ACLR - outcome measures and end stage rehabilitation

Clare Dohoo Senior II Project

Contents
Review of current class Problems with current format Outcome measures
Pre-class subjective questionnaires Functional assessment

End Stage Rehabilitation

ideas

Why chose this topic?

Running ACL class Are we over and under providing for our patients?

Current Format
1:1 Assessment Refer to ACL class when objective markers met Attend x2 a wk until 20/52 post op ROM, proprioceptive and functional markers taken throughout.

Problems with format

No assessment of patients pre-injury function. All patients attend for same duration and complete same exercise programme. Outcome measures not subjective and functional?

Subjective Outcome Measures

Include: Lysholm Knee Scoring Scale Cincinnati Knee Rating System Tegner Sports Knee Rating System Knee injury and Osteoarthritis Outcome Score (KOOS) Oxford Knee Score Lower Extremity Functional Scale

Lysholm Knee Scoring Scale

Limp Support Stair Climbing Squatting Pain Swelling Instability Locking

Patients suffering from knee instability scored significantly lower than patients with minimal or no instability. Intra-rater reliability and reproducibility
Lysholm et al (1982) and Strik et al

Is responsive, but sensitivity of questionnaire has not yet been established.

Neeb et al (1997)

Tegner Sports Knee Rating System

Details competitive and recreational sports, and occupation. Gives indication on demands placed on knee 2 5 recreational, 9 10 competitive Valuable addition to Lysholm score. Need to be used in combination, as may have a high Lysholm score and still not return to their previous sporting level.
Neeb et al (1997) Erjhed et al (2001)

Knee injury and Osteoarthritis Outcome Score (KOOS)

Looks at symptoms/experiences within the last week. Range from 0-100. 0 extreme symptoms, 100 symptom free.

Moderate to high correlation when comparing to Lysholm knee scoring questionnaire. Sport/Rec and QofL subsets are the most sensitive subscales preoperatively and changes the most post-operatively.
KOOS has high test retest reliability, content validity and construct validity, and have evidence for responsiveness.
Garratt et al (1999)

Functional Outcome Measures

Dominant or nondominant leg? - can be used as a reference guide for outcome from rehabilitation. Petsching et al (1998) Conflicting evidence about correlation between subjective knee scores and functional testing. Phillips et al (2000), Neeb et al (1997) Functional tests produce anterior-posterior instability whereas Tegner score includes rotational instability. Neeb et al (1997)

 The addition of the crossover hop test does add a rotational element to the functional tests.

Should not use hop tests in isolation if all four functional tests are used single hop, cross over hop, timed hop and triple hop was quoted as a 97% accuracy for predicting functional limitation . Eastlack et al (1999) Patients with poor movement discrimination performed best in the hop test, it suggests that good proprioception may not be essential for adequate functional performance. Beard et al (1998)

 Studies have been performed that find fairly good reliability for single hop for distance, triple hop for distance, triple crossover hop for distance and 6meter timed hop. Studies have also been shown that subjects who are ACL deficient may have normal LSIs on hop tests and it is not clear if an LSI is capable of determining a persons overall ability. Fitzgerald (2001) One legged hop and timed hop - moderate sensitivity and high specificity. Noyes et al (1991)

Do ACLR patients need to attend classes regularly?

Evidence suggests that those wishing to return to recreational sport can without the need to attend long courses of group treatment. Those with higher demands on their knees high performance athletes may need further support to allow a return to full function. Risberg et al (2004)

Supporting recreational athletes

Need to offer teaching and patient education on progression of exercises with clear written guidelines and exercise booklet.

Follow up sessions limited number of education sessions.

Offers flexibility to patients to rehabilitate around their daily activities. Risberg et al (2004) Grant et al (2005)

Review of local hospital services

Contacted 11 local hospitals and emailed questionnaire. 5 responses 45% response rate! 1 too late to be included

Hospitals named and shamed!

