Research ReportComparison of the Effects of Exercise in Water andon Land on the Rehabilitation of Patients WithIntra-artic...
effects of surgery through ROM and                   impairments of patients following ACL               more effective in...
-Table 1 . Rehabilitation PmgramsWeek 1 and Home Program Exercises (Both Groups)1. Wall slides: 25 repetitions2. Active-as...
achieved a maximum height of 30.48                                                                                        ...
ware (version 5.1)* were used to                                                                                          ...
-Table 2. Results o Analysis o Variance o Dzferences in Joint Laxity MeasurementsSource                     f             ...
-Table 3. Results of Analysis of Variance of Differences in Joint Laxity MeasurementsDuring a 9.1-kg (20-lb)Lachrnan TestS...
in greater circumferential                                                                                              me...
restoring muscle perf0rmance.3~This        tions resulted in donor site pain (the       step-ups, and the land pulleys ap-...
collection; and Piedmont Hospital for               tions Springfield, Ill: Charles C Thomas, Pub-      loskeletal conditi...
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Comparison of the effects of exercise in water and on land on the rehabilitation of patients with intra articular acl reconstructions


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Comparison of the effects of exercise in water and on land on the rehabilitation of patients with intra articular acl reconstructions

  1. 1. Research ReportComparison of the Effects of Exercise in Water andon Land on the Rehabilitation of Patients WithIntra-articular Anterior Cruciate LigamentReconstructions Background and Purpose. Exercises in water have been shown to be effective Brlan J Tovlnfor improving strength and passive range of motion (PROM). Traditional rehabili- Steven L Wolf tation following intra-articular anterior cruciate ligament (ACL) reconstruction Bruce H Greenfield has taken place o n land. This study was designed to compare the effects of exer- Jerl Crousecises in water o n strengh and girth of the thgb musculature, knee PROM, joint Blane A Woodfin laxity, e m i o n , and functional outcome with the effects of similar mercises o n land in subjectsfollowing intra-articular reconstruction of the ACL. Subjects. Twenty subjects were randomly asstgned to either a group that exercised o n land or a group that exercised i n water. Metbods. Thigh girth, joint effmon, and kneePROM measurements were recorded at 2-week intervalsfor the first 8 weeks post-operatively. Isokinetic and isometric peak torque measurementsfor the thigh mus- culature, knee joint laxity assessments, and Lysholm scores were obtained at the end of 8 weeks. Results. Higher outcome scores were recorded in the watergroup than in the landgroup, as measured by Lysholm scales. No dtferences were noted between groups for knee PROM, thigh girth, or quadriceps femoris musclep e r f o m w e . In the water group, lessjoint e f m o n was noted aJer the 8 weeks.In the land group, greater peak torquefor isokinetic knee flexion was recorded. Concluston and Discussion. Although exercise in water may not be as effec- tive as exercise o n land for regaining maximum muscle perfomnce, rehabilita- tion in water may minimize the amount of joint effiion and lead to greater self-reportsof functional improvement in subjects with intra-articular ACL recon- structions. [Tovin BJ, Wolf SL, Greenfield BH, et al. Comparison of the effects of exercise in water and o n land o n the rehabilitation of patients with intra- articular anterior cruciate ligament reconstmctions. Phys Ther. 199g 74: 710-719.1Key Words: Knee; Ligaments; Lower extremity, knee; Muscle pe$omance, lowerextremity; Rehabilitation.Rehabilitation following anterior cru- have influenced rehabilitation, as have months.2 Primary goals continue to beciate ligament (ACL) reconstruction knowledge of stress-strain patterns in the recovery of joint range of motionhas evolved over the past few decades the ACL during various exercises.2 (ROM), quadriceps femoris muscleand is considered important in guar- Twelve-month protocols requiring force-generating capability, and ambu-anteeing a beneficial outcome follow- immobilization and non-weight bear- latory skills.2 Attaining these goals,ing surgety.1 Advances in surgical ing3 have given way to accelerated however, may be delayed by postop-approaches, such as graft placement protocols permitting immediate erative joint effusion and the persis-and graft fixation, and the use of ar- weight bearing, no immobilization, tence of pain. Early phases of rehabili-throscopically assisted procedures and return to activity within 6 tation must minimize the deleterious22/710 Physical Therapy/Volume 74, Number B/August 1994
