Post anterior cruciate ligament protocol of recovery

ACL protocol guideline
Bismillahirahmanirahim ,
For this entry i would like to share one of the protocol of the guideline after went
Anterior Cruciate ligament Replacement patella tendon autograft.

ACL RECONSTRUCTION REHABILITATION  PROTOCOL

PROCEDURE :PATELLA TENDON  AUTOGRAFT 

GENERAL CONSIDERATION

1.         Pre-surgical phase to explain the protocol ,condition ,non injured extremities

2.         Shown  post –op basic quad /hamstring /gastroc exercises

3.         Gait training  instruction with crutches  -FWB as soon as tolerated

STAGE 1

GOAL

·         Reduce pain/oedema  and swelling

·         Promote muscle activity and strength

·         Maximum protection of graft

EVALUATION

1.      Pain and swelling

2.      Quadriceps contraction

3.      Patella mobility

4.      ROM

TREATMENT

DAY 1

·           Brace locked 0 degree and worn 24 hours (keep extension 0 degree)

·           Ice and elevation of knee – compression wrap should  be warn  to control swelling

·           Active calf and ankle pumping

·           Heel slides (as tolerated )

·           Static quads  to SLR

·           Stretching  hamstring and gastroc

DAY 2

·           CPM (0- flexion as tolerated –heel slides

·           Active /assisted ROM as tolerated

·           Knee brace  locked at 0 degree (aggressive  measure  must be taken  to regain extension )

·           PWB to FWB as tolerated –with bilateral axillary crutches

·           SLR  for quads (multiple angle )/isometics

·           Balance /weight  shifting

·           Soft tissue treatment –gentle patella mobs and incision

·           Hamstring set /slides ,resisted  exercises  with sand bag /theraband

·           Hip abduction /adduction

·           Stretching hamstring and gastrocnemius  

·           Finish  with ice /IFT /current stimulation VMO

DAY 3-4

·           Continue CPM and increase ROM as tolerated

·           PWB to FWB as tolerated

·           Start active /resisted exercises  with sand bag /theraband

·           Patella mobility

·           Prone lying –prone hang  for extension 

·           Finish with ice /IFT/current stimulation

DAY 4-7

·           Discharge  home –continue physio as out patient daily

·           Achieve  full extension knee /SLR /no ext lag

·           Continue CPM  until FROM

·           Continue strengthening and stretching exercises for gastroc /calf raise up on steps

·           Leg press <90 -0

·           Continue with modalities and ice .

WEEKS  1

GOALS

·         PROM 20-70 degree

·         control of inflammation and effusion

·         prevention of adhesion of patellofemoral  joint

·         WBAT

·         Quadriceps set with patella movement

·         promote muscle activity and strength

EVALUATION

1.      pain

2.      heamathrosis

3.      patella mobility and ROM

4.      quadriceps contraction

TREATMENT

·      Pain management and control of hemarthrosis  with ice ,EGS ,elevation ,ankle pumps 5’/hours  for circulation

·      Mobilisation of patella for 5 minutes /4x/day

·      Rom exercises :heel slides /prone curl

·      Muscle reeducation :Quad set ,hamstring set ,SLR in 2 position 10 sec x10 /SLR in supine ,electrical  stimulation /biofeedback as needed for VMO  reeducation

·      Start stepper

·      ROM brace 0-90 degree (open brace for quad function )

·      Still locked in extension for sleep

·      Balance  and proprioceptive  exercises

WEEKS 2-3

GOALS

1.      Stitches /staple out at 2 weeks post op

2.      PROM 0-125 degree /AROM >110degree

3.      Quadriceps muscle control

4.      Control  of inflammation and effusion  to prevent scaring

5.      WBAT  with crutches

6.      Normal patella mobility

7.      Prevent of quadriceps  athropy

EVALUATION

1. Pain and effusion

2. Patella mobility

3. ROM

4. Muscle control

TREATMENT

·      Continuation pain management and effusion  control with ice , elevation ,continuation  of ankle pumps

·      Continuation  of patella  mobility

·      ROM : heel slides  ,AAROM  on bike  with no resistance (cycle with high reps /low torque),continuation of CPM  until achievement of 0-120degrees

·      Continuation of electrical stimulation biofeedback for VMO until good quad set with full patella movement

·      Strengthening exercises :

Ø  4 ways SLR ,beginning  weight proximal –distal  when patient has good knee control

Ø  Prone curl

Ø  Sitting hip flexion ,weight proximal

Ø  Pillow squeezes adduction

Ø  Leg press are used within a pain free range of motion /stepper

Ø  Weight –bearing exercises begin when 50% WB

Ø  -toe raise  on step

Ø  Mini squat /mini wall squats -45 degree –progression from standing both legs to single leg

·      Balance board

·      Continuation of ROM brace 0-120 degree

·      Water exercises may be recommended –home progress such as knee bending /straighthening  and pool  walking with emphasis on forward /backward and sideways movement –depend on surgical area

·      Progression using a stairs ,stepper from sitting position to a standing position at 3-4 week if good quadriceps  control present .

