Anterior Cruciate Ligament Replacement and the BASI Approach to Rehabilitation

Transcription

1 Anterior Cruciate Ligament Replacement and the BASI Approach to Rehabilitation Written by Adriana Ferrer- Perez Date January, 2007 This is a student paper, submitted to BASI Pilates by the writer as a requirement for completion of the BASI Pilates Comprehensive Teacher Training Course. The contents are not endorsed by BASI Pilates. The paper is being provided by the writer and BASI Pilates as a service to the Pilates community. Copyright 2013 BASI Pilates All rights reserved. This paper or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of BASI Pilates, except for the use of brief quotations with the appropriate attribution.

2 ABSTRACT Accidents can change the course of a life and confront a person with many challenges, especially a person who is very physically active. This paper illustrates how sound therapy, begun in a timely manner, can benefit both the outcome of surgery and postsurgery recovery. The user case discussed in this paper is that of Maria, a very dedicated teacher and an athletic person, who was confronted by the rupture of her Anterior Cruciate Ligament in her left knee. Not only did Maria have the patience and dedication to do the therapy, but she also chose the best tools and therapy available to her. With her Pilates training and her teacher s help, she was able to progress in her training from simple floor exercises to more advanced and difficult repertoire on the Pilates apparatus. She gradually moved from the least demanding to more demanding exercises. Most importantly, she regained the full use of her leg and returned to her regular activities in a timely manner. She achieved greater success in her recovery using the Pilates repertoire than she would have had she relied only on regular physical therapy

3 TABLE OF CONTENTS I. Anatomical Description..page 2 II. ACL Rupture..page 3 III. Case Study...page 5 IV. Conditioning Program...page 5 V. The Goals..page 6 a. Short Term.....page 6 b. Mid Term...page 6 c. Long Term..page 7 VI. Sample of Exercises Used for Rehabilitation.page 8 a. Mat Work...page 8 b. Exercise progression on the Reformer, Cadillac and Chair...page 9 VII. Conclusion page12 VIII. Bibliography.page

4 ANATOMICAL DESCRIPTION The Anterior Cruciate Ligament (ACL) is a major stabilizing ligament in the knee, connecting the tibia (leg bone) to the femur (thigh bone) and keeping the two in proper alignment. The ACL is located in the center of the knee, forming an X shape where it crosses the Posterior Cruciate Ligament (PCL). The ACL keeps the tibia and the femur in proper relationship with each other and prevents non-physiological anterior movement or the tibia on the femur. 1 When looking at the function of the ACL one can see that it is a complex one. It not only provides mechanical stability, but also proprioceptive feedback to the knee. As a stabilizer it has four main functions: Restrains anterior translation of the tibia, Prevents hyperextension of the knee, Acts as a secondary stabilizer to valgus stress, reinforcing the medial collateral ligament, and Controls rotation of the tibia on the femur in femoral extensions of 0-30 degrees. (2) 1 (1)Saunders Clinic, (2) Encyclopedia of Sports Medicine and Science

5 This final role is the main clinical function of the ACL. This critical function in the range of motion of 0-30 degrees is important for movement such as side stepping and pivoting. On the Pilates Reformer, one would not be able to perform side splits or single leg skating without the stabilization of the ACL. ACL RUPTURE The most common causes of ACL rupture is a traumatic force being applied to the knee in a twisting movement. This can occur with either direct or indirect force. About half of the cases occur without contact, i.e., while side-stepping, pivoting or landing from a jump. The other half are associated with some type of contact, whether it be on the sports field, while skiing or even in a motor vehicle accident. Skiing injuries usually occur during a fall or when the binding does not release. The latter was the cause of injury in our case study (see illustration on Page 4.) Typically, a patient reports hearing a pop sound and explains that the knee went out. According to Dr. Mark Sanders of Sanders Clinic, an ACL tear is a severe injury and typically a patient cannot finish the day s activities. Left untreated, it can lead to post traumatic arthritis. After the rupture, it is common for a patient to frequently experience subluxation (a partial or incomplete dislocation) of the knee, which can also lead to posttraumatic arthritis. ACL injury requires a reconditioning program to maintain the strength of the surrounding muscles and tendons. Reconstruction and rehabilitation is recommended for athletes or very active people who wish to continue their activities