Chelsea and Westminster Mayday Guys and St. Thomas Hammersmith/Charing Cross Royal Free Queen Elizabeth Greenwich St Georges Lewisham Stanmore St. Marys, Paddington University College Hospital

Comparison of our service. Number of ACLRs Performed in year

300 250 200 150 100 50 0 Ham/CC Mayday Chel/West Guy/Thom KCH

Comparison of our service. Hammersmith and Charing Cross

Weekly class Hydrotherapy initially then gym class Attend for 16 weeks

Comparison of our service. Mayday

Attend circuit class Run by PTA Appt with PT 3/52 to review exercises and set SMART goals for class Attend for as long as is required

Comparison of our service. Chelsea and Westminster

Twice a week Start 2-4/52 post op 2 stages of rehab
level 1 for 6/52 level 2 for further 6/52

Reviews regularly with referring physio Encourage joining gym to reduce reliance

Comparison of our service. Guys and St. Thomas

3 classes a week 90 mins each (8 9.30 W & F, 5.30 7pm M!!) Attend for 6 weeks or until running Return at 6 months to commence rotation and back to sport drills for upto further 6 weeks

Comparison of our service. Pre-injury level Outcome Measures

Only Guys and St. Thomas use subjective questionnaires KOOS on ACL pts LEFs and VAS for all pts in class
Others felt covered in subjective Ax

Comparison of our service. Streaming

None of the hospitals divide the patients according to their pre-injury level All patients appear to have access to the same rehabilitation despite varying demands on their knees.

Comparison of our service. Discharge Outcome measures

Guys and St. Thomas
Vertical jump 3 hops test 3 cross over hops test Measure squat ROM in degrees Flex/ext ROM SLS balance

Comparison of our service. Discharge Outcome measures

Chelsea & Westminster
Crossover hop 3 hop test for distance

Mayday
Hop test Triple jump test Ability to figure of 8 run Shuttle runs Acceleration/deceleration

Comparison of our service. Discharge Outcome measures

Hammersmith & Charing Cross
SLS Hop test Lisholm questionnaire ROM Muscle strength Running/biomechanical Ax

Comparison of our service. Return to Contact Sport

Hammersmith and Charing Cross
6 12 months Rarely able to rehab to return to sport

Mayday
1 year Generally no, but advice re. return to sport

Comparison of our service. Return to Contact Sport

Chelsea and Westminster
Consultant advice - ~ 9/12 Yes, can rehab to return to sport

Guys and St. Thomas

When completed 2nd 6/52 course ~ 8/12 Yes, rehab to return to sport

Proposed Changes to ACLR Rehabilitation

1:1 assessment and treatment as currently provided. Include completion of Tegner scale and KOOS Reach objective markers as now to enable entry to the ACL class Attend ACLR class once a week for 6 weeks Aim of stage 1 class to enable patient to begin independent exercise ideally gym based

 At end of stage 1 complete KOOS Patient continues on an SOS basis independently until 4 months post-operatively. 4 months review with referring therapist

Those with high physical demands are offered the second stage of rehabilitation, Tegner > 2
Attend stage 2 ACLR rehabilitation class for further 6 weeks once a week

 Aim of stage 2 class to introduce cutting and turning, rotational stresses and sport specific training/advice.

At end of stage 2 complete KOOS, Tegner and hop test as currently performed.
Patient is discharged confident to return to their pre-injury sporting levels.

References
Beard et al (1998) How important is proprioception? The relationship between active kinaesthesia and the functional hop test after ACL reconstruction. Australian Conference of Science and Medicine in Sport. Adelaide 13-16 October 1998. Briggs et al (2005) Reliability, validity and responsiveness of the Lysholm Knee Score and Tegner Activity scale for patients with meniscal injury of the knee. Fitzgerald (2001) Hop tests as predictors of dynamic knee stability JOSPT Vol. 31 No.10 Garratt et al (1999) Patient-assessed health instruments for the knee: a structured review. Grant et al (2005) Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomised clinical trial. The American journal of Sports Medicine Sept 33(9) 1288-1297 Hooper et al (2002) Test-retest reliability of knee rating scales and functional hop tests one year following anterior cruciate ligament reconstruction. Physical Therapy in Sport 3, 10-18.

Neeb et al (1997) Assessing Anterior Cruciate ligament injuries: the association and differential value of questionnaires, clinical tests, and functional tests. JOSPT (vol. 26, no.6) Petsching et al (1998) The relationship between isokinetic quadriceps strength test and hop tests for distance and one-legged vertical jump test following anterior cruciate ligament reconstruction. JOSPT 28(1) Phillips et al (2000) Outcome and progression measures in rehabilitation following anterior cruciate ligament injury. Physical Therapy in Sport 1, 106-118 Risberg et al (1994) Assessment of functional tests after anterior cruciate ligament surgery. JOSPT vol 19,no 4 Risberg et al (2004) A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Physical Therapy in Sport, 5, 125-145

Questions?