  2. 2. effects of surgery through ROM and impairments of patients following ACL more effective in retarding thigh atro-muscle strengthening exercises while reconstruction, research suggests that phy than traditional rehabilitationensuring that each activity is per- closed-chain exercises are safer than alone. Thigh atrophy, however, is onlyformed without overstressing the ACL open-chain exercises because there is one measure of recovery. Whethergrafts.435 less stress on the graft.11-13 Despite rehabilitation in water will be differ- this fact, some subjects experience ent from traditional rehabilitation inElectromyographic biofeedback5j6 and increased pain and knee effusion reducing knee joint laxity, enhancingneuromuscular electrical stimulation7.8 following closed-chain exercises.14 muscle force, and improving func-are two modalities used in the early Therefore, performing closed-chain tional outcomes in subjects with intra-phases of rehabilitation following ACL exercises in an environment in which articular ACL reconstructions isreconstruction to reduce muscle atro- the forces around the knee joint are uncertain.phy and to facilitate strengthening. reduced may aid in reducing kneeThe effectiveness of these modalities pain and joint effusion. The purpose of this study was toin imprc~ving quadriceps femoris determine whether exercises in amuscle force in subjects with ACL Fkercises in water could expedite pool will lead to less joint effusion,reconstruction has been measured by rehabilitation because of the de- less thigh atrophy, increased ROMisokinetic dynomometry.6~7 These creased stress on the joints, improved and thigh musculature strength, andstudies, however, applied feedback o r circulation, and facilitated movement less difficulty with activities of dailyneuroml~scularelectrical stimulation that occur in water.15.16 Researchers living in patients after intra-articularduring isometric quadriceps femoris have analyzed limb movement in ACL reconstruction compared withexercises, and this approach may not water17-9 and have compared differ- exercises on land. An effort was madesimulate functional activities. ent aquatic exercise devices,2&22but to match specific exercises in both few studies have quantified gains in groups so that each program wasWe believe knee extension exercises muscular force that occur following identical and only the rehabilitationshould be designed to simulate func- an aquatic exercise program. Bartow environment was manipulated.tional activities. "Closed-chain" knee and Diamond23 have concluded thatextension has been advocated as a exercises performed using water as Methodsafe exercise for patients after ACL resistance can increase the torque-reconstruction.9 These exercises in- generating capabilities of the thigh Subjectsvolve applying resistance through the musculature in healthy subjects.terminal joint of a limb segment, Gehlsen et a124 have made similar Twenty subjects (14 male, 6 female)which restrains the joints free move- conclusions in patients with multiple ranging in age from 16 to 44 yearsment (eg, rising from a chair), sclerosis, but no control group was @=29.0, SD=7.8) participated in thiswhereas "openchain" exercises in- used for comparison. study. All subjects had undergonevolve applying resistance to an ex- arthroscopically assisted intra-articulartremity in a way that the distal joint is NapoletanZ5found that in subjects ACL reconstruction using a bone-free to move (eg, kicking into the with ACL reconstructions, underwater patellar tendon-bone autograft, per-air).IO Although both of these forms of treadmill ambulation in conjunction formed by the same orthopedic sur-exercise can address the physical with traditional rehabilitation was geon. Subjects who had prior ACL surgery to either knee or who had a meniscus repair at the time of surgery were excluded from the study.BJ Tovin, IT, ATC, is StafT Physical Therapist, Physiotherapy Associates, 2770 Lenox Rd NE, Ste 102,Atlanta, GA 30324 (USA), and Director of Rehabilitation, Georgia Tech Athletic Association, Atlanta, ProcedureGA 30332. Mr Tovin was a student at Emory University, Atlanta, GA, at the time this study was com-pleted in partial fulfillment of the requirements for his Master of Medical Science degree. Addressall correspondence to Mr Tovin. During the preoperative visit, subjectsSL Wolf, PhD, FT,FAlTA, is Professor and Director of Research, Department of Rehauilitation Medi- were familiarized with the study andcine, Professor, Division of Geriatrics, Department of Internal Medicine, and Associate Professor, postoperative rehabilitation protocolsDepartment of Anatomy and Cell Biology, Emory University School of Medicine, 1441 Clifton Rd were explained. Each subject signedNE, Atlanta, GA 30322. an informed consent statement, writ-BH Greenfield, FT,OCS, is Clinical Coordinator of Education and Clinic Director, Physiotherapy Associ- ten to conform with the guidelines ofates, Jonestmro, GA 30236, and Clinical Instructor, Division of Physical Therapy, Emory University. Emory University and Piedmont Hos-J Crouse, IT, is Clinical Coordinator of Physical Therapy, HealthSouth, Atlanta, GA 30342. pital (Atlanta, Ga), and a questionnaire was administered. Subjects were as-BA Woodfin, MD, is Orthopaedic Surgeon, Resurgeons Orthopaedics, and Team Physician, GeorgiaTech Athletic Association. signed to either a traditional rehabili- tation (TR) group or a pool rehabilita-This study was approved by the Human Investigation Committee of Emory University and Pied- tion (PR) group using the followingmont Hospital. method of group assignment. The firstThis article was submitted April 13, 1993, and was accepted Januaty 6, 194. 2 subjects were randomly assigned toPhysical Therapy /Volume 74, Number 8/August 1994
