ACL rehab (Full Version)

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pappawheelie -> ACL rehab (March 3, 2008 6:01:54 PM)

I have a young woman 18 days s/p ACL reconstruction (cadaver graft).  Extension is lacking 20 degrees and flexion limited to about 50 degrees.  She complains that her knee really hurts.  ROM is limited by pain. 

So I'm interested in how hard to push ROM at this point and how other therapists would approach this scenario.  Personally, I've never had a client that was THIS stiff and sore after an ACL repair and have not had to use bullet-biting force.  Part of me is saying "don't panic, the ROM will return with time and persuasion," but the other half is thinking "we've gotta move this!"

I did have a clinical instructor who told me I had too much human compasion to be an effective therapist, and the subject of how much force has been brought up recently in certain threads, so I'm interested to hear what people say.

One other thing, after our first visit she did not report being sore even though she did cry "because it hurts".

Thanks 




orthotherapist -> RE: ACL rehab (March 3, 2008 6:13:32 PM)

If she is that painfull I would venture to guess that she is non-compliant with her HEP.  I have found that high frequency/low intensity ROM is most beneficial for regaining post op ACL ROM.  If she fails to do this at home and instead waits for therapy she will continue to be limited and painful which will prevent goal attainment.

In other words if she is doing her HEP regularly you should not have to use bullet biting force



Tom Reeves DPT ATC -> RE: ACL rehab (March 3, 2008 6:20:31 PM)

I agree.  I have seen 100s of ACLs and TKAs.  They behave the same.  The tough/compliant patients get better, the whimps/non-compliants don't.

You could try some gentle pa and ap tibial glides.  OR numb her up with ice. None of it will work though unless she ponies up and participates in her own recovery.



Sebastian Asselbergs -> RE: ACL rehab (March 3, 2008 6:26:11 PM)

I am tempted to say: "don't push it hard ".  Get your hands on, move the knee joint, skin, scar and the whole shebang nice and gently - let her and her nervous system get "used" to your touch, let her get more relaxed and I bet she will already feel less in agony.  She likely IS so stiff and sore due to very strong post-surgical (and maybe pre-surgical) neuromuscular defensive reflexes - those are enhanced by anxiety and stress - so, pushing harder is not exactly gonna help right now.
I would work with repetitive, gentle ROM within the pain limits, help her learn how "teasing" the limits feels, tell her about the pain being an alarm system set a little TOO sensitive right now...  etc etc


Good luck.



Sebastian Asselbergs -> RE: ACL rehab (March 3, 2008 6:29:45 PM)

Tom , I am sure you don't mean there there are  only 2 types in post-ACLs?  I have seen patients with horrible traumas getting big ACL enhancements and having great difficulty in rehab - while motivated to the max (one of them a store-owner - losing money every day he wasn't walking 10 miles....) - and the opposite, big trauma, big repair, easy rehab and doing minimal homework... and everything in between....



Tom Reeves DPT ATC -> RE: ACL rehab (March 3, 2008 7:36:58 PM)

Seb,
No I was oversimplifying a bit. OK a lot.  but if you hear hoofbeats, in the US and our neighbors to the north, you expect to see horses.  First ask the patient how much she is doing her HEP at home.  then, if she is compliant, she may need to back on the intensity and increase the frequency of "teasing the limits" (I like that phrase) 

Gentler is usually better with the tough ones but they MUST be doing their stuff at home.  They need to avoid the "happy position" when they sit down, they need to use the motion that is available to them during daily life and use the rational side of their brain to overcome what the lizard brain tells them to avoid.



jma -> RE: ACL rehab (March 3, 2008 10:56:51 PM)

The one thing that I learned from post-ACL repair/reconstructions, is that if it isn't 90 degrees within two weeks, then the orthopedic surgeon is quickly consulted. This usually results in a quick followup and then the surgeon takes it from there.



