This document discusses concepts and applications for knee rehabilitation. It covers several key points, including how injury affects proprioception, gait, and recovery duration. Specifically, it notes that an ACL injury can decrease proprioception for 1-3 years and alter muscle activation timing and recruitment. It also discusses developing a neuromuscular rehabilitation program with a functional focus, using exercises that provide cognitive sensory-motor challenges to facilitate motor learning. Finally, it emphasizes taking a functional approach to rehabilitation by using a patient's own movement patterns whenever possible.

1. Knee Rehab
Novel Concepts
&
Application
B.KANNABIRAN

2. Existing
• Home Versus Supervised
Therapy
• Home Exercise Versus
Weight Machines
• Aquatic Therapy
• Open Versus Closed
Chain Exercise
• Progression Based on
Objective Criteria
What's new?

3. Critical Points EFFECTS OF INJURY ON
PROPRIOCEPTION,
GAIT, AND DURATION OF INJURY
• A decrease in proprioception
and kinesthesia occurs after
anterior cruciate ligament (ACL)
injury. Changes that occur
within the joint affect normal
recruitment and timing patterns
of the surrounding musculature.

4. Critical Points EFFECTS OF INJURY ON
PROPRIOCEPTION,
GAIT, AND DURATION OF INJURY
• After ACL rupture, patients
walk with greater hamstring
activity, a flexed knee, and
minimal to no quadriceps
electro myographic activity.
• Altered proprioception of
the knee joint may last 1 to
3 yr after injury.

5. Critical Points EFFECTS OF INJURY ON
PROPRIOCEPTION,
GAIT, AND DURATION OF INJURY
• There is a significant decrease in muscle
activation timing and recruitment order in the
lower extremity in response to anterior tibial
translation in ACL-deficient knees compared
with uninjured controls.

6. ARTHROGENIC INHIBITION

7. Critical Points LOWER EXTREMITY
MUSCLE STRENGTH
RECOVERY AFTER SURGERY
• Abnormal gamma loop function in quadriceps
muscles from lack of normal sensory function
(loss native ACL mechanoreceptors) in the
reconstructed ACL.
• Non-optimal activation of muscles during
voluntary contraction in ACL-deficient knees.

8. Developing a Neuromuscular
Rehabilitation program
• 1. The focus on functional
movement
• 2. The principle of
skill/ability level
rehabilitation
• 3. The code for motor
adaptation
….that ought to
participate in this
particular
movement &
accompany the
stabilization of the
body.

9. Neuromuscular exercises
– do they exist?
• Peripheral plasticity –
muscle, the acrobat of
adaptation
• Neuromuscular
rehabilitation is not just
about exercising.
It is about providing cognitive
sensory-motor challenges
that will facilitate motor
learning/adaptation.

10. A functional approach
in KNEE Rehabilitation
• Functional movement is
defined here as the
unique movement array
of an individual.
• Functional rehabilitation of a
person to recover their
movement capacity by using
own movement repertoire
(whenever possible)

11. A functional approach
in KNEE Rehabilitation
• However, rehabilitatio
n is likely to be less
effective if the
remedial movement
patterns or tasks are
outside the
individual’s
experience
(extra-functional).

12. A functional approach
in KNEE Rehabilitation

13. Rehabilitation levels:
skill and
ability level KNEE Rehabilitation
• The center of attention in
this form of movement
recovery is on the overall
skill of performing the
particular
movement, which is
loosely referred to as skill
rehabilitation

14. The code for neuromuscular
adaptation

15. “Simplified complexity” in tensional
fields.
Shaded circles represent tension created
by muscle groups

16. MOTOR COMPLEXITY MODEL

17. Neuromuscular Rehabilitation in Manual
and Physical Therapies , Eyal Lederman 2010

18. The motor system as a process. The
inner circle represents processes occurring at
reflexive, sub-awareness level.

19. The comparator system identifies
movement
irregularities/errors.

20. Change in proprioceptive acuity
Damage to proprioceptive apparatus peripherally combined with nociception will result in
unrefined motor output.

21. Experiences that contain the five code
elements are more like to promote
adaptive changes within the
neuromuscular system resulting in
movement and behavioural changes.

22. The transition from cognitive to
autonomous phase during motor learning.
Throughout the transition some elements
will remain cognitive and autonomous.

23. ADAPTIVE CODE & PHYSICAL
STIMULATION FOR PROPRIOCEPTION

24. To treat or not to treat
• Can the motor changes lead to further injury
or progressive damage?
• The primary aim of neuromuscular
rehabilitation is to help individuals to recover
their control movement. It is unknown if
rehabilitation would confer protective
function against progressive tissue damage in
the future.