  3. 3. -Table 1 . Rehabilitation PmgramsWeek 1 and Home Program Exercises (Both Groups)1. Wall slides: 25 repetitions2. Active-assistive range of motion: 25 repetitions --3. Passive knee extension: 10 minutes4. Hamstring muscle and calf stretching: 10 minutes each5. Quadriceps femoris muscle sets6. Straight leg raisesa: 3 sets x 10 repetitions for hip flexion, abduction, adduction, and extension7. Active knee flexiona: 3 sets x 10 repetitions8. Toe raises: 3 sets x 10 repetitions9. Partial wall squats (usually added to the home program after first week): 3 sets x 10 repetitionsWeek 2-8 Exercise ProgramsTraditional Rehabilitation Group Pool Rehabilitation Group1. Stationary cycling: 10 minutes 1. Stationary cycling: 10 minutesb2. Gait training without brace, alternating forward and backward 2. Gait training without brace, alternating forward and backward ambulation: 10 min ambulation: 10 min3. Side step-ups, front step-ups, step-downs: beginning with 3 sets 3. Side step-ups, front step-ups, step-downs: beginning with 3 sets of of 10 repetitions, progressing to 3 sets of 15 repetitions 10 repetitions, progressing to 3 sets of 15 repetitionsC4. Hip flexion, extension, abduction, adduction in standing using a 4. Hip flexion, extension, abduction, adduction in standing using the wall pulley with 4.54-kg (10-lb) plates: beginning with 3 sets of 10 Hydrotone resistance boot: beginning with 3 sets of 10 repetitions repetitions, progressing to 3 sets of 15 repetitions and progressing to 3 sets of 15 repetitions5. Knee flexion in sitting: 3 sets of 10 repetitions; boot: beginning 5. Knee flexicn in standing using the Hydrotone resistance boot: with 3 sets of 10 repetitions, progressing to 3 sets of 15 repetitions beginning with 3 sets of 10 repetitions and progressing to 3 sets of 15 repetitions"Cuff weights were added to straight leg raises and knee flexion in increments of 0.91 kg (2 lb).*stationary cycling in the pool rehabilitation group used a peddling device (see Fig. 1) rather than a stationary bicycle.Step-ups in the water were done with 20.32-cm (8-in) and 40.64-cm (16-in) of the two groups using a coin which one of the authors reviewed how to keep a log of their hometoss. The next 2 subjects recruited the home program to ensure that the exercise p r o g m , which was checkedwere placed in opposite groups of the exercises were done safely and inde- by one of the authors to help assessfirst 2 subjects. This procedure was pendently. To facilitate passive knee compliance.continued for every 4 subjects until extension, each subject was posi-20 subjects were recruited. As a result, tioned prone and the involved leg Weight Bearing6 men and 4 women were placed in (from the superior third of the tibiathe P group and 8 men and 2 R to the foot) was placed off the side of Gait training was also initiated on thewomen were placed in the TR group. a treatment table or bed, letting grav- first postoperative session with axil-This method of group assignment was ity pull the knee into extension. Resis- lary crutches and a hinged kneeused to evenly distribute subjects tance for the straight leg raises and brace. The braces were locked in fullbetween the two groups over time, leg curls was added using variable- extension for the first 4 to 7 days, andwhile also incorporating random resistance cuff weights. Subjects initi- subjects were instructed to bear asassignment to groups. ated each exercise, performing three much weight as they could tolerate. sets of 10 repetitions without weight Subjects were progressed from twoWeek 1 Exercises for Both and progressing until they could per- crutches to one crutch between theOroups form three sets of 15 repetitions with- 4th and 7th postoperative days and out difficulty. Subjects then added 0.9 were usually off the crutch by theDuring the first postoperative session, kg (2 lb) to the cuff weight and re- 10th postoperative day. The hingedpatients in both groups were in- peated the progression starting with knee brace was unlocked at the be-structed in an identical program (Tab. three sets of 10 repetitions. This pro- ginning of the 2nd week, permittingI), which they performed at home cedure was continued, and resistance 90 degrees of knee flexion. The ROMtwice per day. The first week of post- was added in 0.9-kg increments (most of the braces were increased to 120operative rehabilitation consisted of patients progressed their weight every degrees by the beginning of the 3rdthree o r four treatment sessions in 2-3 days). Subjects were instructed postoperative week, and subjects were24/712 Physical Therapy /Volume 74, Number 8/August 1994
  4. 4. achieved a maximum height of 30.48 cm (12 in). Subjects in the P group initiated R closed-chain exercises on a 20.32-cm (8-in) step. Subjects began with three sets of 10 repetitions and progressed until they could do three sets of 15 repetitions without difficulty. This progression usually occurred within 1 week of rehabilitation in the water. Between the second and third weeks, subjects were advanced to a 40.64-cm (16-in) step in chest-deep water and the progression format was repeated. Between the fourth and eighth weeks, subjects used the 40.64-cm step in waist-deep water to reduce the force of buoyancy on body weight, thereby increasing resistance. Exercises in waist-deep water progressed in the same manner. If subjects were able to perform three sets of 15 repetitions on the 40.64-cm step in waist-deep water without difficulty, they were positioned on a 40.64-cm step in thigh-deep water for maximal resis- tance and the sequencing format was repeated. The next group of exercises consisted of standing hip flexion, extension, abduction, adduction, and knee flex- ion strengthening. The TR group performed these exercises using pul-Figure I. Pedalling device used by subjects in the water group. leys that contained a stack of 4.5-kg (10-lb) plates. Subjects initiated eachout of the brace by the 6th postopera- with the same exercises, but used a exercise with a weight they could lifttive week. pedalling device underwater (Fig. 1) comfortably for three sets of 10 repe- instead of a stationary bicycle. titions and progressed until theyRehabliltation Programs could perform three sets of 15 repeti- Subjects in the TR group initiated tions without difficulty. Another 4.5-kgDuring the second through the eighth