Sebastian Asselbergs -> RE: ACL rehab (March 3, 2008 11:09:43 PM)

Tom, I thought so. And I totally agree with the general issue of HEP compliance.



bobmfrptx -> RE: ACL rehab (March 4, 2008 12:45:14 PM)

quote:

ORIGINAL: Sebastian Asselbergs

I am tempted to say: "don't push it hard ".  Get your hands on, move the knee joint, skin, scar and the whole shebang nice and gently - let her and her nervous system get "used" to your touch, let her get more relaxed and I bet she will already feel less in agony.  She likely IS so stiff and sore due to very strong post-surgical (and maybe pre-surgical) neuromuscular defensive reflexes - those are enhanced by anxiety and stress - so, pushing harder is not exactly gonna help right now.
I would work with repetitive, gentle ROM within the pain limits, help her learn how "teasing" the limits feels, tell her about the pain being an alarm system set a little TOO sensitive right now...  etc etc


Good luck.

Then just say it Bas...Tempted!
The first thing to do after any surgery is to treat the pain system.  Gentle transverse plane releases to soothe the fascia, Nervous system, protective reactions, fear ....I really don't care what you call it...Neuromodulation, unwinding, simple contact, grade 1 don't bend the flys knees mobs....It allows exactly what Bas was tempted to say happen.
After that obtaining ROM is easy!!! Or you could just blame the patient for your inadequacy...must be a whimp!
Keep that attitude it is good for my business. 
Keep the human compassion it works just learn gentle handling techniques first then progress to the movement phases...Ice is for edema you do want the client to feel, it is therapeutic.
my two cents.
let the bashing begin



proud -> RE: ACL rehab (March 4, 2008 1:26:28 PM)

quote:


Keep that attitude it is good for my business. 


No, what's good for your business is the fact that the conservative NMSK industry has yet to establish regulations on exactly what defines an expert. Despite skyrocketing NMSK associated costs.

So far, it's been free rein for massuers, Chiro's and yes...PT's to milk the patient satisfaction gravy train for all it's worth. I mean hey...if I have back pain would I "feel" satisfied with a rub job and a strange jolt of electricity? Or perhaps some odd guru type touching me gently and stretching my skin? If I did not know any better, I bet I would.

Would it fundamently change the long term outcome? Nope.

So yes Bob, keep milking, you have been at it for 26 years I heard so when regulation and close scrutiny of outcomes arrive full force...you will be off counting the dirty money leaving the younger generation of evidence based PT's to mop up your mess.



bobmfrptx -> RE: ACL rehab (March 4, 2008 1:32:02 PM)

quote:

ORIGINAL: proud

quote:


Keep that attitude it is good for my business. 



Would it fundamently change the long term outcome? Nope.

So yes Bob, keep milking, you have been at it for 26 years I heard so when regulation and close scrutiny of outcomes arrive full force...you will be off counting the dirty money leaving the younger generation of evidence based PT's to mop up your mess.


Proud....of what????
My outcomes are better than the exercise mill down the street.
I average less than 10 visits per client.  Two year follow ups via patient  survey reveals less than 10 percent recurrence.
Bring on the outcome studies your youthfulness!
I'll match you right along.
Sorry to burst your pumped up bubble mate just the facts.
Bob



proud -> RE: ACL rehab (March 4, 2008 1:45:41 PM)

quote:


Proud....of what????
My outcomes are better than the exercise mill down the street.
I average less than 10 visits per client.  Two year follow ups via patient  survey reveals less than 10 percent recurrence.
Bring on the outcome studies your youthfulness!
I'll match you right along.
Sorry to burst your pumped up bubble mate just the facts.
Bob


And this would be published where exactly?

Sorry "bob", based on your "right leg theory" over in the neck discussion, you have no research credibility in the eyes of most here.



pappawheelie -> RE: ACL rehab (March 4, 2008 1:46:42 PM)

Thanks to everyone who replied and it's nice to see that a simple ROM question can spark some banter and bashing. 

Probably helpful to note that the surgeon held her out for two weeks during which time she reported she did nothing.  Also, the tone in her hams is remarkable--like a stretched out bungie cord.  And she is pretty freaked out by the whole thing.  Therefore, gentle persuasion does seem like the route to go.  I haven't seen hundreds of ACLs--far from it, but I have heard stories about therapists really laying into people and have always wondered if it was true and or necessary.