6 - 6 -

7 CASE STUDY Maria is a 44-year-old woman who has been very active throughout her life, including as a dancer and an aerobics and yoga instructor. She ruptured her ACL during a skiing accident. For several reasons, Maria s medical provider delayed her reconstructive surgery for eight months, though she began her rehabilitation program earlier, in preparation for the surgery. That conceivably made the surgery more successful. One of Maria s goals was to restore full motion to her knee. Her wish was to be able to return to her physical activities and teaching of yoga, cycling and other aerobic activities. Prior to the surgery, she was walking with the injured knee bent and leaning on her right leg. The left knee would not extend all the way. She had cramping in her calves and pain in her lower back. Research indicates that only 15 percent of the population can survive happily with a ruptured ACL and that it takes a special kind of patient to be able to sustain the physically demanding and long commitment required to rehabilitate the knee. Maria was committed to her recovery and willing to do all the hard work. CONDITIONING PROGRAM BASED ON THE BASI APPROACH Starting from the 5 th week post-surgery Because of the injury to the knee, other joints of the kinetic chain - like the hips, back and ankles - were feeling the impact and being stressed. A work-out that addressed the body as a whole was important to help improve these symptoms By the time Maria came to her Pilates sessions with me, she had just been allowed to remove the knee immobilizer and was able to walk unassisted or without crutches. THE GOALS Short term goals After the surgery, the goals for the first four weeks were to desensitize the scar, reduce the swelling and allow the scar and soft tissue to gain some mobility and prevent the - 7 -

8 formation of a raised thickened scar. Tissue still needed time to heal and repair. The job was to deal with the pain, discomfort, stiffness and numbness at the knee. All exercises at this point were geared towards maintaining range of motion of the knee and achieving knee extension. According to the Kaiser Permanente physical therapy department, ACL protocols call for working on full extension of the knee, work on patella mobilizations and leg flexion and working toward at least 90 degrees of flexion by the end of the first week. At this point, the immobilizer and/or crutches were used all the time. Mid-term goals: The immobilizer was now no longer in use. Since Maria had already been doing therapy through her medical provider, our goal was to improve the range of motion and improve what she had already gained in knee flexion and extension, as well as to deal with the pain and swelling she experienced after exercise. The work that she had been doing and the addition of the Pilates mat exercises proved to be very beneficial to her knee as well as her overall sense of wellbeing. Exercises like Pelvic Curl and Shoulder Bridge Prep helped strengthen the hamstrings and the quadriceps. The seated stretches like Spine Stretch and Saw, helped with hamstring flexibility. Additional leg work exercises from the BASI Auxilary Workbook, like Side Leg Lift, Forward and Lift, Forward with Drops, the Adductor Squeeze and the Adductor Lift for the adductor group work, were very useful in strengthening the muscles around the leg and the knee without putting any stress on the new ligament. In order to progress through the rehabilitation program and following the guidelines from her medical provider, we began to add resistance around week eight, in order to strengthen the supporting muscles of the knee, quadriceps and hamstrings. We started with ankle weights and began using the magic circle for her leg work: for example, the Circle by the ankles, above the knee and the supine series. Also the Ankles bent knees in the prone position. To integrate her whole body in the conditioning program, Maria practiced the mat program and added arm work using rubber bands or tubing, doing the same type of movement used on the reformer for sitting arm work and using the pole for shoulder stretches like overhead stretch, side stretch and twist. Long-term goals: - 8 -

