 22, 2010). doi:10.1007/s00167-010-1113-5. • Fitzgerald, G K, M J Axe, and L Snyder-Mackler. ―A Decision-making Scheme for Returning Patients to High-level Activity with Nonoperative Treatment after Anterior Cruciate Ligament Rupture.‖ Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA 8, no. 2 (2000): 76–82. • ———. ―Proposed Practice Guidelines for Nonoperative Anterior Cruciate Ligament Rehabilitation of Physically Active Individuals.‖ The Journal of Orthopaedic and Sports Physical Therapy 30, no. 4 (April 2000): 194–203. • ———. ―The Efficacy of Perturbation Training in Nonoperative Anterior Cruciate Ligament Rehabilitation Programs for Physical Active Individuals.‖ Physical Therapy 80, no. 2 (February 2000): 128–40. • Frobell, Richard B, Ewa M Roos, Harald P Roos, Jonas Ranstam, and L Stefan Lohmander. ―A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears.‖ The New England Journal of Medicine 363, no. 4 (July 22, 2010): 331–342. doi:10.1056/NEJMoa0907797. • Frobell, Richard B, Harald P Roos, Ewa M Roos, Frank W Roemer, Jonas Ranstam, and L Stefan Lohmander. ―Treatment for Acute Anterior Cruciate Ligament Tear: Five Year Outcome of Randomised Trial.‖ BMJ (Clinical Research Ed.) 346 (2013): f232. • Grindem, Hege, Ingrid Eitzen, Håvard Moksnes, Lynn Snyder-Mackler, and May Arna Risberg. ―A Pair-matched Comparison of Return to Pivoting Sports at 1 Year in Anterior Cruciate Ligament-injured Patients after a Nonoperative Versus an Operative Treatment Course.‖ The American Journal of Sports Medicine 40, no. 11 (November 2012): 2509–2516. doi:10.1177/0363546512458424. • Grindem, Hege, David Logerstedt, Ingrid Eitzen, Håvard Moksnes, Michael J Axe, Lynn Snyder-Mackler, Lars Engebretsen, and May Arna Risberg. ―Single-legged Hop Tests as Predictors of Self-reported Knee Function in Nonoperatively Treated Individuals with Anterior Cruciate Ligament Injury.‖ The American Journal of Sports Medicine 39, no. 11 (November 2011): 2347–2354. doi:10.1177/0363546511417085. • Hurwitz, D E, T P Andriacchi, C A Bush-Joseph, and B R Bach Jr. ―Functional Adaptations in Patients with ACL-deficient Knees.‖ Exercise and Sport Sciences Reviews 25 (1997): 1–20.
  • References: • Irrgang, J J, and G K Fitzgerald. ―Rehabilitation of the Multiple-ligament-injured Knee.‖ Clinics in Sports Medicine 19, no. 3 (July 2000): 545–71. • Lewek, Michael D, Terese L Chmielewski, May Arna Risberg, and Lynn Snyder-Mackler. ―Dynamic Knee Stability after Anterior Cruciate Ligament Rupture.‖ Exercise and Sport Sciences Reviews 31, no. 4 (October 2003): 195–200. • Mihelic, Radovan, Hari Jurdana, Zdravko Jotanovic, Tomislav Madjarevic, and Anton Tudor. ―Long-term Results of Anterior Cruciate Ligament Reconstruction: a Comparison with Non-operative Treatment with a Follow-up of 17-20 Years.‖ International Orthopaedics 35, no. 7 (July 2011): 1093–1097. doi:10.1007/s00264-011-1206-x. • Moksnes, H, and M A Risberg. ―Performance-based Functional Evaluation of Non-operative and Operative Treatment after Anterior Cruciate Ligament Injury.‖ Scandinavian Journal of Medicine & Science in Sports 19, no. 3 (June 2009): 345–355. doi:10.1111/j.1600-0838.2008.00816.x. • Moksnes, Håvard, Lars Engebretsen, Ingrid Eitzen, and May Arna Risberg. ―Functional Outcomes Following a Non- operative Treatment Algorithm for Anterior Cruciate Ligament Injuries in Skeletally Immature Children 12 Years and Younger. A Prospective Cohort with 2 Years Follow-up.‖ British Journal of Sports Medicine 47, no. 8 (May 2013): 488–494. doi:10.1136/bjsports-2012-092066. • Moksnes, Håvard, Lars Engebretsen, and May Arna Risberg. ―The Current Evidence for Treatment of ACL Injuries in Children Is Low: a Systematic Review.‖ The Journal of Bone and Joint Surgery. American Volume 94, no. 12 (June 20, 2012): 1112–1119. doi:10.2106/JBJS.K.00960. • Moksnes, Håvard, Lynn Snyder-Mackler, and May Arna Risberg. ―Individuals with an Anterior Cruciate Ligament- deficient Knee Classified as Noncopers May Be Candidates for Nonsurgical Rehabilitation.‖ The Journal of Orthopaedic and Sports Physical Therapy 38, no. 10 (October 2008): 586–595. • Snyder-Mackler, Lynn, and May Arna Risberg. ―Who Needs ACL Surgery? An Open Question.‖ The Journal of Orthopaedic and Sports Physical Therapy 41, no. 10 (October 2011): 706–707. doi:10.2519/jospt.2011.0108. • Thorstensson, Carina A, L Stefan Lohmander, Richard B Frobell, Ewa M Roos, and Rachael Gooberman-Hill. ―Choosing Surgery: Patients‘ Preferences Within a Trial of Treatments for Anterior Cruciate Ligament Injury. A Qualitative Study.‖ BMC Musculoskeletal Disorders 10 (2009): 100. doi:10.1186/1471-2474-10-100.