The Effect of Bracing on Proprioception of Knees With Anterior Cruciate Ligament Injury CLINICAL COMMENTARY Key Words:

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1 The Effect of Bracing on Proprioception of Knees With Anterior Cruciate Ligament Injury Bruce D. Beynnon, PhD 1 Lars Good, MD, PhD 2 May Arna Risberg, PT, PhD 3 Journal of Orthopaedic & Sports Physical Therapy This paper is a comprehensive review on the effect of bandaging, bracing, and neoprene sleeves on knee proprioception following anterior cruciate ligament (ACL) injury and reconstruction with a focus on studies that have measured joint position sense and threshold to detection of passive knee motion. Disruption of the ACL does not appear to alter joint position sense soon after injury, although there is evidence that in some subjects deterioration may occur over time. An ACL tear creates a deficit in the threshold to detection of passive knee motion soon after injury and in those with chronic tears. The magnitude of worsening is less then 1.0 of movement in flexion-extension and of questionable concern from a clinical and functional perspective. Application of a functional brace or neoprene sleeve to the ACL-deficient limb does not improve the threshold to detection of passive knee motion; however, application of an elastic bandage to a knee with an ACL tear improves joint position sense. Reconstruction of a torn ACL is associated with a deficit in the threshold to detection of passive knee motion, and during the first year of healing the use of a neoprene sleeve provides improvement. Two years following ACL reconstruction there is no deficit in the threshold to detection of passive knee motion and the use of a brace has no effect on this outcome. J Orthop Sports Phys Ther 2002;32: Key Words: anterior cruciate ligament, bracing, proprioception 1 Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, VT. 2 Department of Orthopaedics, University Hospital, Linköping, Sweden. 3 Center for Clinical Research, Ullevall University Hospital, Oslo, Norway. Send correspondence to Bruce D. Beynnon, The University of Vermont, Department of Orthopaedics and Rehabilitation, McClure Musculoskeletal Research Center, 438A Stafford Hall, Burlington, VT bruce.beynnon@uvm.edu The stability of the knee is derived from the forces generated by the muscles, the geometrical congruency between articulating surfaces, and the ligaments that span the joint. There is little congruency between the tibia and femur, particularly on the lateral side of the joint, and therefore the knee is highly dependent on the muscles, joint capsule, and ligaments for stability. The ligaments that span the tibiofemoral joint, particularly the anterior cruciate, are vulnerable to injury because of the large moments that can be generated through the forces acting on the long lever arms of the femur and tibia. 5 Consequently, it is not surprising that athletics is associated with a high frequency of ACL disruptions. An injury to the ACL results in extensive disability because it alters knee kinematics (the displacements between the tibia and femur as the knee flexes and extends), locomotion, 1 and muscle activation patterns. 34,35,39 The cruciate ligaments receive their innervations from the posterior articular nerve, a branch of the posterior tibial nerve, and are directly linked to the sciatic nerve, 23 the spinal dorsal ganglion, 27 and the cerebral cortex. 31 Mechanoreceptors have been found in different regions of the ACL. 14,15,20,21,36,37 The connective tissue between the ACL and synovial membrane has small Ruffini and lamellar corpuscles, and septa between the fascicles of the ACL contain Ruffini corpuscles and free nerve endings. The presence of these mechanoreceptors combined with the fact that the ACL is strained with knee motion and muscle contraction 5 suggest that disruption of the anterior cruciate ligament compromises an important stabilizer of the knee and produces partial deafferentation of the joint. This review will focus on what is known about the effect of bracing and bandaging on knee proprioception following ACL injury and reconstruction with particular focus on the measurement Journal of Orthopaedic & Sports Physical Therapy 11

2 of joint position sense and the threshold to detection of passive knee motion. TECHNIQUES THAT MEASURE THE EFFECT OF BANDAGING AND BRACING ON KNEE PROPRIOCEPTION For the purpose of this review, we considered proprioception as Lephart et al have recently described it, 25 The acquisition of stimuli by peripheral receptors, as well as the conversion of these mechanical stimuli to a neural signal that is transmitted along afferent pathways to the central nervous system for processing. From this perspective, proprioception is the mechanism and process that exists along the afferent (sensory) portion of the sensorimotor system. This is an important distinction, because it neither relates to the central nervous systems processing of the afferent signal, nor does it include activity along the efferent (motor) pathway in response to a sensory stimulus. Currently, the most common means of evaluating proprioception of the knee is either through the measurement of joint position sense, or the measurement of the threshold to detection of passive knee motion. There are large variations that exist with the measurement of joint position sense, and differences with regard to data analyses. As a result, comparisons between joint position sense studies can be confounded by differences between measurement techniques. In contrast, the measurement of the threshold to detection of passive knee motion has been made with similar approaches, and comparisons between studies based on this approach can be made with clarity. Measurement of joint position sense has relied upon the matching of a defined index angle (ie, the flexion angle that must be reproduced by the study subject). The index angle has been defined either passively (without muscle contraction by the subject 2,8,16,38 ) or actively (with muscle contraction by the subject 6,29 ). Many different approaches have been used to match index