28. appendix g: rehabilitation procedure … · appendix g: rehabilitation procedure ......
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Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries – A Randomized study. Draft date 2001-08-31, version 10 Page:
Print date 2009-04-24
52
28. APPENDIX G: REHABILITATION PROCEDURE Rehabilitation procedure
The rehabilitation procedure follows the general principles described below. The protocol is moderately aggressive but avoids exercises with heavy loads on the graft initially. Each level ends with a set of goals to be achieved before the next level of rehabilitation is started. Time intervals are suggested and not superior to the goals. Pain, swelling and general discomfort slows down the rehabilitation process until each levels set of goals can be achieved without any problems. In addition to the protocol below there will be a bank of exercises coupled to each level of rehabilitation. This bank of exercises is formed by all participating physiotherapists and includes their traditional work with patients with deficient ACL. Anti- inflammatory drugs (NSAID) may be needed. A lack of extension in ROM shall be carefully analyzed and treated, if necessary with arthroscopy, early in the course.
Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries – A Randomized study. Draft date 2001-08-31, version 10 Page:
Print date 2009-04-24
53
0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Unloaded range of motion (ROM)
As tolerated As tolerated Normal Normal Normal
Goals Full extension
Flexion > 120 deg Full extension Flexion comparable to other side
Comparable to other side
Comparable to other side
Comparable to other side
Muscle function Quadriceps: unloaded full control Hamstrings: loaded exercises Exercises for other lower limb muscles and trunk are initiated
Quadriceps: loaded non-weightbearing in 40-120 deg and closed-chain (weightbearing) exercises in 0-80 Hamstrings: full ROM Exercises for other lower limb muscles and trunk
Quadriceps: closed-chain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk
Quadriceps: open-chain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk
Quadriceps: open-chain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk
Goals Full quadriceps
control in sitting and standing
Non-surgical: Less than 10% difference in quadriceps and hamstrings strength between legs
Surgical: Less than 10% difference in quadriceps and hamstrings strength between legs
Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries – A Randomized study. Draft date 2001-08-31, version 10 Page:
Print date 2009-04-24
54
0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Symptoms Pain: tolerated,
treated if necessary Swelling: tolerated, treated if necessary
Pain: tolerated, treated if necessary Swelling: tolerated, treated if necessary
No pain Occasional activity-related swelling tolerated
No pain Occasional activity-related swelling tolerated
No pain Occasional activity-related swelling tolerated
Goals No morning
swelling No pain Occasional activity-related swelling
No activity-related pain Occasional activity-related swelling
No activity-related pain Occasional activity-related swelling
No activity-related pain Occasional activity-related swelling
Walking As tolerated forward and backwards without pain* and limping (initially with crutches)
Full weight-bearing Daily walking without restrictions
Full weight-bearing Slow and fast walking on treadmill
Full weight-bearing Running on treadmill/even surface Non-surgical: Unrestricted running
Full weight-bearing Surgical: Unrestricted running
Goals Full weight-bearing
without pain or limping Crutches may be discharged when patient is able to walk backwards without limping
Full weight-bearing Walking without pain or limping
Full weight-bearing Walking without pain, swelling or limping
Full weight-bearing Non-surgical: Running without pain, swelling or limping
Full weight-bearing Surgical: Running without pain, swelling or limping
Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries – A Randomized study. Draft date 2001-08-31, version 10 Page:
Print date 2009-04-24
55
0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Balance/ Coordination
One-leg standing in functional positions
One-leg standing in functional positions on soft ground and Babs-board
One-leg standing in functional positions on more demanding surfaces and Babs- board
One-leg standing in functional positions on more demanding surfaces Two legged bounces Easy sport-specific movements Easy agility exercises
One-leg standing in functional positions on more demanding surfaces One legged bounces Provoked sport-specific movements Provoked agility exercises
Goals One-leg standing
without difficulties Comparable to other side
Comparable to other side
Non-surgical: One-legged hop and square-hop1 less than 10% difference between legs
Surgical: One-legged hop and square-hop1 less than 10% difference between legs
Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries – A Randomized study. Draft date 2001-08-31, version 10 Page:
Print date 2009-04-24
56
0-4 weeks 5-8 weeks 9-12 weeks 13-16 weeks 17-24 weeks Activities Unloaded and
loaded biking on stationary bike backwards and forwards with clips
Biking on stationary bike without restrictions Wet-vest exercises and running in deep water Non-surgical: Outdoor biking without restrictions
Biking on stationary bike without restrictions Wet-vest exercises and running in deep water Slide-board training
Non-surgical: Introduction of sport-specific exercises Surgical: Outdoor biking without restrictions
Surgical: Introduction of sport-specific exercises
Goals Unloaded biking
forward with clips Non-surgical:
Back to pre-injury activity level
Surgical: Back to pre-injury activity level
Action if goal is not reached
If ROM, Symptoms, Weightbearing goals are not reached: Doctors Visit
*As tolerated = acceptable pain according to Pain Monitoring System Visual Analog Scale 5 (0-10) (Thomeé 199?) 1Östenberg et al 1998
Phase 1
2-7 days after injury/operation (home practice)
Mobility:
Lay on your stomack, bend your knee and lift it against the ceiling
Vastus medialis:
Sit with your X-leg slightly bent with a ball under it.Put the foot against the wall and press the knee towards the ground. Keep the tension in the thigh.
