December 2009

Early, active ACL rehab maximizes ROM

By Barbara Boughton

Achieving full range of motion is a key outcome of any rehabilitation program after ACL reconstruction. But what are the ingredients of a rehabilitation program that produces the best outcomes in terms of ROM?

One is early and active rehabilitation, most exercise and orthopedics experts agree. But there is still some debate about the usefulness and safety of certain types of exercise early in the rehabilitation process—i.e. open versus closed chain exercises. Other key ingredients for successfully restoring ROM are creative and varied exercises that motivate the patient and enable him or her to enjoy therapy, experts say.

Since the early 1990s, it’s been known that early and active rehabilitation produces better outcomes than recovery programs that include long periods or weeks of immobilization. The benefits of aggressive early rehabilitation after reconstruction using a patellar tendon-bone graft are unquestioned. But researchers have even found that three-day immobilization is superior to two-week immobilization, even when a multistranded hamstring is used in reconstruction, according to a study published in Knee in 2007.

“What’s important is performing activities that will optimize the return of function, while not compromising the graft,” said Craig Bottoni, MD, sports medicine orthopedic surgeon.

At about three months, particularly after allograft reconstruction, the patient will experience significantly decreased pain, and improved motion and strength. But experts caution that at this point, the graft is actually at its weakest point as it undergoes remodeling, and too much exercise is a danger. Unfortunately, because they often feel better, many patients try out activities that may compromise the graft during this time period.

“That’s when they rupture the graft,” said Jonathan Chang, MD, clinical assistant professor of orthopedics at the University of Southern California.

Bottoni and Chang both favor using only closed chain exercises during the rehabilitative period, because these exercises produce less stress on the graft, they say.

“As a general rule of thumb, it’s probably safe to allow open chain exercises only after a year’s time following surgery,” Chang said.

Yet some research has indicated that there’s no difference in healing response or pain when open or closed chain exercises are used during rehabilitation. And sports medicine experts such as Tim Hewett, PhD, utilize both open and closed chain exercise even in early phases of rehabilitation.

“But you need to do both within reasonable ranges,” said Hewett, professor and director of the Sports Medicine Biodynamics Center at Cincinnati Children’s Hospital and the University of Cincinnati. “In the early phase of rehabilitation you want to stay away from open chain exercises that have terminal extension, because higher loads occur near full extension. With closed chain exercises, you should stay away from deep flexion, because that creates strain.”

Another key outcome in rehabilitation after ACL reconstruction is symmetry between limbs in terms of both strength and range of motion. In fact, symmetry in range of motion is one of the outcomes Hewett tests for before returning the athlete to sports. Although return to sports should be based on achieving rehab goals rather than an abstract timetable, the process often takes at least six months, and sometimes up to one year.

Hewett believes that variety is the key to achieving full ROM after ACL reconstruction.

“There isn’t just one set of exercises that’s the answer for rehabilitation—but many different varied types of exercise. You need to use exercise during rehabilitation that will load the joint in many varied ways to prepare the athlete for return to sport,” he said.

Creativity, specifically in encouraging patients to do exercises at home, can also enhance compliance.

“Virtually any kind of exercise to rehabilitate from an ACL can be done from a home setting,” Chang said. “All it takes is a little imagination.”

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