ACL Reconstruction Rehabilitation Terese L. Chmielewski, PT, PhD, SCS

Transcription

1 ACL Reconstruction Rehabilitation Terese L. Chmielewski, PT, PhD, SCS Tackling Football Injuries Course

2 Objectives Identify successes and short-comings in ACL reconstruction outcomes Describe the course of ACL reconstruction rehabilitation and the critical clinical decision-making points Examine the potential need for addressing psychosocial factors in ACL reconstruction rehabilitation

3 ACL Reconstruction Highly researched musculoskeletal condition

4 Rehabilitation Advances Casting early weight-bearing and knee ROM Knee impairments (pain, ROM loss, effusion, quadriceps weakness) Open vs closed kinetic chain exercise Proprioception and neuromuscular control Protocol structure Patient outcome measures

5 Perception

6 76% of patients expect to return to their pre-injury level of sports participation after ACL reconstruction Feucht M et al. KSSTA 2014 (epub ahead of print)

7 Re-injury Rates Within 2 years after ACL reconstruction around 20% sustain a second ACL injury to either the surgical or non-surgical knee The risk is higher for the non-surgical knee Wright et al. JBJS 2011 Kamath GV et al. AJSM 2014 Paterno MV et al. AJSM 2014

8 Knee Osteoarthritis Within 10 years after ACL reconstruction up to 80% show signs of post-traumatic knee osteoarthritis Oiestad BE et al. AJSM 2010

9 Return to Sport Rates Not everyone returns to sports participation after ACL reconstruction 81% returned to any sport 65% returned to their pre-injury level of sport 55% returned to competitive sport Arden CL et al. Br J Sport Med 2014

10 Successes Understanding of knee impairments and intervention Shortcomings Outcomes Not as good as expected Not entirely clear what contributes

11 ACL Reconstruction Rehabilitation Surgery Early Phase Late Phase Return to Sport Resolve knee impairments Low-level activities Prepare for sports High-level activities

12 Areas for Improvement Inconsistency in measures and targets used for clinical decision-making Kvist J. Sports Med 2004 Barber-Westin SD & Noyes FR. Arthroscopy 2011 Thomee R et al. KSSTA 2011 Missing relevant impairments Psychosocial factors Fear of re-injury and self-efficacy

13 Right now cutting is the hardest thing in the world right now to do. I'm scared of it. Derrick Rose, Chicago Bulls point guard After I blew out my knee in a crash while training for a competition, jumps scared me. Picabo Street, Olympic skiing champion

14 Response to Sports Injury U Pattern Initial Rehabilitation Return to Sport Emotions Negative, severity is based on appraisal Improves, frustration Mixed, excitement fear of re-injury low confidence Morrey MA et al. Clin J Sport Med 1999 Tracey J. J Appl Sports Psych 2003 Clement D et al. JAT 2015

15 Fear of Re-injury and Return to Sport Return to Sport NRTS-Fear NRTS- Other Kvist et al. KSSTA 2005 Lee DY et al. Ann Acad Med Singapore 2008 Lentz et al. JOSPT 2012

16 Fear of Re-injury and Knee Function Early Rehabilitation Late Rehabilitation Return to Sport Inconsistent negative association Chmielewski et al. JOSPT Chmielewski et al. PTJ George et al. Clin J Pain 2012 Fair to moderate negative association Kvist et al. KSSTA 2005 Chmielewski et al. JOSPT 2008 Lentz et al. Sports Health 2009 Ross. J Orthop Traumatol 2010 Hartigan et al. JOSPT 2013 Lentz et al. AJSM 2015

17 TSK-11 scores Changes in Fear of Re-injury Early Phase Late Phase Return to Sport Sports Health 2009 PTJ 2011 AJSM in press wk 1 mo 3 mo 6 mo 1 yr

18 Fear of re-injury and return to sport N-RTS n = 42 Y-RTS n = 52 Knee effusion 21.4% 1.9%.005 Knee extensor torque/bw 73.9 ± ± Knee instability 73.8% 44.2%.004 Pain rating 1.0 ± ± IKDC score 78.0 ± ± 6.3 <.001 TSK-11 score 19.6 ± ± 4.1 <.001 p * * * Lentz et al. JOSPT 2012

19 Fear of re-injury and return to sport Ardern et al. AJSM 2013

20 Self-Efficacy (Confidence) Perceived ability to perform a task regardless of physical ability Can be described for any task Associated with rehabilitation adherence Bandura A. Psychol Rev 1977

21 Knee Self-Efficacy I believe I can Daily activities Physical activities Sports/leisure activities Future knee function Pre-operative knee self-efficacy predicts return to sport at 1 year post-surgery Thomee et al. KSSTA 2008

22 I believe I can Knee Self-Efficacy Chmielewski et al. Perform a full squat, run straight ahead, hop on the injured leg Early Phase Late Phase Baseline 1 mo 3 mo 6 mo n = 83 n = 24

23 Self-Efficacy vs Fear of Re-injury TSK-11 Knee Selfefficacy 20 0 Baseline 3 6 Months Post-op Chmielewski et al. JOSPT 2013: A48

24 Knee Self-Efficacy Scores Late Rehab and Self-Efficacy Pre Pre-treatment Post Post-treatment Mean = 73.7 Mean = 90.6

25 TSK-11 Scores Late Rehab and Fear of Re-injury TSKTot_V1 Pre TSKTot_V2 Post Mean = 17.6 Mean = 17.5

26 Addressing Psychosocial Factors 51% of physicians often discuss fear of re-injury with patients Less for other psychosocial factors Mann et al. AJSM 2007 Sports clinicians do not perceive fear of re-injury to impede return to sport after ACL reconstruction Mc Veigh and Pack. J Sport Rehabil 2015

27 Summary ACL reconstruction rehabilitation focus areas: Improve return to sport rates Lower re-injury rates Minimize post-traumatic knee OA Addressing psychosocial factors (fear of re-injury and selfefficacy) may facilitate a return to sport in some people

28 Acknowledgements UF Collaborator Steve George, PT, PhD Clinicians at the UF & Shands OSMI Peter Indelicato, MD Michael Moser, MD Kevin Farmer, MD Susan Tillman, PT, CSCS, SCS Trevor Lentz, PT, CSCS, SCS Giorgio Zeppieri, PT, CSCS, SCS Students Sarah Weisbruch, DPT Michael Rademaker, DPT Brittney Herder, DPT Penny Goldberg, ATC, DPT Ariel Botwin, BS Funding NIH-K01 (HD052713) NFL CHARITIES

29