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Similar results with accelerated, delayed rehab after ACL reconstruction
Researchers theorized the 32-week delayed rehabilitation program could be reduced by several weeks without affecting outcomes.
KEYSTONE, Colo. — Investigators compared an accelerated vs. a delayed rehabilitation protocol for patients who underwent ACL reconstruction and found that both programs achieved similar results at two-year follow-up.
These findings highlighted several important issues. To a certain extent they showed that more aggressive postop ACL rehab might not be as detrimental as once thought. They also suggested that perhaps thousands of dollars in physical therapy expenses and lost time at work and play might be saved each year if patients completed their rehabilitation programs even a few weeks earlier than expected.
“Knee biomechanics change during the initial six months of healing. Both of the programs we studied showed similar increases in combined anterior knee translation and internal rotation of the tibia relative to the femur. Our two-year follow-up showed that both programs had the same effect on clinical outcome, patient-oriented outcome, functional outcome, activity levels, as well as knee proprioception,” said Bruce D. Beynnon, PhD, professor of orthopedics and director of research in the department of orthopedics and rehabilitation, University of Vermont, Burlington.
Beynnon presented the findings at the American Orthopaedic Society for Sports Medicine (AOSSM) 2005 Annual Meeting. They consisted of results, including knee proprioception outcomes, beyond those of a prior study the researchers conducted, which were published in March in the American Journal of Sports Medicine.
Two-incision B-PT-B technique
All patients underwent arthroscopically assisted, two-incision ACL reconstruction done by one of two surgeons using a central-third, bone-patellar tendon-bone autograft. The researchers excluded patients with any other knee pathology. The surgeons operated on patients who were 18 to 50 years old and had a preop Tegner activity scores of 5 or greater.
The researchers randomized the patients postoperatively to a nonaccelerated or accelerated rehabilitation program administered by one therapist; each group had 21 patients.
The study was double blinded. Only the therapist knew which patients followed which rehabilitation program.
Beynnon said investigators based the rehab protocols on previous research. “Our choice of what exercise to prescribe and when to prescribe them was based on the strain biomechanics of the normal ACL characterized in our prior research.”
Investigators hypothesized that there would be “no difference between an accelerated and nonaccelerated (or delayed) rehabilitation program in terms of anterior-posterior displacement of the tibia relative to femur and the coupled internal rotational laxity (primary outcome)” and other important secondary outcomes for pain, function, patient satisfaction and quality of life, Beynnon said.
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COURTESY: BRUCE D. BEYNNON |
Both patient groups performed identical exercises. Investigators used a special system to track compliance, which was similar in both groups. The only difference was the time at which specific exercises were started. For example, patients in the accelerated group began total knee extension exercises with progressive resistance at five weeks postop; those in the delayed group started at 12 weeks.
19-week program
The accelerated program lasted 19 weeks, whereas the delayed program lasted 32 weeks.
“Our two-year follow-up captured 85% of our patients,” Beynnon said. He told ORTHOPEDICS TODAY that investigators planned to stay in contact with all the patients and follow them up again at four and six years postop.
At follow-up, the researchers administered the Tegner activity scale, the Knee Osteoarthritis Outcome Score to track activities of daily living, symptoms, pain and quality of life, function and knee proprioception. They also performed three-dimensional (3-D) radiostereophotogrammetric analysis or RSA of tibia position relative to the femur, something not included in the earlier pilot study done by the group.
“We measured the 3-D changes in the envelope of joint laxity is. ... That's really the advance here — more accurate, reliable and comprehensive measures of joint biomechanics.”
Beynnon and his co-investigators received the O'Donoghue Award from the AOSSM for this research.
For more information:
- Beynnon BD, Johnson RJ, Brattbakk B, et al. Rehabilitation of the knee following anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft: A prospective, randomized, double-blind comparison of accelerated versus delayed programs. Presented at the American Orthopaedic Society for Sports Medicine 2005 Annual Meeting. July 14-17, 2005. Keystone, Colo.