CRITERIA FOR PROGRESSION FROM ACUTE  PHASE TO RECOVERY PHASE

1.             Pain and effusion control

2.             ROM 5-115 degrees

3.             Quadriceps control ,ability to lift 8-10 lbs for SLR

4.             Ambulation single crutches to independent –no crutches if possible

RECOVERY PHASE

WEEK 4-8

GOALS

1.      ROM 0-135 degree push  full ROM with normal patella mobility

2.      100% FWB with a normal gait and coordination

3.      Improvement of muscular endurance and control

4.      Control of inflammation and effusion

5.      Fit with functional brace

EVALUATION  

1. Pain and effusion

2. Patella mobility and ROM

3. Complete extension

4. Gait

5. Muscle control

TREATMENT

·         Continuation of pain management /effusion control

·         ROM  ,flexibility (quad ,hamstring ,gastroc, illiopsoas )

·         Strengthening /endurance training ;closed chain ,isotonic ,bike (increase resistance )

·         Balance training(balance board ) ,bilateral stance activities progressing to single stance

·         Addressing of gait abnormalities –gait training on the treadmill ,using slight incline and progress to pedaling backward

·         Functional brace

·         Calf stretching and strengthening , cont all previous hamstring exercises

CRETERIA FOR PROGRESSION FROM RECOVERY PHASE TO FUNCTIONAL PHASE

1.             Absence of effusion

2.             Joint stability 

3.             FWB with normal gait

4.             Performance of ADL without pain

5.             Knee ROM 0-135 degree to FROM

MAINTENANCE PHASE

WEEKS 8-24++

GOALS

1.      Increase in strength and endurance so that there is no fatigue with ADLs

2.      Preparation for return to sport activity

3.      Sport –specific training to full return to athletic activity

4.      Full ROM of the knee

EVALUATION

1.      Swelling

2.      PF mobility and crepitus

3.      Ligament stability

TREATMENT

·           Increase in isotonic exercises :per iodization or daily adjustable progression resistive exercises (DAPRE);initiation  of isokinetics  midrange velocity Q/H ,initiation of quads isotonics 90-30 degree with care for PF symptoms

·           Aerobic conditioning :low –impact bike ;stairs masters ,treadmill ,swimming

·           Proprioceptive  training :progress to closed chain  rehabilitation exercises /balance board

·           Progression to jogging when medically cleared –individual progress

·           Progression in sport –specific activity

·           Maintenance and improvement in neuromuscular strength

·           Cross over walking /figure of eight  

·            

CRITERIA FOR PROGRESSION FROM STAGE 111 TO RETURN TO SPORT

1.             Absence of pain

2.             Isokinetics test 80 % of uninvolved leg

3.             Satisfactory clinical exam by physician

4.             Normal performance of sport –specific exercises 

Note :this general guideline for ACL Reconstruction .The exercises programs may be advance if patient tolerate more but careful assessment of laxity ,increases effusion  or pain  must be monitored by Physiotherapist .

Patient with collateral ligament  involvement  may need  to avoid certain  exercises in first 6 week period post-op ,however  those  with meniscus  involvement  should have no problems with this rehabilitation  programs .

Wallahuaklam...

Best Exercise prevention of Osteoporosis

Exercise for prevention of osteoporosis

Bismillahirahmanirahim...
I this entry just want to share with you , what is important of the exercise for prevention of osteoporosis.

Osteoporosis bone

Vs

Healthy Bone

RISK  FACTORS  FOR OSTEOPOROSIS

·         AGE    - >menopause (women)

Ø  60 years (men)

·         SEX    -  1 in 3 women; 1 in 12 men

·         ETHNIC GROUP – Caucasian; Asian

·         FAMILY HISTORY

·         EARLY MENOPAUSE – or surgical

·         BODY TYPE – thin body structure

·         OTHER DISORDERS, e.g., Anorexia; RA; Ankylosing Spondylitis

CONTROLLABLE FACTORS

·         Long Term DRUGS - steroids

·         LACK OF EXERCISE – general physical inactivity

·         LACK OF DIETARY CALCIUM & Vit. D

·         ANOREXIA/AMENORRHEA

High Intake of:          

·         ALCOHOL

·         TOBACCO

·         CAFFEINE

WHY EXERCISE IS SO IMPORTANT

·         Osteoporosis is a major health problem as it leads to weak bones & if left untreated can lead to poor posture, reduced ability to carry out normal daily activities, and even lead to fractures (broken bones)

·         Exercise has been proven to help both prevent and treat osteoporosis by improving the density of bone and slowing the loss of bone density often associated with menopause

EXERCISE FOR PREVENTION

·         Exercise can help women with normal bone mass who may be “High Risk”  or others keen to reduce the risk of developing problems

·         People with osteopaenia (early, but not serious changes in bone mass)

·         People already diagnosed with osteoporosis but who are still active

WHAT TYPE OF EXERCISE?