closed-chain exercises on a 5.08-cm plate was then added, and the exer-postope~ztive weeks, the TR group (2-in) step. Three sets of 10 repeti- cise was repeated with three sets ofperformed a land rehabilitation pro- tions were performed, progressing to 10 repetitions.gram and the P group performed a R three sets of 15 repetitions. Whensimilar program in the water (Tab. 1). subjects could perform three sets of Hip strengthening and knee flexionBoth programs were performed three 15 repetitions comfortably at a given exercises were done using a Hydro-times per week in the same sequence. height, the height was increased by tone exercise boot* (Fig. 2). Exercises 5.08 cm and they started with three consisted of three sets of 10 repeti-Subjects in the TR group warmed up sets of 10 repetitions again. Subjects tions for hip flexion-extension,with 10 minutes of stationary cycling, usually advanced every two or three abduction-adduction, and knee flex-followed by 10 minutes of gait train- sessions and continued the same ion. Because this study did not intending (alternating forward and backward exercise progression while the height to quantify the amount of resistancewalking) and 5 minutes of passive of the step was increased in incre- in the water or to increase the surfacestretching. The P group warmed up R ments of 5.08 cm. Subjects usually area of the Hydrotone boot, subjects were instructed to move their in- volved legs through the water as fastHydrotone International Inc, 3535 NW 58th St, Ste 1000, Oklahoma City, OK 73112. as they could. As symptoms decreasedPhysical Therapy /Volume 74, Number 8/August 1994
  5. 5. ware (version 5.1)* were used to calculate and record peak torque (in foot-pounds), and gravity-corrected measurements were obtained. Accord- ing to the manufacturer, the dyna- mometers accuracy is self-calibrated through the computer software pack- age. One tester, who was blind to group assignment, performed all the testing. During the testing session, subjects were positioned with their hips in 80 to 90 degrees of flexion. The hips and tested limb were stabilized with Vel- cro@ straps across the pelvis and over the thigh. Subjects were in- structed to grasp the handrails during the test. The axis of rotation of the dynamometer was aligned with that of the knee, and the lever arm pad was placed 7.62 cm (3 in) below the tibial tubercle. Subjects were allowed a short period of familiarization at each speed. Isometric testing consisted of three maximal 5-second repetitions with the knee flexed 85 degrees to measure knee extension torque and three maximal 5-second repetitions with the knee flexed 60 degrees to measure knee flexion torque. Subjects were given a 30-second rest period be-Flgure 2. Hydrotone resistance boot used by subjects in the water group. tween repetitions. The highest torque value was recorded.and muscle performance improved, tibia on the femur was measured (insubjects increased the speed and millimeters) during 6.8-kg (15-lb) and Isokinetic testing consisted of threecreated more resistance. 9.1-kg (20-lb) Lachman tests. Greater separate contractions at 90°/s with a forces were not used in fear of over- 30-second rest period between repeti-Data Collection stressing the graft during this critical tions. Isokinetic extension was tested period of graft healing. The testers from 80 to 40 degrees of knee flex-Arthrometric measurements.Joint maintained 100% agreement, within ion, and isokinetic flexion was testedlaxity was measured preoperatively 0.5 mm, both with a prior reliability from 0 to 70 degrees of knee flexion.and at 8 weeks following surgery. study and throughout this study. Isohnetic extension was done sepa-Measurements were made by one of rately from isokinetic flexion to pre-two physical therapists (BJT and JC) Muscle performance vent possible shearing during changesusing a KT-1000 knee arthrometer. measurements. Isometric and isoki- in direction. The maximum peakThis device has the highest diagnostic netic peak knee torques were mea- torque for the three repetitions wasaccuracy of five different arthrometric sured at the end of the eighth week recorded for each of the four tests. AUde~ices.~6 Anterior drawer testing was of rehabilitation and compared be- subjects were tested in the sameperformed with the knee flexed 30 tween groups. An electromechanical order.degrees. Anterior displacement of the dynamometer$ and LIDO@AC+ soft- Passlve range of motion measurements. Passive range of+Medrnetric,San Diego. CA. motion (PROM) measurements for knee flexion and extension were$Loredan Biomedical Inc, 2121-B 2nd St, Ste 107, Davis, C 95616. A taken by one of the two physical ther-"elcro U A Inc, 406 Brown Ave, Manchester, NH 03108. S apists using a standard plastic goni-26/714 Physical Therapy/Volume 74, Number 8/August 1994
  6. 6. -Table 2. Results o Analysis o Variance o Dzferences in Joint Laxity MeasurementsSource f df fDuring a 6.8-kg (15-lb) Lachmun Test SS f MS F P The ROM measurements for weeks 2, 4, 6, and 8 were analyzed using a two-way ANOVA (groups X weeks) for repeated measures. A Tukeys pair- wise comparison post hoc test for significance was used for within- group comparisons, and a BonferroniBetween subjects pair-wise comparison was used for between-group comparisons. Groups (A) 1 21 .OO 21 .OO 3.43 ,082 Error 17 104.08 6.12 Girth measurements were calculatedWithin subjects from measurements of girth at mid- Weeks (B) 1 50.84 50.84 8.39 .01 patella and 15.24 cm above mid- AxB 1 0.003 0.003 0.00 ,984 patella. Mean differences were com- Error 17 103.05 6.06 pared at 2, 4, 6, and 8 weeks using tests identical to those undertaken for ROM. The alpha level of