7/26/2011. Knee Disorders: ICF practice guidelines. Authors

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1 Authors Knee Disorders: ICF practice guidelines Orthopaedic Section of the American Physical Therapy Association February 10, 2011 David Logerstedt, PT, MPT 1 Lynn Snyder-Mackler, PT, ScD, FAPTA 1,2 Richard Ritter, PT, DPT 3 Michael J Axe, MD 2,4 Joseph Godges, PT, DPT, OCS 5 1 Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware 2 Department of Physical Therapy, University of Delaware 3 UCSF/SFSU Graduate Program in Physical Therapy 4 First State Orthopaedics, Newark, DE 5 School of Allied Health Professions, Loma Linda University Knee Classification APRIL 2010 Volume 40, No. 4 June 2010 Volume 40, No. 6 Risk factors Knee Disorders Diagnosis/Classification 1

2 Stability and Movement Coordination Impairments Body functions stability of single joint control of complex voluntary movement Body structures knee joint muscles of thigh muscles of lower leg structures of lower leg, specified as ligaments Activities and Participation completing daily routine moving around, specified as direction changes while walking or running Stability and Movement Coordination Impairments Most literature has focused on injuries to the anterior cruciate ligament Incorporates both acute injury/non-operative care and post-surgical management Up to 250,000 injuries/year in US ~ 100,000 ACL reconstructions 70% noncontact Greater in sports with multidirectional movement 20% athletic knee injuries Risk factors-noncontact ACL Clinicians should consider as predisposing factors for the risk of sustaining a noncontact anterior cruciate ligament (ACL) injury. (Recommendation based on Non-operative care Clinical course Environmental Shoe-surface interaction Anatomical Increased body mass index Narrow femoral notch width Increased joint laxity Hormonal Preovulatory phase of the menstrual cycle in females Neuromuscular Combined loading pattern Strong quadriceps activation during eccentric contractions Hewett 2005 Outcomes Improve over time Previous level of activity Up to 42% resume pre-injury activity w/in 3 years Select group (potential coper): 72% returned for limited period Clinical course Diagnosis/Classification Post-operative care Outcomes Improve over time Up to 25% may have knee extension loss Quadriceps strength deficits may persist Previous level of activity Up to 92% resume pre-injury activity by 1 year Deceleration/acceleration w/ valgus load at or near full extension Hear or feel a pop Hemarthrosis w/ 0-2 hours Hx of give way Loss of end range knee extension Lachman test w/ nondiscrete endfeel and increased anterior tibial translation Positive pivot shift test 6-m timed hop test < 80% MVIC quadriceps strength < 80% 2

3 Diagnosis/Classification Small % successfully return to sport w/o ACL surgery in short term Screening exam Giving way episodes < 1 Classification 6-meter timed hop > 80% limb symmetry index KOS-ADLS > 80% GRS > 60% Classification status Potential coper: Meets all criteria Non-coper: Does not met at least one criteria Outcome measures Self reported knee injury scales Health questionnaire SF-36 Patient-reported outcome measure KOS-ADLS - Lysholm Knee Scale KOOS - Cincinnati Knee Rating Scale IKDC 2000 Activity scale Tegner Activity Level Scale Marx Activity Level Scale Activity limitation/participation restriction measures Single-limb hop testing Physical impairment measures Effusion Range of motion Ligament stability Muscle strength Sturgill 2009 Continuous Passive Motion Clinicians can consider using continuous passive motion in the immediate postoperative period to decrease postoperative pain. (Recommendation based on weak Early Weight Bearing Early weight-bearing can be used for patients following ACL reconstruction without incurring detrimental effects on stability or function. (Recommendation based on weak Knee bracing The use of functional knee bracing appears to be more beneficial than not using a brace in patients with ACL deficiency. (Recommendation based on weak The use of immediate postoperative knee bracing appears to be no more beneficial than not using a brace in patients following ACL reconstruction. (Recommendation based on Conflicting evidence exists for the use of functional knee bracing in patients following ACL reconstruction. (Recommendation based on conflicting 3

4 Immediate vs delayed mobilization Clinicians should consider the use of immediate mobilization following ACL reconstruction to increase range of motion, reduce pain, and limit adverse changes to soft tissue structures. (Recommendation based on Cryotherapy Clinicians should consider the use of cryotherapy to reduce postoperative knee pain immediately post-acl reconstruction. (Recommendation based on weak Supervised rehabilitation Clinicians should consider the use of exercises as part of the in-clinic program, supplemented by a prescribed homebased program supervised by a physical therapist in patients with knee stability and movement coordination impairments. (Recommendation based on moderate Therapeutic exercise Clinicians should consider the use of non weight-bearing (open chain) exercises in conjunction with weight-bearing (closed chain) exercises in patients with knee stability and movement coordination impairments. (Recommendation based on strong Neuromuscular electrical stimulation Neuromuscular electrical stimulation can be used with patients following ACL reconstruction to increase quadriceps muscle strength. (Recommendation based on Neuromuscular reeducation Clinicians should consider the use of neuromuscular training as a supplementary program to strength training in patients with knee stability and movement coordination impairments. (Recommendation based on moderate Accelerated rehabilitation Rehabilitation that emphasizes early restoration of knee extension and early weight bearing activity appears safe for patients with ACL reconstruction. No evidence exists to determine the efficacy or safety of early return to sports. (Recommendation based on Eccentric strengthening Clinicians should consider the use of an eccentric exercise ergometer in patients following ACL reconstruction to increase muscle strength and functional performance. (Recommendation based on Pain and Mobility Impairments Body functions pain in joints mobility of single joint gait pattern functions Body structures bones of thigh bones of lower leg knee joint structures of lower leg, specified as fibrocartilage/hyaline cartilage Activities and Participation completing daily routine moving around, specified as direction changes while walking or running 4