Sit on a chair and stand up controlled with even loadon both feet.
Approximately 2-4 weeks after injury/operation
Mobility:
Start using bicycle, 8-12min.
Lay on your back with your hips and knees in 90` angle with your feet against the wall. Slide your X-leg up and down.
Vastus medialis:
Stand with your back against the wall and a softballbehind your X-knee. Squeeze the ball against the wall.
"Norwegian push-ups"Have a ball between your knees, bend and stretch.
Stand on the floor, step up on a board
...in front
...sideways
Legpress, start at 90`degrees and stretch your knees.
Kneebend with a stick, the hips shall be rotated outwards.
Hamstrings:
Lay on your back with the X-knee on the pillow, keep your handsaround your other knee. Lift your pelvis.
Lay on your back with both legs on the pillow. Lift your pelvisand alternately move your legs sideways one at the time.
Triceps surae:
Stand with your X-knee slightly bent on the step.
Take one step up with your X-leg and stretch your knee.
Tensor fascia latae:
Lean towards the board with the X-knee. Lift your hip away fromthe board together with the other leg.
Balance:
Stand with your X-knee on a balanceboard.
Stand with your X-leg on the trampoline, bend your knee slightly.
Stand with your weight on your X-leg and glide with your other leg sideways and back again, have a small towell under your foot.
GOALS FOR PHASE 1: Full extention Flexion>120 degrees
Phase 2:
Approximately 5-8 weeks after op/injury
Quadriceps:
Legpress, full ROM
Stand up from the chair using only your X-leg.
"Stairsteptraining", bend your X-knee deeper.
Stand on your X-leg, keep balance with your hands, smallquick kneelifts.
Balance/Proprioception
Stand on your X-leg, pull with your other arm forwards and down.
Stand on your X-leg, have the pully around the other leg and pull in all four directions.
Stand with your X-leg on the balanceboard and throw a ball in the air.
Hamstring:
Lay on your back on a board with your X-leg on a Boobathball,hold around your well leg. Lift your pelvis.
Triceps surae:
Stand on your X-leg placed on a tilted board, and the other leg on the floor. Go up on your toes while your knee stretches and take the other leg forward and up.
Complementing treatment: Mobilising patella Stretching of tractus iliotibialis Stretching of quadriceps Stretching of hamstrings
GOALS FOR THE PHASE 2: Full control of quadriceps Easily stand on X-leg.
Phase 3
Approximately 9-12 weeks after op/injury
Lunge in different directions.
Rubberbandstraining
"Quick walk" on a thick math with a rubberband aroundyour waist.
GOALS FOR PHASE 3: Walk fast without limping, pain or swollness. Do onelegged kneebendings to at least 60 degrees kneeflection.
Phase 4:
Approximately 13-16 weeks after op/injury
Jogging
Lunge with medicinball to both sides.
Sidestep from stepboard with deep kneebends.
Leg extentions
Stand on your X-leg with your other leg on a pillow.With weights in your hands, do kneebends.
Have a ball between your legs and jump up and downon several stepboards with even legs.
GOALS FOR PHASE 4: <10% differense in onelegged jump. <10% differense in legpresstest. No differense in balance.
Tests: One-legged jump Balance "Stand up" Kneextentions/flexions