significanceometer (17.78 cm [7 in] long with a 100% agreement, within 0.636 cm (Y4 was set at .05.360" scale and 1" increments). The in), both with a prior reliability studytesters maintained 100% agreement, and throughout this study. Resultswithin 5 degrees, both with a priorreliability study and throughout this Functional questlonnalre.A func- Results of the ANOVAs for joint laxitystudy. tional questionnaire was administered measurements, presented in Tables 2 at the end of the eighth postoperative and 3, showed no significant differ-Passive range of motion was mea- week. The questionnaire consisted of ence between groups (F=3.43, 4.04;sured at the beginning of each treat- a Lysholm scale,27 which quantifies df=l,l;P=.08, .06), indicating thatment session at 2, 4, 6, and 8 weeks the functional use o the knee joint f neither program induced more laxitypostoperatively. Subjects were al- using a scale of 0 to 100. This rating than the other. A significant effect forlowed a 3-minute warm-up, which system is a self-report of the subjects time did exist at both the 6.8-kgconsistell of self-stretching within perceived ability of activities such as (F=8.39, df=l, P=.01) and 9.1-kgtheir available ROM. Both measure- walking, stair climbing, and squatting forces (F=24.0, df= 1,P=.0001), indi-ments were taken with subjects posi- and is an accepted method of evaluat- cating that both groups had sign&-tioned supine. Knee extension mea- ing functional impairment.27,28 Higher cantly less joint laxity at 8 weeks aftersurements were taken with a towel scores indicated better functional use surgery compared with beforeroll under the heel of the involved with fewer symptoms. surgery.extremity. Knee flexion measurementswere taken with the hip maintained at Data Management and Analysis Comparison of quadriceps femoris90 degrees of flexion, while the heel and hamstring muscle isometric andwas moved toward the buttocks. End- Side-to-side differences in joint laxity isokinetic peak torque percentagesrange was determined by applying measurements were calculated and (Tab. 4) between groups revealed nooverpressure until firm resistance was used to compare the values between significant differences for isometricmet. The maximum value o threef groups prior to surgery and 8 weeks knee flexion, isometric knee exten-measurements was recorded. following surgery. Mean differences sion, and isokinetic knee extension were compared using an analysis of peak torque percentages. The isoki-Girth measurements. Girth mea- variance (ANOVA). A Tukeys pair-wise netic knee flexion peak torque per-surements were taken by one of the comparison was used for within- centage, however, was significantlytwo physical therapists during the group comparisons, and a Bonferroni higher for the TR group @=96.4,preoperative visit and at 2, 4, 6, and 8 pair-wise comparison was used for SD=13.5) than for the PR groupweeks following surgery. Measure- between-group comparisons. @= 81.7, SD=11.1) (P=.01).ments were taken at the mid-patellalevel and 15.24 cm (6 in) above the Measurements of isometric and isoki- Passive range of motion measure-mid-patella using a standard tape netic peak torque for the quadriceps ments were recorded at weeks 2,4, 6,measure (increments of 0.3175 cm femoris and hamstring muscles were and 8. Table 5 shows that there were[?h with subjects positioned su- in]) normalized to the values of the unin- no significant differences betweenpine with their thigh musculature volved contralateral musculature and groups at each measurement periodrelaxed. These measurement locations expressed as a percentage. The mean (F=0.38, df=l, P=.546). As expected,were used to document changes in peak torque percentage and the mean there was a significant effect for timeknee joint e h s i o n and thigh muscu- Lysholm score were compared be- (F= 116.49,df=3, P=.0001), implyinglar atrophy. The testers maintained tween groups using a Students t test. that knee joint PROM for both groupsPhysical rherapy/Volume 74, Number
  7. 7. -Table 3. Results of Analysis of Variance of Differences in Joint Laxity MeasurementsDuring a 9.1-kg (20-lb)Lachrnan TestSource df SS MS F P between the baseline measurement and the second postoperative week, but no difference existed between groups. Mean Lysholrn scores were significantly higher in the P group R @=92.2, SD=4.31) than in the TR group @=82.4, SD=12.36) (P=.03)Between subjects Groups (A) Error 17 156.20 Lysholm scale measurements showedWithin subjects that the P group scored significantly R Weeks (B) 1 123.73 higher than the TR group at 8 weeks, A x B 1 0.25 indicating that this group had fewer Error 17 87.64 problems with activities o daily living. f Increased pain, based on the subjects self-report, and knee swelling duringimproved over the 8 weeks. At 2 Girth measurements taken at mid- activities of daily living were primarilyweeks following surgery, the first patella and 15.24 cm above mid- responsible for lower scores in thePROM measurement showed that patella were compared between T group. The results of the laxity Rboth groups had an average of 117 knees to determine mean differences and girth measurements may offerdegrees of knee PROM. Both groups (Tab. 6). Between-group analysis possible reasons why the P group Rshowed progressive increments over showed that the P group had less R had higher Lysholm scores.time, averaging 20 degrees between girth than the TR group for each mid-weeks 2 and 4, 8 degrees between patella measurement, but the differ- A 8 weeks following surgery, both tweeks 4 and 6, and 4 more degrees ence was significant only at 8 weeks. groups had less than 3 mm of differ-between weeks 6 and 8. Mean knee