9 These were to restore Maria s ability to perform athletic activities, such as walking, running, spinning and stair-climbing. These goals were achieved at around six months post-surgery, after permission was received from her doctor. Additionally, Maria s goal was to be able to do the majority of the Pilates repertoire without knee pain. She experienced pain and the knee would swell during the first few months of working out. Several exercises in which the knee had to bear weight needed to be modified or avoided and we used extra padding under the knee in such exercises as the knee stretch series. Now that she was feeling more in control of her rehabilitation, Maria was encouraged to begin to expand the capabilities of her knee and to bring the leg as close to normal functioning as was possible. According to the Kaiser Permanente Protocols for ACL replacement, her doctor gave permission to gradually increase the weight load and the number of repetitions. There was only one restriction we had to keep in mind throughout the entire program; not to strengthen in the 30 degrees of extension for three months after the surgery. The Pilates whole-body approach suited Maria, even if the intensity was less than what she was used to. These workouts gave her a sense of wellbeing while her knee was healing. SAMPLE EXERCISES USED FOR REHABILITATION: We began without ankle weights for the first months before adding light ankle weights in the 5th th week. As Maria continued to progress and improve, we added more resistance and challenge, using the Reformer and other pieces of equipment Mat Work Warm up Pelvic Curl, Spine Twist, Chest Lift, Chest Lift with Rotations, Leg Changes (the post surgery knee was allowed to be slightly more extended than the other one due to difficulty in holding knee flexion). Hundred, Roll up, Spine Stretch, Spine Twist, Leg Circles, and Rolling like a Ball with modification on the last one: The post surgery knee was allowed to be slightly more extended than the other one due to difficulty in holding knee flexion and pain - 9 -

10 Double Leg Stretch (at a slower pace, due to the need to avoid the last 30 degrees of extension for the first three months.) Single Leg, same approach; the injured leg would not extend all the way to protect the new graft. Spine Stretch and Open Leg Rocker, and Saw, these were excellent for her hamstrings. Cork Screw, Jack knife Side lifts and side kicks - not Side Bend, because it put too much pressure on the knee while bearing weight on the leg for support. Back Extension, Single Leg Kick, Double Leg Kick, and Swimming For full body integration exercises Maria was able to do Front Support, Back Support, Leg Pull Front and Leg Pull Back. These last two with difficulty, due to the pain of gravity pull on the knee. In addition we did some leg work and upper body work to help restore some balance. Since the accident, Maria had been compensating on the right leg, creating imbalances at her hips, ankles and lower back. Exercises that helped bring some balanced to the hips were; Side Leg Lifts, Forward and lift and the other exercises from the BASI Auxiliary Workbook that were mentioned above for the mid-term goals. Around week ten, we were able to progress onto the equipment. We added the reformer for added resistance and to address the muscles in a more challenging way. Later, the cadillac and wunda chair were included. Exercise Progressions on the Reformer, Cadillac and Wunda Chair: The following exercises were chosen to help improve the knee and balance the right and left sides of the body, as well as to increase strength and muscular balance. Foot Work: all of it on the Reformer and/or the Cadillac and Chair. We used lighter resistance at first, so as to avoid compromising form and range of motion