25. Optimal functional activity

26. A functional approach

27. A functional approach

28. Merging the adaptive code
with rehabilitation Similarity spheres

29. Rehabilitation
Similarity spheres

30. Context and specific injury
rehabilitation
(the amazing clinical shortcut)

31. Amazing clinical shortcut

32. Beyond the session: creating
a challenging environment
for repair and adaptation

33. challenging environment

34. Complexity
• Complexity rules! Don’t become lost in the
labyrinth of the neuromuscular system; look
at the whole, not at minute details.

35. Creativity
• Neuromuscular rehabilitation is a creative process;
it is not protocol-based. Every patient is different
and presents with new challenges. You will forever
have to problem-solve on your feet.

36. Clinical certainty is uncertainty
• The only clinical certainty is uncertainty – don’t
fight it, learn to work with it. You will never know all
the answers but you will be expected to provide
expert care.

37. Finally Think movement not muscles.
• There is nothing like one
brain to stimulate another.
• Make it fun, interesting
and continuously
challenging.

38. Functional approach composite abilities

39. Functional approach composite
progression

40. Functional Approach Rehabilitation
(Re–abilitation)

41. Functional Approach Rehabilitation
(Re–abilitation)

42. Functional Approach Re-abilitation

43. Functional approach
Advanced composite workouts

44. Balance/postural
stability challenge.
Balancing on the
affected
side and drawing
imaginary
numbers from 0-
10 with the
unaffected side.
Demonstration

45. challenge to balance/postural stability
• Unexpected
challenge to
balance/postural
stability can be
introduced by
multidirectional
perturbations
provided by the
practitioner.

46. The Future Trends in
Rehabilitation/ RE-ABILITATION
• The Facility
• Influence of Technology
• Recognizing the importance of progressing
rehabilitation objectively and preventing the
detrimental effects of immobilization, but also
protecting the integrity of healing tissue.

47. Take Home
• One is the restoration of neuromuscular control
almost immediately after surgical procedures to
the knee joint to prevent deafferentation
of the joint.
• The progression of the patient must be
increased gradually, and therefore, it is the
responsibility of the therapist to find a balance
between a detrimentally slow progression and
advanced techniques prematurely that could
have dangerous results.

48. • Teamwork
• Goals
• Communication
• Motivation
• Compliance
• Reinforcement
• Managing Complications
• Optimizing Results
• Rehabilitation Protocols
• Healing Tissue Should Never Be Overstressed
• Preventing the Detrimental Effects of Immobilization
• Cardiopulmonary Conditioning
• Program Based on Current Research & creativity

50. Refereces
•Hole CD, Smit GH, Hammond J, et al. Dynamic control and conventional strength ratios of the
quadriceps and hamstrings in subjects with anterior cruciate ligament deficiency. Ergonomics
2000;43(10):1603–1609.
• Patel RR, Hurwitz DE, Bush- Joseph CA, et al. Comparison of clinical and dynamic knee function
in patients with anterior cruciate ligament deficiency. Am J Sports Med 2003;31(1):68–74.
• St Clair Gibson A, Lambert MI, Durandt JJ, et al. Quadriceps and hamstrings peak torque ratio
changes in persons with chronic anterior cruciate ligament deficiency. J Orthop Sports Phys Ther
2000;30(7):418–427.
• Konishi Y, Ikeda K, Nishino A, et al. Relationship between quadriceps femoris muscle volume
and muscle torque after anterior cruciate ligament repair. Scand J Med Sci Sports 2007;
17(6):656–661.
• Berchuck M, Andriacchi TP.Gait adaptations by patientswho have a deficient anteriorcruciate
ligament. J BoneJoint Surg Am1990;72A:871–877.
• Thambyah A, Thiagarajan P,Goh Cho Hong J. Knee jointmoments during stair climbing of
patients with anterior cruciate ligament deficiency. Clin Biomech (Bristol, Avon)2004;19(5):489–
496.
• Robon MJ, Perell KL, Fang M,et al. The relationship betweenankle plantar flexor muscle
moments and knee compressive forces in subjects with andwithout pain. Clin
Biomech(Bristol, Avon) 2000;15(7):522–527.
• Shrader MW, Draganich LF, Pottenger LA, et al. Effects of knee pain relief in osteoarthritis on
gait and stair-stepping. Clin Orthop Relat Res 2004; (421):188–193.
• Mu¨ndermann A, Dyrby CO, Hurwitz DE, et al. Potential
strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying
severity: reduced walking speed. Arthritis Rheum 2004;50(4):1172–1178.