No significant difference between ence in joint laxity between the in-PROM for both groups at the end of groups was noted (F=2.09, df= 1, volved and uninvolved knees for boththe 8-week program was 150 degrees. P=.l66). A time effect was shown the 6.8- and 9.1-kg Lachman tests.Post hoc analysis revealed that gains (F=23.45, df=4, P=.0001), as both Neither program induced knee jointin PROM were significant for both groups had a significant increase in laxity, as a laxity difference of 5 3 mmgroups only during the first 6 weeks. girth at mid-patella between the base- is considered normal.29 AlthoughNo significant differences were noted line measurement and the second between-group comparisons revealedbetween groups. There was no signifi- postoperative week. Additionally, both no significant difference, the within--cant groupx time interaction, indicat- groups showed a significant decrease group means at the end of 8 weeksing that change in PROM over time in girth at mid-patella after the second indicated that the T group had Rwas not dependent on assignment. week, but only until week 4. At 15.54 greater than 1.5 mm more laxity for cm above mid-patella, both groups both tests than the P group. The R had significant decreases in girth inability to detect a significant differ- ence between groups may have been due to insufficient sample size. This result may be due to the increased stresses on the knee joint duringTable 4. Means and Standard Deviations for Group Peak Torque Recovery at the rehabilitation on land withEighth Postoperative Week (Percentage of Nonoperative Limbs Peak Torque) in water.l5 Increased knee joint laxity in the surgical knee at 8 weeks could lsometrlc Peak lsoklnetlc Peak have resulted in increased knee joint Torque Percentage Torque Percentage effusion, which may have led to the (07s) (90°1s) lower Lysholm scores.Group % SD % SD Girth measurements taken at 15.24 kg- above mid-patella showed no signs-Traditional rehabilitation (n=9) cant difference between groups for Flexion 85.1 9.1 96.4 13.5 atrophy of the thigh musculature. Extension 43.1 11.6 56.1 9.2 Within-group comparison, however,Pool rehabilitation (n=10) revealed that both groups followed Flexion 83.7 10.6 81.7 1l.l the same significant changes from the Extension 42.8 12.7 50.6 18.1 presurgical measurement until the eighth postoperative week. Both Physical Therapy /Volume 74, Number 8/August 1994
  8. 8. in greater circumferential measurements.Table 5. Results of Analysis of Variance of Dgerences Between Groups in Recoveyof Range of Motion Girth measurements taken at mid- patella showed that the girth for theSource df SS MS F P PR group was consistently less at each time period, but these differencesBetween subjects were significant only at 8 weeks. As discussed earlier, the increased ginh Groups (A) 1 132.61 132.61 0.38 ,546 in the TR group may have been Error 18 6287.63 349.31 caused by the joint effusion resultingWithin subjects from greater stress on the joint dur- Weeks (B) 3 13277.84 4425.95 1 16.49 .0001 ing land exercises compared with AXB 3 48.24 16.08 0.42 ,737 water exercises. This increased joint Error 54 2051.66 37.99 effusion may have led to lower Ly- sholm scores.groups experienced the greatest Thigh girth began to increase after Within-group comparison reveals thatchange between the presurgical mea- the fourth postoperative week, and mid-patella ginh measurementssurement and the second postopera- the involved extremity was within changed similarly for both groups;tive week, with the greatest decrease 1.90 cm (0.75 in) of the contralateral that is, measurements at this locationin girth occurring at the fourth post- extremity by the eighth postoperative were inversely related to the mea-operative week. Thigh musculature week for both groups. Increases in surements taken at 15.24 kg aboveatrophy is commonly observed during thigh girth at this time may be attrib- mid-patella. The greatest increase inthe acutt: postsurgical period due to uted to several factors. As postopera- girth was noted between the presurgi-muscle inhibition that takes place tive joint effusion and pain decrease cal measurement and the secondfrom the increased joint effusion and while ROM increases, the thigh mus- postoperative week, suggesting the-increased pain. DeAndrade et a 3 1O culature can b e exercised through a increased joint effusion that typicallyhave shc~wn that with increased knee greater ROM. As exercises are per- occurs following surgery. These re-joint effusion, there is less muscle formed more vigorously, muscle sults indicate that as joint effusionoutput as measured by electromyo- tissue begins to hypertrophy, resulting decreases, muscle girth increases,graphic activity. with the transition occurring around 4 to 6 weeks following surgery. Between-group comparison for peak torque percentages (PTPs) showedTable 6. Results of Analysis of Variance of Dzffwences Between Groupsfor Girth that the T group had a significantly RMeasurenzents at Mid-patella and 40.62cm (6 in) Above Mid-patella higher PTP for the hamstring muscles at 90°/s, indicating that the traditionalSource df SS MS F P rehabilitation approach was more effective than the pool rehabilitation approach for strengthening the ham-Mid-patella string muscles. This result may have Between subjects occurred for two reasons. First, resis- Groups (A) tance in the water was partially deter- Error mined by the speed of limb move- Within sl~bjects ment, which was controlled by each Weeks (B) subject.16 Subject effort can be affected A x m B by pain and motivation. Therefore,40.64 cm above mid-patella subjects may not have generated Betweeri subjects enough resistance to facilitate maxi- mal strengthening. Hamstring muscle Groups (A) 1 0.006 0.006 0.01 ,933 exercises in the TR group were done Error 17 15.53 0.80 using weights, so resistance was not Within S L J ~ ~ ~ C ~ S self-paced. Second, there is a differ- Weeks (B) ence in the type of muscle contrac- AXB tion that occurs o n land. Empirical Error evidence suggests that an eccentric muscle contraction is important forPhysical Therapy /Volume 74, Number 8/August 1994
