28. APPENDIX G: REHABILITATION PROCEDURE. Rehabilitation procedure

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1 Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries A Randomized study. Draft date , version 10 Page: APPENDIX G: REHABILITATION PROCEDURE Rehabilitation procedure The rehabilitation procedure follows the general principles described below. The protocol is moderately aggressive but avoids exercises with heavy loads on the graft initially. Each level ends with a set of goals to be achieved before the next level of rehabilitation is started. Time intervals are suggested and not superior to the goals. Pain, swelling and general discomfort slows down the rehabilitation process until each levels set of goals can be achieved without any problems. In addition to the protocol below there will be a bank of exercises coupled to each level of rehabilitation. This bank of exercises is formed by all participating physiotherapists and includes their traditional work with patients with deficient ACL. Antiinflammatory drugs (NSAID) may be needed. A lack of extension in ROM shall be carefully analyzed and treated, if necessary with arthroscopy, early in the course. Print date

2 Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries A Randomized study. Draft date , version 10 Page: 53 Unloaded range of motion (ROM) 0-4 weeks 5-8 weeks 9-12 weeks weeks weeks As tolerated As tolerated Normal Normal Normal Goals Muscle function Full extension Flexion > 120 deg Quadriceps: unloaded full control Hamstrings: loaded exercises Exercises for other lower limb muscles and trunk are initiated Full extension Flexion comparable to other side Quadriceps: loaded non-weightbearing in deg and closed-chain (weightbearing) exercises in 0-80 Hamstrings: full ROM Exercises for other lower limb muscles and trunk Comparable to other side Quadriceps: closedchain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk Comparable to other side Quadriceps: openchain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk Comparable to other side Quadriceps: openchain exercises without limitations Hamstrings: exercises without limitations Exercises for other lower limb muscles and trunk Goals Full quadriceps control in sitting and standing Non-surgical: Less than 10% difference in quadriceps and hamstrings strength between legs Surgical: Less than 10% difference in quadriceps and hamstrings strength between legs Print date

3 Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries A Randomized study. Draft date , version 10 Page: 54 Symptoms 0-4 weeks 5-8 weeks 9-12 weeks weeks weeks Pain: tolerated, Pain: tolerated, No pain No pain No pain treated if necessary treated if necessary Occasional activityrelated Occasional activity- Occasional activity- Swelling: tolerated, Swelling: tolerated, swelling related swelling related swelling treated if necessary treated if necessary tolerated tolerated tolerated Goals Walking No morning swelling As tolerated forward and backwards without pain* and limping (initially with crutches) No pain Occasional activityrelated swelling Full weight-bearing Daily walking without restrictions No activity-related pain Occasional activityrelated swelling Full weight-bearing Slow and fast walking on treadmill No activity-related pain Occasional activityrelated swelling Full weight-bearing Running on treadmill/even surface Non-surgical: Unrestricted running No activity-related pain Occasional activityrelated swelling Full weight-bearing Surgical: Unrestricted running Goals Full weight-bearing without pain or limping Crutches may be discharged when patient is able to walk backwards without limping Full weight-bearing Walking without pain or limping Full weight-bearing Walking without pain, swelling or limping Full weight-bearing Non-surgical: Running without pain, swelling or limping Full weight-bearing Surgical: Running without pain, swelling or limping Print date

4 Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries A Randomized study. Draft date , version 10 Page: 55 Balance/ Coordination 0-4 weeks 5-8 weeks 9-12 weeks weeks weeks One-leg standing in functional positions One-leg standing in functional positions on soft ground and Babs-board One-leg standing in functional positions on more demanding surfaces and Babsboard One-leg standing in functional positions on more demanding surfaces Two legged bounces Easy sport-specific movements Easy agility exercises One-leg standing in functional positions on more demanding surfaces One legged bounces Provoked sportspecific movements Provoked agility exercises Goals One-leg standing without difficulties Comparable to other side Comparable to other side Non-surgical: Onelegged hop and square-hop 1 less than 10% difference between legs Surgical: Onelegged hop and square-hop 1 less than 10% difference between legs Print date

