4/26/2017. Disclosures. Early rehabilitation following ACLR: are we doing enough? Common impairments after ACLR. Objectives

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1 Disclosures Early rehabilitation following ACLR: are we doing enough? None Laura Schmitt, PT, PhD Associate Professor of Physical Therapy, School of Health and Rehabilitation Sciences Ohio State University OSU Sports Medicine, Jameson Crane Sports Medicine Institute Objectives Discuss o persistent quadriceps femoris (QF) strength deficits o impact of QF strength deficits on function o impact of QF strength deficits as an underlying impairment of altered movement patterns Review objective measures of QF strength (lab) Common impairments after ACLR Pain Limited joint ROM Joint effusion Muscle weakness Decreased muscle activation Altered joint loading Poor neuromuscular control Common impairments after ACLR Pain Limited joint ROM Joint effusion Muscle weakness Decreased muscle activation Altered joint loading Poor neuromuscular control Common impairments after ACLR Pain Limited joint ROM Joint effusion Muscle weakness o Quadriceps!!! o Graft type Decreased muscle activation Altered joint loading Poor neuromuscular control 1

2 Persistent QF weakness Involved limb QF weakness o At return to sport (RTS) (Schmitt 2012) 55 participants following unilateral, primary ACLR Average age 17.3 years 40 females, 15 males 29 PT BTB, 20 HS, 6 AL 44% Persistent QF weakness Involved limb QF weakness o At RTS (Palmieri-Smith 2015) Persistent QF weakness Involved limb QF weakness o At RTS (Schmitt 2012; Palmieri-Smith 2015) 66 participants following unilateral, primary ACLR Average age years 25 females, 41 males All PT BTB 63% o Up to 2+ years following ACLR (Kuenze 2015; Otzel 2015) Why is QF strength important? Why is QF strength important? Early marker of successful outcome at RTS Marker of successful outcome at RTS Marker of successful outcome after RTS 2

3 early early n=24 QF strength LSI at ~3 months patient-reported function at RTS IKDC score (r=0.49, p=0.02) KOOS pain (r=0.45, p=.03) KOOS sports (r=.47, p=.02) n=26 QF strength LSI at ~3 months performance-based function at RTS single hop (r=0.49, p=0.01) triple hop (r=0.55, p<.01) cross over hop (r=.40, p=.05) Zwolski 2017 (CSM) Paterno 2017 (CSM) early early QF strength LSI at ~3 months a predictor of knee confidence at RTS (sensitivity = 0.769, specificity = 0.846) QF strength LSI at ~3 months Confident group = 84.8% Lacking confidence = 73.1% (p=.05) QF strength at 3 months movement patterns during jogging at 6 months knee flexion excursion knee extension moment Paterno 2017 (CSM) Kline 2016 early Why is QF strength important? Early marker of successful outcome at RTS early QF strength function at RTS performance at RTS knee confidence at RTS knee mechanics during jogging at 6 mos Marker of successful outcome at RTS Marker of successful outcome after RTS 3

4 n=55 worse IKDC score at RTS Schmitt 2012 Schmitt 2012 n=55 Weaker QF strength at RTS worse hop test performance at RTS QF strength symmetry at RTS predicted hop test performance beyond graft type presence of meniscus injury knee pain knee symptoms Schmitt 2012 Schmitt 2012 Weaker QF strength at RTS greater asymmetry during landing (LQ) HQ=CTRL Schmitt 2015 Schmitt

5 QF strength QF strength symmetry at RTS predicted landing symmetry beyond graft type meniscus injury knee pain knee symptoms Schmitt 2015 Ithurburn 2015 greater asymmetry during landing knee flexion excursion greater asymmetry during landing knee flexion excursion trunk flexion angle Ithurburn 2015 Ithurburn 2015 QF strength greater asymmetry during landing knee flexion excursion trunk flexion angle internal knee ext moments QF strength at RTS function at RTS performance at RTS symmetry in landing mechanics at RTS Ithurburn

6 Why is QF strength important? marker of success after RTS Early marker of successful outcome at RTS Marker of successful outcome at RTS Marker of successful outcome after RTS worse function 1 year later IKDC score KOOS sport Altenburger (2016, CSM) marker of success after RTS marker of success after RTS worse triple hop 1 year later greater landing asymmetry 2 years post-rts vertical GRF (trend) loading rate Altenburger (2016, CSM) Ithurburn 2017 (CSM) marker of success after RTS How do I objectively measure QF strength? QF strength at RTS function at 1 year post-rts performance at 1 year post-rts symmetry in landing mechanics at 2 years post-rts additional analysis ongoing 6

7 Sports Section Survey N=719 How do you assess quadriceps strength? % of Respondents DO Not Assess quad strength MMT HHD Isokinetics Functional Use another Analysis method to assess quad strength 99% use more than one method Dynamometry o Isometric/isokinetic evaluation Peak torque symmetry Dynamometry o Isometric/isokinetic evaluation Dynamometry o Hand-held (Whiteley 2012) Peak torque symmetry raw/normalized value 31 mos post-aclr, QF strength > 3.00 Nm/kg good patient function (KOOS) (Kuenze 2015) High inter-rater reliability ICC (2,1): Moderate to good correlation with isokinetic dynamometry (60, 300 deg/sec) QF: HS: Other tests o 1-repetition maximum test (Sinacore 2016) Calculating symmetry o Limb Symmetry Index (aka: Quadriceps Index) High clinical agreement with isometric testing on isokinetic dynamometer Knee extension 90 to 45 (ICC: 0.67) Handheld dynamometry (ICC: 0.70) Overestimation of symmetry consider more stringent symmetry values Ft-lbs/BW Limb Symmetry Index (LSI): (involved value/uninvolved value)*100% INV UNIN LSI: (1.78/1.90)*100% 93% Ft-lbs/BW INV UNIN LSI: (1.26/1.70)*100% 74% 7

8 Calculating symmetry o Limb Symmetry Index (aka: Quadriceps Index) Limb Symmetry Index (LSI): (involved value/uninvolved value)*100% Acknowledgements Colleagues at OSU and CCHMC Mark Paterno PT, PhD, SCS; Staci Thomas MS Matt Ithurburn DPT and team 2 Ft-lbs/BW INV UNIN LSI: (1.78/1.90)*100% 93% Target LSI at RTS > 90% (for young active population) Funding sources F32-AR laura.schmitt@osumc.edu 8