11 The Abdominal Work, like the Hundred Prep, the Hundred, Coordination and Legs in Straps, was more difficult, due to the placement of the straps over the knees, Maria had to wait to gain more strength for these ones. All of the Short Box Series abdominals work well. These were particularly useful to improve the balance at the hips. On the Cadillac the Roll Up with The Roll Up Bar, Mini Roll Ups, and Mini Roll Ups with Obliques, Roll Up Top Loaded, Teaser, Breathing with The Push Through Bar, helped improve the abdominals as part of addressing the body as a whole. Hip Work helped with knee flexion and hip disassociation to improve the movement at the hips. The intermediate exercises on the reformer, like Extended Frog, were done with lighter resistance at first and without the full extension of the knee to protect the new ligament. On the Cadillac, Bicycle was very useful for hamstring flexibility to restore coordination and to continue to improve knee flexion. It was challenging, however, because Maria had to keep the leg from extending the last 30 degrees of the extension. This required a lot of concentration. The left knee was allowed to stay slightly flexed to stay within this rule. Once the three month period was over, around week 13, she began to work the full extension of the knee with resistance. Spinal Articulation: Bottom Lift and Bottom Lift with Extension. These were good for hamstring strengthening or hip extensor strength, in addition to articulation of the spine. Short Spine and Long Spine were excellent for both spinal articulation and strengthening of the hamstrings. After the first six months Maria could perform Monkey Original and Tower Prep on the Cadillac, since by then the knee could be extended all the way against resistance without any fear of ligament damage. Stretches: Maria could only do the standing lunge, and that with difficulty. Kneeling Lunge and Full Lunge were too difficult and put too much pressure on the knee. Full Body Integration 1: For full body integration exercises we included Scooter, Upstretch 1 and Elephant. We left the knee stretches out of the program at this point since she was unable to lean on the knee. We modified it later by adding towels for padding. The stomach massage series worked well. Arm Work: the arm work on the Reformer was done in supine and sitting positions. Kneeling was not suitable. She also did the arm work standing on the Cadillac. Full Body Integration 2: Maria had to avoid these exercises for another six months

12 Leg Work: Maria could use the reformer for Hamstring curl, however Single leg Skating had to wait since the knee could not tolerate the balancing needed for this exercise. On the Cadillac Maria did Leg Changes, Scissors and Forward and Back Circles. The chair was very useful for leg work. Maria did the Hamstring Curl and Leg Press Standing to both help strengthen the hamstring and improve balance. Hip Opener brought some balance to the hips. At this point, Forward Lunge, Backward Step Down and Frog Front were not included because the knee could not tolerate the pressure. However, we used the Reformer box to improvise step up and down to help the tracking of the knee. Lateral Flexion: We started with the side over on the box, and side stretch on the chair. Mermaid was added later on when the hips were more relaxed and allowed Maria to sit in the set-up position. She had to start it with legs extended over the side of the Reformer. Later, she was able to move into the position with legs bent. However, Side Over the Box in the short box series worked well. Back Extension: There were many exercises in this block that Maria could practice. Starting on the Reformer, she did Breaststroke and Pulling straps 1 and 2. On the Wunda Chair, she did Swan Basic and Swan on the Floor and Back Extension Single Arm. On the Cadillac, the two back extension exercises used were Prone 1 and Prone 2. CONCLUSION Maria continued to progress through her Pilates program. A year after the surgery, she was able to add more exercises, including those in which the knee is weight-bearing. The knee would swell up after some of the practices, especially on the days she had increased the resistance, but she treated it at home with ice, elevation and rest. As the sessions progressed, the leg continued to improve and her sessions began to bring balance and more stability to her leg. The sessions also helped her improve her hip imbalance. She had been having hip pain on the side she had favored during her long wait for surgery. As the body began to work more evenly, the tension in her hips and ankles began to diminish. Her gait improved and her muscles began to recruit more efficiently. These improvements were apparent when she performed some of the more difficult exercises, such as the Frog Front or Frog Back, both of which put pressure on the knees, as well as when she began to do reformer

13 stretches, such as Kneeling Lunge. Her hips began to look more level and her movement were more precise and balanced. Overall, she gained flexibility, control and strength. The whole-body approach was key in helping her restore her sense of wellbeing and satisfaction. Maria recovered full use of her knee and began to return to her old self

14 BIBLIOGRAPHY "Anterior Cruciate Ligament." SandersClinic.Net. 20 Oct < Cross, Mervin J. Encyclopedia of Sports Medicine and Science North Sydney Orthopedic and Sports Medicine Centre. 20 Oct < Fillon, Mike. "Best Cure for Some Knee Injuries? Postpone Surgery." WebMD. 14 Dec < ACL Reconstruction Protocol. Fairafax, VA: Kaiser Permanente, Calais-Germain, Blandine. Anatomy of Movement. 11th ed. Seatle, WA: Eastland P, 1991 Knee Ligament Injury. San Bruno, CA: Krames Communications,