5 Pain and Mobility Impairments Incorporates both acute injury/non-operative care and postsurgical management Meniscus Incidence 12-14%, prevalence 61/100,000 persons 10-20% all orthopaedic surgeries Articular cartilage 32-58% lesions due to traumatic, noncontact Medial femoral condyle, patella articular surface Medial meniscus tears (37%), ACL tears (36%) Risk factors-meniscus Predisposing factors for having a meniscal injury Patients age Greater time from injury More likely to have late meniscal surgery Participated in high-level sports Increased knee laxity after ACL injury (Recommendation based on weak Risk factors-articular cartilage Clinical course Odds of having a chondral lesion subsequent to having an ACL injury Patients age Presence of a meniscal tear Predictive factors of the severity of chondral lesions Greater a patient s age Longer time from initial ACL injury Associated with the number of chondral lesions Time from initial ACL injury Knee pain and mobility impairments associated with meniscal and articular cartilage tears can be the result of a contact or noncontact incident, which can result in damage to 1 or more structures. Clinicians should assess for impairments in range of motion, motor control, strength, and endurance of the limb associated with the identified meniscal or articular cartilage pathology following meniscal or chondral surgery. (Recommendation based on weak (Recommendation based on weak Meniscus lesions Diagnosis/Classification Twisting injury Tearing sensation Delayed effusion History of catching or locking Pain with forced hyperextension Pain with maximum flexion Pain or audible click with McMurray s maneuver Joint line tenderness Discomfort or a sense of locking /catching in the knee over either joint line during the Thessaly Test at 5 or 20 of knee flexion Articular cartilage lesions Acute trauma with hemarthrosis (0-2 hours) (associated with osteochondral fracture) Insidious onset aggravated by repetitive impact Intermittent pain and swelling History of catching or locking Joint line tenderness Outcome measures Self reported knee injury scales Health questionnaire Patient-reported outcome measure Activity scale 5

6 Activity limitation/participation restriction measures Single-limb hop testing 6-minute walk Timed up-and-go Stair measure Physical impairment measures Effusion Range of motion Strength Joint line tenderness Other tests Progressive knee motion Clinicians may utilize early progressive knee motion following knee meniscal and articular cartilage surgery. (Recommendation based on weak Progressive weight bearing There are conflicting opinions regarding the best use of progressive weight bearing for patients with meniscal repairs or chondral lesions. (Recommendation based on conflicting Progressive return to activity Clinicians may utilize early progressive return to activity following knee meniscal repair surgery. (Recommendation based on weak Clinicians may need to delay return to activity depending on the type of articular cartilage surgery. (Recommendation based on theoretical Supervised rehabilitation There are conflicting opinions regarding the best use of clinic-based programs for patients following arthroscopic meniscectomy to increase quadriceps strength and functional performance. (Recommendation based on conflicting Therapeutic exercise Clinicians should consider strength training and functional exercise to increase quadriceps and hamstrings strength, quadriceps endurance, and functional performance following meniscectomy. (Recommendation based on Neuromuscular electrical stimulation Neuromuscular electrical stimulation can be used with patients following meniscal or chondral injuries to increase quadriceps muscle strength. (Recommendation based on R01 HD Funding Sources PODS I scholarship

7 Knee stability and movement coordination Roy D. Altman, MD Anthony Delitto, PT, PhD Amanda Ferland, DPT Helene Fearon, PT G. Kelley Fitzgerald, PT, PhD Freddie H. Fu, MD Joy MacDermid, PT, PhD James W. Matheson, DPT Philip McClure, PT, PhD Andrew Naylor, DPT Paul Shekelle, MD, PhD A. Russell Smith, Jr., PT, EdD Leslie Torburn, DPT Reviewers Knee pain and mobility Roy D. Altman, MD Constance Chu, MD Anthony Delitto, PT, PhD John Dewitt, DPT Amanda Ferland, DPT Helene Fearon, PT G. Kelley Fitzgerald, PT, PhD Joy MacDermid, PT, PhD James W. Matheson, DPT Philip McClure, PT, PhD Paul Shekelle, MD, PhD A. Russell Smith, Jr., PT, EdD Leslie Torburn, DPT Lynn Snyder-Mackler, PT, ScD, FAPTA Richard Ritter, PT, DPT Michael J Axe, MD Joseph Godges, PT, DPT, OCS Orthopaedic Section of APTA Journal of Orthopaedic and Sports Physical Therapy 7

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