REGAINING QUADRICEPS STRENGTH & FUNCTION FOLLOWING ACL RECONSTRUCTION J E S S I C A H A R T C L I N I C A L P R O B L E M S O LV I N G I I

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1 REGAINING QUADRICEPS STRENGTH & FUNCTION FOLLOWING ACL RECONSTRUCTION J E S S I C A H A R T C L I N I C A L P R O B L E M S O LV I N G I I

2 PURPOSE Present patient S/P ACL reconstruction and medial/lateral meniscus repair Evaluate best evidence for quadriceps strengthening and return to function following knee ligament reconstruction

3 PATIENT DEMOGRAPHICS 21 yo Caucasian female Full-time student Elementary education Worked several part-time jobs Not married/ no children Living with boyfriend

4 HEALTH CONDITION Medical diagnosis L knee ACL tear + posterior horn medial/ lateral meniscus tears Females are 2-8x more likely to sustain an ACL injury Environmental Anatomic Hormonal Neuromuscular Biomechanical factors 70% are non-contact 28% caused by straight knee landing Footprint of torn ACL Incidence of ACL tears with meniscal injury is ~50% Surgical repair preferred for pts with combined soft tissue injuries

5 HEALTH CONDITION MOI L knee hyperextension during gymnastics routine L knee ACL reconstruction (BPB) + medial/lateral meniscus repairs

6 PATIENT HISTORY PMH: R knee ACL & MCL sprain 4 years ago No L knee injuries Comorbidities: None Medication(s): Oral contraceptive Hydrocodone Post-op complications: None New ACL being anchored down

7 PT EXAMINATION Pain (NPRS): 7/10 Skin integrity: No drainage or s/s of infection Swelling/edema/girth: L >5cm: 37cm >10cm: 39cm R >5cm: 36cm >10cm: 41.5cm ROM: Flexion: 40 Extension: 0 POW1 Strength (L): Flexion: 3-/5 Extension: 3-/5 Cannot move through full ROM Joint mobility: Good patellar mobs Quadriceps activation: Fair SLR in 20 flexion LEFS: 7/80 Ambulation: B AC

8 EXAMINATION: TREATMENT POW2/3 Pt education No knee flexion > 90 WBAT w/ brace locked in ext Quad sets 10x holding for 3 Ankle pumps 30x Heel-slides 15x SLR (flex, abd) 5x ea Prone hang 10 Game Ready 15 min

9 EVALUATION Impairments (L knee): Pain Edema Decreased strength Decreased ROM Decreased flexibility Decreased proprioception Decreased balance Abnormal gait pattern Activity Limitations (L knee): ADL/Functional deficits Walking Stair climbing Participation Restrictions (L knee): Unable to work Unable to drive Unable to participate in gymnastics/exercise

10 PROGNOSIS: EXCELLENT Favorable: Young Motivated Great family/friend support Non-smoker Healthy BMI Unfavorable: Concomitant injury Conservative rehab protocol MRI of torn ACL

11 PHYSICIANS PROTOCOL

12 PHYSICAL THERAPY GOALS In 2-3 weeks Pt will demonstrate independence in a HEP to maintain gains made in PT between treatment sessions. Pt will report decrease in pain to 3/10 on the NPRS (MDC= 2 pts) to allow for full weight bearing during ambulation. Pt will score a 16/80 on the LEFS (MDC= 9 pts) in order to improve independence in I/ADLs. Patient goal Return to normal pre-injury activities without pain or feelings of instability

13 OUTCOME: POW 8 Seen 2x/week for 8w Pain (NPRS): 0/10 ROM: Contralateral side Girth: L >10cm: 39cm (2.5cm atrophy) LEFS: 55/80 Ambulation: I w/ brace Weaning Therapeutic Exercise: E-stim 15 min 2x/week for 8w 4-way SLR Quadburners ABD walks Hooklying abd w/ theraband Patella mobs/stm to ITB LP w/ theraband Clams Bridging on ball w/ knees extended Marching w/ theraband HR/TR Single leg balance w/ foam LAQs Bike

14 CLINICAL QUESTION For my 21 yo patient, is neuromuscular electrical stimulation (NMES) an effective intervention for strengthening the quadriceps femoris and improving selfreported function after anterior cruciate ligament (ACL) reconstruction?

15 Study design: Systematic review Level of evidence: 1a Objective: Perform a systematic review of RCT assessing the effects of NMES on quadriceps strength, functional performance, and self-reported function after ACL reconstruction Theory: NMES restores quadriceps strength by recruitment of the muscle that may experiencing arthrogenic muscle inhibition

16 KIM ET AL., 2010 Materials & Methods: Electronic database search for RCTs from Quality was assessed using the Physiotherapy Evidence Database Scale (PEDro) Inclusion Criteria: English RCTs w/ human subjects Exclusion criteria: No true randomization No group means or standard deviations No comparison group 8 RCTs included Mean PEDro score of 4.3 Other: Electrodes placed over VM and VL Pts maximal tolerable intensity Variability in NMES parameters Duration of tx ranged from 3-11w with a mean of 6w Number of tx s ranged from with a mean of 34

17 RESULTS: STRENGTH Cohen s d Effect Size: Weak: <0.2 Moderate: Strong: >0.8 NMES + Ex vs Ex (28) = to moderate effect of NMES on quadriceps muscle strength as compared to exercise alone NMES vs Ex (6) NMES vs Ex (9) NMES + Ex vs. Ex (31) NMES + Ex vs TENS + Ex, Ex only (20) NMES + Ex vs Ex (25) NMES + Ex vs EMG Biofeedback + Ex (7)