  9. 9. restoring muscle perf0rmance.3~This tions resulted in donor site pain (the step-ups, and the land pulleys ap-type of contraction is more likely to anatomical site at which the central peared to be most beneficial for ham-occur on land than in water due to third o the patellar tendon was surgi- f string muscle and hip strengthening.increased gravitational forces. cally removed for use as an au- Isolated quadriceps femoris muscle tograft) in some subjects in both contractions in a safe range usingIn both groups, there was equal effec- groups, which may have altered the open-chain exercises may have bene-tiveness in restoring quadriceps femo- remaining tests. Anterior knee pain is fited both groups.ris muscle strength. These results also common in the early phases of ACLshowed that greater joint effusion in rehabilitation if a patellar tendon Patients using a pool for rehabilitationthe TR group did not significantly autograft is used. Testing isometrically are likely to tolerate an even moreaffect peak torque muscle perfor- and at slow speeds increases the joint aggressive rehabilitation program thanmance. A possible reason for this reaction forces around the patella, but that presented in this study. In thisfinding is that all subjects were tested usually is a better indicator of study, however, exercises in bothin the range of 85 to 40 degrees of strength. Although strength testing in groups had to be carefully matched toknee flexion, rather than at the end- this study provided adequate graft ensure that the main effect betweenrange where joint effusion has been protection, testing at faster speeds first rehabilitation programs was due toshown to s e c t muscle perfonnance.30 and slower speeds at the end of the the environment. The PR group could testing session might have resulted in have performed more advanced exer-The mean PTPs for both groups are better PTP scores. The testing proce- cises, but varying the exercises wouldsimilar to those reported for other dure in this study did not take these have made interpretation of resultssubjects with ACL reconstructions.5 factors into account because at the unclear because differences betweenOther studies,7,8 however, have dem- time the study was proposed, no groups could have then been attrib-onstrated higher peak torque values. published research had incorporated uted to the environment, exercises, orTwo possible explanations for lower isokinetic testing at 8 weeks, using interaction between the two.PTPs in this study are the type of only subjects with patellar tendonquadriceps femoris muscle strength- autografts.ening and methodological factors. Clinical lmpllcatlons Although traditional exercises haveType of Quadriceps Femoris been the treatment choice of mostMuscle Strengthenlng Although a primary goal in the reha- clinicians, the results of this study bilitation of patients with ACL recon- suggest that a rehabilitation programThe method of quadriceps femoris structions is the restoration of quadri- for patients with intra-articular ACLmuscle strengthening in both groups ceps femoris muscle performance, the reconstructions performed in a poolfocused on closed-chain exercises, means of achieving this goal must is more effective in reducing jointwhich may not have provided enough avoid overstressing the graft and in- effusion and facilitating recovery ofisolated stimulus to the quadriceps creasing joint ehsion. Addttionally, to lower-extremity function as indicatedfemoris muscle to facilitate maximum expedite recovery, patients must toler- by Lysholm scores. The results alsostrength gains. Previous studies,7.8 ate the rehabilitation program. Some suggest that rehabilitation in water iswhich demonstrated higher strength patients find postoperative exercises equally effective as on land for restor-gains, applied neuromuscular electri- too uncomfortable because of age, ing knee ROM and quadriceps femo-cal stimulation during open-chain low presurgical activity level, o r low ris muscle strength, but not as effec-knee extension exercises. Both pain tolerance, and progression dur- tive in restoring hamstring musclegroups in this study may have bene- ing the early phases of rehabilitation strength. Clinicians who wish to allowfited from isolated knee extension is limited. maximal weight bearing may find theexercises through a limited ROM (90" adjunct of aquatic exercises 40" of knee flexion to ensure graft Exercises in water may make the total Future studies should analyze theprotection), as recent research find- rehabilitation program more tolera- effectiveness of a program that com-ings indicate that closed-chain exer- ble. Although a complete aquatic bines traditional and water exercises,cises alone may not b e enough to exercise program may be unneces- using larger sample sizes and afacilitate maximum muscle perfor- sary, augmenting a land program with longer follow-up period.mance as measured by isokinetic pool exercises may permit loadingdynamometry.32 the joint to a greater degree. For Acknowledgments patients who are unable to tolerateMethodological Factors traditional exercises on land, water We thank Lynn Snyder-Mackler, ScD, can be used to facilitate progression PT, for assisting with preparation ofChanging the methodology may have to more aggressive exercises. In this this manuscript; Roberto Infante, PT,resulted in higher mean PTPs. Per- study, a water environment was most and the staff at Resurgeons Ortho-forming three 5-second isometric beneficial for facilitating closed-chain paedics for their assistance with dataquadriceps femoris muscle contrac- exercises, such as gait training and Physical Therapy/Volume 74, Number 8/August 1994
