Dengan Nama Allah,yang tidak memberikan mudarat sesuatu di bumi dan juga di langit dan dia maha mendengar lagi maha mengetahui..

Saturday, September 26, 2015

Physiotherapy for ACL protocol Guideline.

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...

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