angles; included has been the use of a visual analog of the leg, 4 actively matching the index angle using the opposite limb, 13 actively matching the index angle with the same leg, 16,38 or passively matching the index angle with the opposite limb. 17 Our research group has measured joint position sense with the use of a passiveactive test (the index angle was established passively by the investigator with the subject in a relaxed condition and then reproduced by the subject through active contraction of the leg muscles) and an activeactive test (the index angle was set actively by the subject through muscle contraction as well as subsequent reproductions of this position 12 ). For each of these methods there are differences with regard to how knee flexion angle has been evaluated, the time interval that the index angle has been maintained, and the angular velocity through which the leg moved. Flexion angle has been evaluated by measuring linear displacement of the foot, the use of a goniometer attached to the leg, evaluating video film, and electrolytic tilt sensors strapped to the leg. Angular velocity of the knee has ranged from uncontrolled to 2.0 /s. Unfortunately, little information is available with regard to the sensitivity of joint position sense to the differences in the before-mentioned techniques. Differences also exist with regard to how joint position sense data have been analyzed. The absolute value of the errors, 3,22,38 the real errors, 6,9 and the variation of the error terms 10 have all been compared. Real errors describe both the direction and magnitude of the error, and can be used to characterize how a subject over- or underestimates an index angle. Absolute errors have only magnitude information and cannot be used to evaluate if a subject overor underestimates knee position. The variation of the error terms describes the precision of a subject s estimates and is represented by the standard deviation of the real error terms. Each of these beforementioned error terms is a unique means of characterizing joint position sense, although they are not independent, and it is likely that correlations exist between these error terms. In contrast to the different approaches that have been used to measure joint position sense, measurement of the threshold to detection of passive knee motion has been consistent between studies. With this approach, the subject sits in a chair with the legs relaxed and supported by an external device. 6 Observation of the lower extremities by the study subject is eliminated, and one leg is slowly moved (either flexed or extended) at a rate of approximately 0.5 /s. The outcome from this test is the magnitude of knee rotation (either extension or flexion) that occurs between the point in time when the subject s limb begins to move and when motion is detected. The differences between the techniques that have been used include how the limb is supported and how the subjects signal detection of limb motion. This has either involved the subject alerting the examiner or the subject pressing a button, and this could introduce differences in outcome. THE EFFECT OF BANDAGING AND BRACING THE KNEE WITH AN ACL TEAR Jerosch and Prymka 19 studied subjects with isolated ruptures of the ACL using a joint position sense measurement technique similar to that described by Barrett et al. 3 They reported that subjects with an ACL tear had significantly worse joint position sense in comparison to a group of control subjects with normal knees and that the use of an elastic knee bandage created a significant improvement. Using a 12 J Orthop Sports Phys Ther Volume 32 Number 1 January2002

3 different approach, our group studied subjects that had chronic tears of the anterior cruciate ligament (the average time between the tear and the time of testing was 5.5 years; range years) and measured the threshold to detection of passive knee motion. 7 The knees with torn anterior cruciate ligaments demonstrated significantly worse threshold to detection of passive motion compared with the contralateral uninjured side, 7 a finding similar to the earlier work of Jerosch and Prymka. 19 In our study, the use of a neoprene sleeve or functional brace did not change the threshold to detection of passive motion, 7 a finding in contrast to that of Jerosch and Prymka. 19 The change of the threshold to detection of passive knee motion associated with the ACLdeficient knee was small (eg, worsening occurred because the limb coursed through an average increase of 0.28 degrees of rotation prior to the subject indicating that the knee moved). It was not correlated with the subjects activity level and function and this led us to question whether this finding was significant from biomechanical and clinical standpoints. 7 The 0.28 degree increase of the threshold to detection of passive knee motion for the ACLdeficient knee compared to normal was consistent with previous reports. Barrack et al 2 studied subjects three months following ACL disruption and revealed a 0.9 degree increase in the threshold to detection of passive motion compared to normal. Likewise, Corrigan et al 8 reported the threshold to detection of passive motion was increased by 0.74 degrees for subjects that suffered an ACL injury an average of 5.25 years before. Similarly, MacDonald et al 26 studied subjects that experienced an ACL injury an average of five years earlier and found the threshold to detection of passive motion was 0.14 degrees worse for ACL-deficient knees compared to uninjured limb. Friden et al 11 studied the temporal behavior of the threshold to detection of passive knee motion following disruption of the ACL and demonstrated significant differences between injured and uninjured knees at one and two months following the index injury, but not thereafter. Review of these previous studies indicates that soon after an ACL tear there is a deficit in the threshold to detection of passive knee motion, and after two months of healing deficits are either very small or do not exist. When one considers this temporal response to an ACL tear, it may not be important for a functional brace or neoprene