Inup/scad bireme bricg-binivilexescad! | BRIQ907443. E-Mail: marcovaz@esef.utrgs.br Pedido:051028-541 Usuario:MarcoVaz ‘Am J Sports Med 1989 17(2) pags. 154-60 / Anderson AF; Lipscomb AB / Analysis of rehabilitation techniques after anterior ‘cruciate reconstruction. [(iah) MEDLINE_ 1966-1992 pid: 2667374] Fonte de referéncia:(iah) MEDLINE_1986-1992 pmid 2687374 — |Prof Dr. Marco Aurelio Vaz Rua Mariz e Barros 392 Ap 501 90690-390 - Porto Alegre - RS BRASIL BRI9907443 E-Mail: marcovaz@esot.ufrgs.br | WLU Pedido:051028-541 1989 17(2) pags. 154-60 / Anderson AF; Lipscomb AB / Analysis of rehabilitation techniques after anterior cruciate reconstruction. [(iah) MEDLINE_1966-1992 pmid: 2667374] Local: BR1.1 Opgées: BR1.1/BR16.1 ‘tendo / Paginas: [_]‘0363-5468 /89/1702-0184802.00/0 ‘Tup AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 17, No.2 (© 1080 Amneriean Orehopaedic Society for Sports Medicine Analysis of rehabilitation techniques after anterior cruciate reconstruction ALLEN F. ANDERSON,” MD, AND A. BRANT LIPSCOMB, MD From the Department of Orthopedic Surgery and Rehabilitation, St. Thomas Hospital, ABSTRACT Numerous postoperative therapies have been advo- cated for the rehabilitation of patients who have under- ‘gone ACL reconstruction. The effectiveness of these Various methods, many of which are based on sound scientific principles, has yet to be documented. The purpose of this study was to determine the efficacy of five commonly used rehabilitation programs. Five ‘groups of 20 patients, all of whom underwent the same method of ACL reconstruction, were compared in order to determine the effects of the following treatments (some in combination): transcutaneous electrical nerve stimulation (TENS), immobilization in flexion, immobi- zation in extension, electrical muscle stimulation (EMS), ‘and continuous passive motion (CPM). Clinical evalua- tion, volumetric. thigh measurements, instrumented varus-valgus stress testing, KT-1000 arthometer (Med- metric, San Diego, CA) measurements, and Cybex It (Cybex, Division of Lumex, Ronkonkoma, NY) muscle ‘evaluation were used to examine the patients. TENS did not reduce the amount of pain medication required, nor was there improvement in any other clin- ically measurable parameter of performance. There was ‘no clear difference in stability between those treated in extension and those treated in flexion; however, since three patients who were treated in extension required manipulation, there may be some advantage to treating Patients with early limited range of motion in flexion. EMS did nat reduce atrophy butit cid minimize strength decrease during immobilization. EMS also resulted in significantly greater range of motion than those treated with extension or flexion with early limited motion. ‘Compared to all groups, EMS patients had a significant reduction in the incidence of patellofemoral crepitation. ‘As compared to immobilization in extension, CPM re- ~ Adress earespondece an repre request: Alen F. Anderson, NO, ‘ontogede end Sports Medco ine, St homes Medal Saldng, ‘Sule 219, 4250 Hardng Rose, Nash, TH 37205. 154 Nashville, Tennessee duced the need for manipulation, but was not as effec- tive as early limited range of motion. ‘The optimal rehabilitation program included EMS and immobilization in flexion with early limited range of motion. ‘The ACL is frequently injured and the literature is replete with descriptions of surgical techniques and rehabilitation, protocols. Although it is widely accepted that postoperative rehabilitation is a key factor in the recovery of function,” little attention has been given to the clinical effects of postoperative rehabilitation modalities. ‘Trends in rehabilitation are changing® because significant” advances have been made in the understanding of knee biomechanics and the physiology of injury and repair. Pro- longed immobilization has been the traditional treatment for postoperative knee injuries,*** but more recently, lengthy immobilization has been associated with severe alterations in cartilage, ligament, and muscle. Adverse effects of im- mobilization on the biochemistry and ultrastructure of ar- ticular cartilage have been demonstrated ® Driscoll et al.* and Salter et al. described the beneficial effects of CPM on the nourishment and healing of articular cartilage, clear- ance of hemarthrosis, and prevention of intraarticular adhe- Immobilization causes a rapid decline in the biomechani- cal properties of ligament” and bone.® Exercise has been shown to increase the strength and stiffness of ligaments and the ligament-bone unit."°S ‘Many authors have documented the deleterious effects of immobilization on skeletal muscle. Disuse atrophy starts immediately and may be significant in 1 week* Prevention of atrophy and restoration of muscle strength is essential in returning a knee to normal function and preventing reinjury. Isometric muscle training and EMS are commonly used after anterior eruciate reconstruction, although there is some controversy as to the benefits of EMS. Several studies have demonstrated that EMS was effective in increasing strength,“Vol 17, No.2, 1989 in healthy adults."*"*** Others have found no significant, Gifference in strength gains with isometric training and EMS.