  10. 10. collection; and Piedmont Hospital for tions Springfield, Ill: Charles C Thomas, Pub- loskeletal conditioning.] Bum Care Rehabil.use of their facilities. lisher; 1955. 1988;9:203-206. 1 1 Pope MH, Stankewich CJ, Beynnon BD, 23 Bartow L, Diamond L. Resistance Training Fleming BC. Effect of knee musculature on in the Water:An Analysis Comparing the anterior cruciate ligament strain in vivo. Jour- Hydro-tone System to Water Resistance WithoutReferences nal of Electromyography and Kinesiology. a Training Tool in Resistance of the Knee Fler- 1991;1:191-198. ors and Extensors. Boston, Mass: Boston Uni-1 Paulos LE, Payne FC, Rosenberg TD. Rehabil- 12 Whieldon T, Yack J, Collins C. Anterior tib- versity; 1989. Masters thesis.itation after anterior cruciate ligament surgery. ial translation during weight-bearing and non- 24 Gehlsen GM, Grigsby SA, Winant DM. Ef-In: Jackson DW, Drez D Jr, eds. The Anterior weight-bearing rehabilitation exercises in the fects of an aquatic fitness program on theCmciate LkJcient Knee. St Louis, Mo: CV anterior cruciate deficient knee. Phys Ther. strength and endurance of patients with multi-Mosby Co; 1987:291-314. 1989;69:151.Abstract. ple sclerosis. Phys Ther. 1984;64:653457.2 Shelbourne KD, Nitz P. Accelerated rehabili- 13 Henning CE, Lynch MA, Glick KR.An in 25 Napoletan JC. The Efect of Undenvatettation after anterior cruciate ligament recon- vivo strain gauge study of elongation of the Treadmill Exercise in the Rehabilitation of Sur-struction. Am ]Sports Med. 1990;18:292-299. anterior cruciate ligament. Am] Sports Med. gical Anterior Cmciate Ligament Repair. Or-3 Paulos IE, Noyes FR, Grood ES, Butler DL. 1985;13:22-26. ange, Calif: Chapman College; 1990. MastersKnee rehabilitation after anterior cruciate liga- 14 Reynolds NL, Worrell TW, Perrin DH. Effect thesis.ment reconstruction and repair. Am] Sports of a lateral step-up exercise protocol on quad- 26 Anderson AF, Snyder RB,Federspiel CF,Med. 1981 9140-149. riceps isokinetic peak torque values and thigh Lipscomb B. Instrumented evaluation of knee4 Shelbourne KD, Wilckens JH. Current con- ginh. ] Orthop Sports Phys Ther. 1992;15: 151- laxity: a comparison of five arthrometers. Am]cepts in ar~terior cruciate ligament rehabilita- 155. Sports Med. 1992;20:135-140.tion. Orthcp Rev. 1990;11:957-964. 15 Golland A. Basic hydrotherapy. Physiother- 27 Lysholm J, Gillquist J. Evaluation of knee5 Draper V, Ballard L. Electrical stimulation apy. 1981;67:25%262. ligament surgery results with special emphasisversus electromyographic biofeedback in the 16 Edlich RF,Towler MA, Goitz RJ, et al. on use of a scoring scale. Am] Sports Med.recovery of quadriceps femoris muscle func- Bioengineering principles of hydrotherapy. 1982;10:150-154.tion following anterior cruciate ligament sur- J Bum Care Rehabil. 1987;8:580-584. 28 Tegner Y, Lysholm J. Rating systems in thegery. Phys Thet. 1991;71:455-464. 17 Hillman MR, Matthews L, Pope J. The resis- evaluation of knee ligament injuries. Clin Or-6 Draper V. Electromyographic biofeedback tance to motion through water of hydrother- thop. 1985;198:43-49.and rec0vt:r-y of quadriceps femoris muscle apy table-tennis bats. Physiotherapy. 1987;73: 29 Daniel DM, Malcom LL, Losse G, et al. In-function following anterior cruciate ligament 570-572. strumented measurement of anterior laxity ofreconstruction. Phys Thm 1990;70:11-17. 18 Harrison RA,Allard LL. An attempt to quan- the knee.] Bone Joint Surg [Am] 1985;67.720-7 Snyder-Mackler L, Ladin 2, Schepsis Aq tify the resistances produced using the bad 726.Young LC. Electrical stimulation of the thigh ragaz ring method. Physiotherapy. 1982;68:23@- 30 deAndrade JR, Grant C, Dixon AJ. Joint dis-musculature after reconstruction of the ante- 231. tension and reflex inhibition in the knee.rior cruciate ligament.] Bone Joint Surg [Am]. ]Bone Joint Surg [Am]. 1965;47:3542. 19 Harrison Rk A quantitative approach to1991;73:1025-1036. strengthening exercises in the hydrotherapy 31 Albert M. Physiologic and clinical princi-8 Delitto A, Rose SJ, McKowen JM, et al. Elec- pool. Physiotherapy. 1980;66:60. ples of eccentrics. In: Albert M, ed. Eccenmctrical stimulation versus voluntary exercise in 20 Abidin MR, Lobardi SA, Devlin PM, et al. A Muscle Training in Sports and Orthopaedics.strengthening thigh musculature after anterior new hydrofitness device for strengthening New York, NY: Churchill Livingstone Inc; 1991:cruciate ligament surgery. Phys Ther. 1988;68: muscles of the upper extremity.] Bum Care 11-23.661-663. Rehabil. 1988;9:402-406. 32 Reynolds NL, Worrell TW, Perrin DH. Effect9 Ohkoshi Y, Yasada K. Biomechanical analysis 21 Abidin MR, Thacker JG, Becker DG, et al. of a lateral step-up protocol on quadricepsof shear force exerted to anterior cruciate liga- Hydrofitness devices for strengthening upper isokinetic peak torque values and thigh ginh.ment durirrg half squat exercise. Orrhop Trans. extremity muscles.] Bum Care Rehabil. 1988; J Orthop Sports Phys Ther. 1992;15:151-155.1989;13:310. 9:199-202.10 Steindler A. Kinesiology of the Human 22 Goitz RJ, Towler TA, Buschbacher LP, et al.Body Under Nonnal and Pathological Condi- A new hydrofitness device for leg muscu-Physical Therapy/Volume 74, Number B/August 1994