sleeve to restore the threshold to detection of passive knee motion back to within the limits of normal. Bandaging and use of a neoprene sleeve have been shown to improve proprioception in normal subjects and those with different types of knee disorders. For example, Perlau et al 30 studied subjects with normal knees and demonstrated that application of an elastic bandage produced a 25% improvement in joint position sense. Similarly, McNair et al 28 studied normal subjects and found that a knee sleeve produced an 11% improvement. Barrett et al 3 studied subjects suffering from osteoarthritis and subjects following treatment of this disease with a knee replacement and revealed that application of an elastic bandage produced a 40% improvement in joint position sense. In contrast, Jerosch et al 18 investigated subjects that suffered meniscal lesions and found that application of a bandage did not change joint position sense. THE EFFECT OF A NEOPRENE SLEEVE AND BRACING ON THE KNEE FOLLOWING ACL RECONSTRUCTION Lephart et al 24 reported the threshold to detection of passive motion was impaired in subjects that underwent ACL reconstruction with either a patellar tendon autograft or allograft and had months of healing, compared to the contralateral, normal knee. In this group of subjects, application of a neoprene sleeve produced a significant improvement in the threshold to detection of passive motion. Our group evaluated the effect of bracing on the threshold to detection of passive motion on subjects who underwent reconstruction with a bone-patella tendon-bone graft shortly after their injury; who had controlled rehabilitation; and who were evaluated two years after their surgery. 32 No differences in the threshold to detection of passive motion were found between the ACL reconstructed knees and the contralateral normal knees, or between the ACL reconstructed knees and a control group with healthy knees. Bracing did not produce a change in the threshold to detection of passive motion for the ACL reconstructed and control groups. The discrepancy between our work and the studies by Lephart et al 24 may have been produced by differences between subjects. Lephart et al 24 studied subjects months following ACL reconstruction, and we studied subjects 24 months following ACL reconstruction. Our prospective study of subjects that suffered an isolated anterior cruciate ligament tear and then underwent reconstruction and controlled rehabilitation revealed no deficit in joint position sense preoperatively and throughout the early healing interval (two and four months postoperatively). 12,33 Therefore, there may not be a need for an improvement in joint position sense. This finding surprised us because it occurred during time intervals when muscle strength is clearly diminished and from most patients perspectives, coordination of the limb is compromised. An explanation for our inability to demonstrate differences in joint position sense after ACL reconstruction may be associated with the measurement technique. Joint position sense was measured with the subject standing upright using a passive-active test and an active-active test. This may J Orthop Sports Phys Ther Volume 32 Number 1 January

4 not have the sensitivity necessary to detect changes in proprioception because of loss of afferent information from the mechanoreceptors in the ACL. Instead, joint position sense may be primarily influenced by feedback from the muscle spindle afferents and to a lesser degree by torn ACL receptors. An alternative explanation for this finding may be the technique we used to measure joint position sense relied primarily on the hamstrings for positioning of the knee, and since these muscles are typically the focus of early rehabilitation following ACL reconstruction with bone-patellar tendon-bone grafts, the receptors in the muscles are not compromised. THE EFFECT OF BRACES ON NEUROMUSCULAR FUNCTION OF THE ACL-DEFICIENT KNEE Wojtys et al 40 developed a device to apply anterior directed loads to the calf, relative to an immobilized thigh, and measure anterior translation of the tibia and the electromyographic response of the quadriceps, hamstrings, and gastrocnemius. They revealed that bracing knees with ACL tears reduced anterior tibial translation between % when the muscles were relaxed. With contraction of the leg muscles, bracing the knees with ACL tears produced a dramatic decrease in anterior tibial translation that ranged between %. Bracing improved the reflex reaction time of the muscles, and this was most pronounced for the quadriceps. In contrast, some of the functional braces tested delayed the onset of voluntary contraction of the hamstring muscles. An explanation for this finding was that the increase in stiffness imparted to the knee by the brace also produced a delay in the deformation of the neuroreceptors about the knee and subsequent voluntary onset of muscle contraction. CONCLUSION In summary, this review found very little information in the literature with regard to the effect of wrapping and bracing on knee proprioception following ACL injury and reconstruction. The few studies that have been reported present contrasting findings. This was attributed to differences among the subjects studied (eg, subjects with acute versus chronic ACL tears), the types of injuries sustained (eg, individuals with combined injuries and those that cope well with the injury versus those who do not), the study design, and the measurement techniques used to quantify joint position sense and the threshold to detection of passive motion. Currently, there is no consensus regarding the magnitude of change in joint position sense or the threshold to detection of passive motion that is significant from a clinical or functional perspective. Subjects that tear their ACL and cope well with the injury do not appear to have substantial deficits in the threshold to detection of passive motion, and it may not be important for a brace or sleeve to produce improvements. The same can be said for those who tear their ACL and undergo reconstruction. 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