5 Frobell BR, Lohmander LS, Roos HP, Roos EM: Surgical vs. Non- Surgical Treatment of ACL-injuries A Randomized study. Draft date , version 10 Page: 56 Activities 0-4 weeks 5-8 weeks 9-12 weeks weeks weeks Unloaded and Surgical: loaded biking on Introduction of stationary bike sport-specific backwards and exercises forwards with clips Biking on stationary bike without restrictions Wet-vest exercises and running in deep water Non-surgical: Outdoor biking without restrictions Biking on stationary bike without restrictions Wet-vest exercises and running in deep water Slide-board training Non-surgical: Introduction of sport-specific exercises Surgical: Outdoor biking without restrictions Goals Action if goal is not reached Unloaded biking forward with clips If ROM, Symptoms, Weightbearing goals are not reached: Doctors Visit Non-surgical: Back to pre-injury activity level Surgical: Back to pre-injury activity level *As tolerated = acceptable pain according to Pain Monitoring System Visual Analog Scale 5 (0-10) (Thomeé 199?) 1 Östenberg et al 1998 Print date

6 Phase days after injury/operation (home practice) Mobility: Lay on your stomack, bend your knee and lift it against the ceiling Vastus medialis: Sit with your X-leg slightly bent with a ball under it. Put the foot against the wall and press the knee towards the ground. Keep the tension in the thigh. Sit on a chair and stand up controlled with even load on both feet.

7 Approximately 2-4 weeks after injury/operation Mobility: Start using bicycle, 8-12min. Lay on your back with your hips and knees in 90` angle with your feet against the wall. Slide your X-leg up and down. Vastus medialis: Stand with your back against the wall and a softball behind your X-knee. Squeeze the ball against the wall.

8 "Norwegian push-ups" Have a ball between your knees, bend and stretch. Stand on the floor, step up on a board...in front...sideways

9 Legpress, start at 90`degrees and stretch your knees. Kneebend with a stick, the hips shall be rotated outwards. Hamstrings: Lay on your back with the X-knee on the pillow, keep your hands around your other knee. Lift your pelvis.

10 Lay on your back with both legs on the pillow. Lift your pelvis and alternately move your legs sideways one at the time. Triceps surae: Stand with your X-knee slightly bent on the step. Take one step up with your X-leg and stretch your knee.

11 Tensor fascia latae: Lean towards the board with the X-knee. Lift your hip away from the board together with the other leg. Balance: Stand with your X-knee on a balanceboard. Stand with your X-leg on the trampoline, bend your knee slightly.

12 Stand with your weight on your X-leg and glide with your other leg sideways and back again, have a small towell under your foot. GOALS FOR PHASE 1: Full extention Flexion>120 degrees

13 Phase 2: Approximately 5-8 weeks after op/injury Quadriceps: Legpress, full ROM Stand up from the chair using only your X-leg. "Stairsteptraining", bend your X-knee deeper.

14 Stand on your X-leg, keep balance with your hands, small quick kneelifts. Balance/Proprioception Stand on your X-leg, pull with your other arm forwards and down. Stand on your X-leg, have the pully around the other leg and pull in all four directions.

15 Stand with your X-leg on the balanceboard and throw a ball in the air. Hamstring: Lay on your back on a board with your X-leg on a Boobathball, hold around your well leg. Lift your pelvis.

16 Triceps surae: Stand on your X-leg placed on a tilted board, and the other leg on the floor. Go up on your toes while your knee stretches and take the other leg forward and up. Complementing treatment: Mobilising patella Stretching of tractus iliotibialis Stretching of quadriceps Stretching of hamstrings GOALS FOR THE PHASE 2: Full control of quadriceps Easily stand on X-leg.

17 Phase 3 Approximately 9-12 weeks after op/injury Lunge in different directions. Rubberbandstraining "Quick walk" on a thick math with a rubberband around your waist. GOALS FOR PHASE 3: Walk fast without limping, pain or swollness. Do onelegged kneebendings to at least 60 degrees kneeflection.

18 Phase 4: Approximately weeks after op/injury Jogging Lunge with medicinball to both sides. Sidestep from stepboard with deep kneebends. Leg extentions

19 Stand on your X-leg with your other leg on a pillow. With weights in your hands, do kneebends. Have a ball between your legs and jump up and down on several stepboards with even legs. GOALS FOR PHASE 4: <10% differense in onelegged jump. <10% differense in legpresstest. No differense in balance. Tests: One-legged jump Balance "Stand up" Kneextentions/flexions