As far as her exercises she is sposed to be working on seated hamstring stretches, prone knee hangs, propping heel on a bolster, and quad sets (seated)for knee extension.  For flexion she is performing assisted heel slides supine and seated, wall slides (supine), prone knee flexion, and just letting her leg hang  (like sitting on a high stool).

Generally I will start with heat and soft tissue work, then work flexion and extension actively with assistance and passively.  Feel free to add.




pappawheelie -> RE: ACL rehab (March 4, 2008 1:53:04 PM)

Sometimes post-ACL patients arrive a few days after surgery, sometimes two weeks--how soon after surgery are you guys seeing your patients?



bobmfrptx -> RE: ACL rehab (March 4, 2008 2:50:02 PM)

I see knee patients the next day after surgery.  The Orthopod I work with likes it that way best.  I also get the clients 7 to 8 weeks post surgery who failed to respond to the therapy they recieved.  In my opinion formed by years of service in this business it is not necessary to yank and crank.

It seems that some on here feel that to be correct one must be published.
So go jump out a window and tell me if gravity exists. 

My PTOS system tracks my outcomes...shall I publish them as well as anecdotal evidence with pt. surveys.  Seems they would be worthless in the eyes of most here as well. 



proud -> RE: ACL rehab (March 4, 2008 3:27:10 PM)

quote:

So go jump out a window and tell me if gravity exists.


The classic choice of the anecdodally inclined. I recall a cranio-sacral therapist sent me this beaut:

[url]http://www.bmj.com/cgi/content/full/327/7429/1459[/url]

YOU as an individual don't have to be published "Bob", but much of what you do should have some reference attached I think( plenty of literature out there). And sorry but"....Gentle transverse plane releases to soothe the fascia..." make my eyebrow raise.

And yes, the "right leg" theory was pretty worthless because you presented it as fact rather than theory and could not back up the claims when asked. That will tend to land you in hot water with the new generation of evidence based PT's. As well it should. I make no apologies for it.



pappawheelie -> RE: ACL rehab (March 4, 2008 4:05:54 PM)

I just saw another client post-ACL who told me that after her surgery she laid in bed for two weeks and DID NOTHING.  She is 51yo and has full ROM with really no problems (now about 12 s/p).  The first time I saw her she had about 110 degrees of flexion and hardly any pain.  Just an illustration of how differently people respond to the same/similar proceedure by the same surgeon.  Makes me wonder what the difference is...

On another note, I've been wondering why there are not more outcome surveys published.  With all of the claims posted in these threads about excellent outcomes, why not publish them, especially if the data is being collected.  Where do outcome studies stand as far as research is concerned? 

Bob-how does your system track outcomes and does it include interventions?  I'd really like to know more about it. 






bobmfrptx -> RE: ACL rehab (March 4, 2008 6:50:43 PM)

PTOS is my billing system from APS software.  The outcomes reports tracks diagnosis, when started, treatments and duration.  There are limited ways to input the parameters. They are on the web.
www.ptos.com
bob



orthotherapist -> RE: ACL rehab (March 5, 2008 10:13:13 AM)

Bob,

Those do not sound like outcomes but strictly stats.  Does it let you track objective improvements etc that occur within those number of visits?

A crappy therapist may show 3 visits on average for low back pain - but actually patients stopped coming after an average of three visits because they were not getting any benefit from the therapy. 

If the data does not show pre and post fucntional status the numbers really do not mean anything.

Just my opinion




proud -> RE: ACL rehab (March 5, 2008 10:22:14 AM)

quote:

ORIGINAL: orthotherapist

Bob,

Those do not sound like outcomes but strictly stats.  Does it let you track objective improvements etc that occur within those number of visits?

A crappy therapist may show 3 visits on average for low back pain - but actually patients stopped coming after an average of three visits because they were not getting any benefit from the therapy. 

If the data does not show pre and post fucntional status the numbers really do not mean anything.

Just my opinion




Yep. Now we have someone who understands outcome data.



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