18 RESULTS: SELF-REPORTED FUNCTIONAL OUTCOMES Cohen s d Effect Size: Weak: <0.2 Moderate: Strong: >0.8 Moderate effect favoring a 4w NMES tx Significant shift favoring NMES

19 LIMITATIONS Small sample size Inconsistencies in NMES parameters, application techniques and dosage across trials Poor quality RCTs (PEDro score) No meta-analysis performed Results skewed towards NMES

20 SUMMARY NMES + exercise results in = to moderately greater quadriceps strength recovery Initiated in week 1 week 4 NMES + exercise has a moderate effect on pt self-reported outcomes vs comparable tx The present review supports the use of NMES + exercise during the first 4w following ACL reconstruction to improve quadriceps strength and self reported outcomes

21 Study design: Randomized controlled trial Objective: To assess the effect of electrical muscle stimulation (EMS) on prevention of muscle atrophy in patients during the early rehabilitation stage after ACL reconstruction Theory: Quad atrophy and strength loss often exceed 20 and 30% respectively during the first 3m following ACL reconstruction This can be prevented with early EMS.

22 HASEGAWA ET AL., 2011 Materials & Methods: 20 pts (16 male, 4 female) S/P ACL reconstruction Average age years Time from ACL tear surgery was months Pts randomly assigned to: CON group 10pts (8 male, 2 female) years Received only standard rehab program EMS group 10 pts (8 male, 2 female) years Received standard rehab+ EMS

23 HASEGAWA ET AL., 2011 Materials & methods cont. : EMS group Standard rehab + EMS 5x/w for 20 minutes for 4w starting POD 2 8 silicon-rubber electrodes with tightly fitted shorts/leg band Handheld stimulation produced co-contraction of the knee extensors/flexors and PFs/DFs without mov t at the joint Parameters: frequency of 20Hz, pulse width of 250 s, duty cycle of 40% Pts maximal tolerable intensity Maximal voluntary isometric contraction was measured prior to surgery and at 4w and 3m post-op Lysholm scores were taken pre-op and at 6m after surgery

24 RESULTS: STRENGTH CON group: Isometric strength 4WPO & 3MPO EMS group: No change in isometric strength from pre 4WPO & a significant at 3MPO

25 RESULTS CONT.: STRENGTH The in quadriceps peak torque of the operated limb was significantly less in the EMS group (1.2%) than in the CON group (39.2%) at 4WPO The recovery ratio in the EMS group was greater, but not significant Difference in muscle strength at 3MPO due to prevention of muscle atrophy via EMS training

26 Lysholm Knee Scale Scores RESULTS: SELF-REPORTED FUNCTIONAL OUTCOMES Pre-op MPO CON EMS Lysholm Knee Scale Gold standard in evaluating the ACL deficient knee 8 items totaling 100 pts Pts perception of function Locking, giving way, AD, p!, swelling, stairs, squatting There were no significant differences in Lysholm scores between the CON and the EMS groups at 6m after surgery

27 LIMITATIONS Small sample size Males > females High dosage protocol that might not be feasible in clinical practice 20 min tx sessions 5x/w for 4w Short follow-up period Quadriceps weakness can persist for 1-6 years

28 SUMMARY 4 weeks of EMS training beginning early in the rehab process following ACL reconstruction, prevented muscle atrophy and weakness No significant difference in Lysholm scores between the CON group and EMS group

29 NMES probably more effective for preventing muscle atrophy ~4w long tx had best evidence IS NMES AN EFFECTIVE INTERVENTION FOR STRENGTHENING THE QUADRICEPS FEMORIS & IMPROVING SELF- REPORTED FUNCTION AFTER ACL RECONSTRUCTION? MAYBE NMES may improve self-reported fx Both studies enrolled pts with isolated ACL repairs Pts with concomitant injuries may have a more difficult time restoring quadriceps strength Unknown long term effects Further research is warranted Optimal dosage and parameters

30 QUESTIONS?

31 REFERENCES ACL Injury: Does It Require Surgery?-OrthoInfo - AAOS. (2009, September 1). Retrieved from Giugliano, D., & Solomon, J. (2007). ACL Tears in Female Athletes. Physical Medicine and Rehabilitation Clinics of North America, doi: /j.pmr Hasegawa, S., Kobayashi, M., Arai, R., Tamaki, A., Nakamura, T., & Moritani, T. (2011). Effect of early implementation of electrical muscle stimulation to prevent muscle atrophy and weakness in patients after anterior cruciate ligament reconstruction. Journal of Electromyography and Kinesiology, 21, doi: /j.jelekin Kim, K., Croy, T., Hertel, J., & Saliba, S. (2010). Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function, and Patient-Oriented Outcomes: A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy, 40(7), Kowalchuk, D. A., Harner, C. D., Fu, F. H., & Irrgang, J. J. (2009). Prediction of Patient- Reported Outcome After Single-Bundle ACL Reconstruction. Arthroscopy : The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 25(5), Toscano, L., & Carroll, B. (2014). Preventing ACL Injuries in Females: What Physical Educators Need to Know. Journal of Physical Education, Recreation & Dance, 86(1), doi: /