*-* Ina small study, Eriksson and Haggmark” found that EMS was effective in preventing atrophy in patients ‘undergoing ACL reconstruction. Morrissey et al. found that EMS was not effective in preventing atrophy; however, ‘the decrease in quadriceps strength after immobilization was. ‘smaller in those treated with EMS. Arvidseon et a.” found that EMS after ACL reconstruction was effective in women Dut not in men, whereas Halkjaer-Kristensen and Inge- ‘mann-Hansen™ could not demonstrate any effect of EMS. ‘Although itis clear that prolonged immobilization is det- imental, unprotected motion may cause excessive strain on reconstructed ligaments, leading to ligament failure. Bio- ‘mechanical studies have documented the strain on the ACL with active and passive motion. Paulos et al.” and Daniel et al demonstrated high strain on the ACL during active knee extension from 40° of flexion to full extension. This strain results from quadriceps contraction, which produces ‘an anterior vector force on the tibia. Simultaneous ham- string contraction has been recommended to neutralize the ‘antagonistic effects of quadriceps contraction on the ACL. However, Arms et al* demonstrated that although ham- string contraction reduced the ACL strain, it was inespable of preventing the potentially harmful effects of quadricops contraction unless the knee was flexed more than 40° to 50’ ‘They also demonstrated that passive motion of 30° to 70 produced the least strain on the ACL and the strain was increased maximally in the extremes of flexion and exten- ‘The goals of rehabilitation after ACL reconstruction are to prevent the deleterious effect of immobilization on carti- lage, ligament, bone, and muscle and to protect the recon- structed ligament until healing and maturation occur. Nu- ‘merous therapeutic modalities have been advocated and ‘many are based upon sound scientific principles, yet their effectiveness after anterior cruciate reconstruction hes not been documented. The purpose of this study is to determine the efficacy of five commonly used postoperative modalities. MATERIALS AND METHODS ‘Five groups of 20 patients who underwent the same operative procedure were compared in a prospective randomized study in order to determine the effect of TENS, immobilization in flexion, immobilization in extension, EMS, and CPM. A strict rehabilitation protocol (Tables 1 and 2) was begun preoperatively and each patient was followed for 18 months. Patients who had acute injuries had an initial preoperat clinical examination and patients who had chronic injuries hhad a preoperative subjective assessment and functional and physical examination. The physical examination consisted of clinical evaluation, volumetric thigh measurements, instrumented varus-valgus stress testing, instrumented ACL evaluation with the KT-1000 arthrometer, and Cybex II ‘muscle evaluation. ‘Volumetric thigh measurements were mado in a standard ‘Rehabilitation after ACL Reconstruction 185 ized fashion. Circumferential measurements were taken at the joint line, at the gluteal crease, and at two-thirds the distance from the joint line to the gluteal crease. The vol- ‘umes were calculated for the two truncated cones and the entire thigh. The volumes were calculated using the formula of % H (A+ (AB) +B) where A and B are the areas of two adjacent, parallel, circular faces, and H is the shortest di tance between them. Gould eta. confirmed that the results, of this method yere similar to those of water displacement. and roentgenographic methods, Stress roentgenograms for medial and lateral stability ‘were made using a device that held the leg in 15" of flexion and placed 15 pounds of stress on each knee with the foot, in neutral position. The KT'-1000 is a knoe ligament test ‘instrument that is used to measure displacement of the tibia, ‘on the femur. It was used to measure the passive Lachman, test between 20° and 30° of flexion, the compliance index, and the active anterior drawer test. Accurate and reproduc ible testing can be performed with this instrument."* AP and lateral roentgenograms were used to determine degenerative changes, including Fairbank’s" postmeniscec- tomy changes and osteoarthritis. Hamstring and adios fanction were tested with the Cybex II dynamometer, str following the Cybex protoco.” Measuremente were made ‘on the 180 ft-Ib, 150° scale of 60° (strength) and 180 deg/ sec (power)."° Both the acute and chronic knees had volumetric meas- ‘urements repeated at 6 weeks and 3 months; at 7 months they had volumetries, instrumented anterior cruciate ex- amination with the KT-1000, and Cybex examination; at 12 ‘months they had volumetries and Cybex examination; and at 18 months they had a repeat of the subjective assessment, . functional and physical examination including clinical eval- uation, volumetric thigh measurements, instrumented ‘varus-valgus stress testing, ACL examination with the KT- 1000 arthrometer, Cybex examination, and AP and lateral roentgenograms. Ninety-six of the 100 patients were evalu- ated at 18 months. Four were lost to followup. Five hundred sixty-nine of the possible 576 examinations were performed on these 96 patients. ‘The five groups were similar with respect to sex, age, and degree of ligamentous and meniscal injury (Table 2). Fach hhad reconstruction of the ACL using the semitendinosus and gracilis tendons intraarticularly through isometric drill, holes in bone and the Losee™ procedure extraarticularly. ‘Meniscal repairs were performed on single longitudinal tears in the peripheral 20% of the meniscus. All procedures were performed by the same surgeon. Postoperatively, Group I was placed in a Lipscomb max- imum support knee immobilizer (Zimmer, Inc., Charlotte, NC) in extension for a total of 12 weeks. At 6 weeks, range ‘of motion and full weightbearing was begun. Group TI had the same protocol, except TENS teaching was begun by physical therapy preoperatively (Table 2). TENS electrodes, were placed on each side of the knee and a Modutens (Zimmer, Inc., Charlotte, NC) was used during the entire hospital stay. The Modutens has a biphasic wave form with,