·         Weight bearing aerobic exercise is mainstay of  bone-loading exercise programme where weight is put through the bones to help strengthen them

·         This is supported by specific exercises to strengthen against resistance, which help strengthen bone where the muscles attach

·         In Malaysia – many women complain of knee pain which led us to adapt the class by introducing the physio gym ball - to cushion the knees

AIMS OF AN EXERCISE CLASS

·         Increase Peak Bone Mass as a preventive step

·         Maintain or increase bone density in those diagnosed with minor bone changes, or deemed “At Risk”

·         Reduce the early rapid bone loss following menopause

·         Improve muscle strength, balance and cardio-vascular fitness levels

·         Improve Posture

·         Improve feeling of general well-being

·         Provide education

A WELL-DESIGNED PROGRAMME

·         Integrate different levels of activity and varying intensities of impact

·         Gradually progress the degree of impact and intensity

·         Develop according to members’ increase in fitness and strength

·         Accommodate any other health problems, e.g., knee Osteo Arthritis

STRENGTH TRAINING

·         Should be site specific

·         Should target high risk parts of the body, i.e., those prone to fracture

·         Radius/Ulnar (Wrist)

·         Neck of Humerus (Shoulder)

·         Neck of femur (Hip)

·         Thoracic and lumbar spine (upper and lower back)

ON THE BALL

·         POSTURE – how to sit upright

·         Hips should be bent < 90 degrees, knees and ankles at 90 degrees with feet flat on the floor

·         Weight should pass through your heels and “sit” bones of your bottom

·         Relax with your shoulders down

·         Imagine you’re being pulled up by a string at the top of your head

BALANCE TRAINING

·         Balance Training is important in anyone with poor bone density

·         Exercises lifting one leg or moving  your arms through space whilst on the ball challenge and train your balance reactions

·         This also strengthens your internal core muscles (deep tummy, back and pelvic floor muscle groups)

BOUNCING ON THE BALL

·         Cardiovascular exercise can be carried out safely sitting on the ball to protect your knee joints and cushion your pelvic floor

·         Moving your arms and legs increases the work of the heart & challenge to balance

·         Pelvic floor and inner tummy muscles are strengthened whilst balancing on the ball

·         “Holding” for one count in half-standing position helps strengthen thigh muscles and areas of bone where muscles attach

WEIGHT BEARING THROUGH ARMS

·         Exercises putting weight through the upper limbs helps strengthen the ulnar and radius (wrists) and upper arm (humerus)

·         If done over the ball exercises can also strengthen the internal tummy, back, and pelvic floor simultaneously

RESISTED STRENGTHENING EXERCISES

·         Resistance bands can be used to increase the work during strengthening exercises

·         Upper limb strengthening for biceps, triceps, upper back, shoulders

·         If exercises are done whilst sitting on the ball the challenge to our balance and core control is increased making internal tummy, back and pelvic floor group of muscles work harder

SPINAL EXTENSION

·         Strengthening the upper and lower back is universally important but especially for those with low bone density – to help avoid spinal osteoporotic fractures

·         Many women have stiff and weak upper backs – active extension exercises can help increase flexibility as well as strengthen vulnerable bones (thoracic)

·         Lower backs also need strengthening (lumbar spine)

BACK STRENGTHENING

·         Common physiotherapy exercises  for back strengthening can be adapted with the ball

·         The ball helps support the trunk but increases the challenge to balance

·         Core control is improved whilst active exercises strengthen the back extensor muscles and spinal bones

HIPS – ANOTHER DANGER AREA!

·         Full-blown osteoporosis sufferers  have a high risk of hip fractures from  falls (especially later in life)

·         It is very important to maintain bone density at the hips

·         Specific strengthening exercises with resistance have been shown to build bone density by stimulating the area of bone where the muscles attach

COOL DOWN & STRETCHING

·         Every exercise class ends with a period of gentle slowing down

·         This “Cool Down” allows the heart rate and body to return to normal

·         Stretching helps improve flexibility, maintaining equal muscles lengthen

·         Keeping muscle groups flexible helps balance the work of the front and back muscles of the body

·         Balanced muscles help us maintain good posture and function more effectively

LIFESTYLE CHANGES!!

·         To ensure on-going protection against bone changes you MUST make exercise a part of your normal daily life

·         Changes can be seen in your bone density after 9 months of exercising

·         If around menopause it may just slow your on-going loss of bone density

·         BUT benefits disappear once you stop exercising!!

SO MAKE THE CHANGE!!

Make exercise part of your life and extend the life of your bones!

Wallahuaklam…