9 14 16 PRISM Syllabus
2016-09-14
: Pdf 9 14 16 Prism Syllabus 9_14_16_PRISM_Syllabus 9 2016 pdf
Open the PDF directly: View PDF 
.
Page Count: 23
| Download | |
| Open PDF In Browser | View PDF |
9/13/2016 Management of Adolescent ACL Injuries: Treatment Outside of the Operating Room: Prevention Christin Zwolski, PT, DPT, OCS Cincinnati Children’s Hospital Medical Center No Disclosures Christin Zwolski, PT, DPT, OCS Cincinnati Children’s Hospital Medical Center How To Prevent an ACL Injury? Neuromuscular Training (NMT) • Plyometric training • Biomechanical technique training • Strength training • Balance training • Core stability training 1 9/13/2016 AAOS Management of ACL Injuries CPG AAOS Management of ACL Injuries CPG Studies that Favor NMT Olsen et al. 2005 (M) • NMT warm-up programs Caraffa et al. 1996 (M) Mandelbaum et al. 2005 (L) • All demonstrate significant reduction in ACL injuries after training Overall strength of study: M=moderate L=low 2 9/13/2016 Studies Found Not Signifigant Gilchrist et al. 2008 (M) Petersen et al. 2005 (M) LaBella et al. 2011 (M) Soderman et al. 2000 (M) Heidt et al. 2000 (M) Hewett et al. 1999 (H) • All suggest NMT can be preventative • Lack large number of exposures Overall strength of study: M=moderate H=high Small Effect Size (AAOS CPG) • NNT = 109 More Recent Evidence… • 72% reduction in ACL injury rates in girls <18 years old vs. 16% risk reduction for those ≥18 years old (LaBella et al. 2014) • Meta-analysis of Level 1 RCTs of soccer players: NMT has protective effect (Grimm et al. 2014) • Neuromuscular and proprioceptive prevention programs reduce ACL injuries by 50.7% (Donnell-Fink et al. 2016) 3 9/13/2016 Most Effective NMT Programs • • • • • • Duration: minimum of 6 weeks Frequency: >1x/week Comprehensive (with strength training) Combined pre- and in-season training Short bursts of activity Real-time Feedback with external-focus instructional strategies • Timing: Early pubertal maturation Benjaminse et al. 2015, Ford et al. 2015, Sugimoto et al. 2015, Hewett et al. 2006 Bonus! Participation in NMT can lead to improved sports performance: • LE and abdominal strength • Vertical jump height • Estimated maximal aerobic power • Speed • Agility • Isokinetic strength • Balance Noyes et al. 2012, DiStefano et al. 2010 Cost-Effective Analysis Swart et al. 2014: On average, the implementation of a universal training program would… • Save $100 per player per season • Reduce the incidence of ACL injury from 3% to 1.1% per season 4 9/13/2016 What happens after one NMT session? Root et al. 2016: • Landing technique improves (LESS) • Does not impair sport performance (vertical jump, long jump, shuttle run) Limitations of NMT Research • Lack of high-strength, double-blind RCTs • Low generalizability (i.e. study populations) • Heterogenous protocols • Lack of compliance Future NMT Research • Multi-site studies using standardized NMT program • Larger sample sizes of high-risk athletes • Optimization of protocols • Improved delivery 5 9/13/2016 Risk Assessment • Tuck Jump (Myer et. al 2008) • Drop Vertical Jump (DL and SL) (Redler et al. 2016) • Landing Error Scoring System (LESS) (Padua et al. 2015) ACL Injury Prevention Programs • Prevent Injury and Enhance Performance (PEP) • Knee Ligament Injury Prevention (KLIP) • FIFA 11+ • FIFA 11+ Kids • Sportsmetrics Thank You! Christy Zwolski, PT, DPT, OCS Christin.Zwolski@cchmc.org 6 9/13/2016 Management of Adolescent ACL Injuries: Work-up Attending Physician, Primary Care Sports Medicine Department of Pediatric Orthopedic Surgery The Children’s Hospital of Philadelphia • ACL rupture is typically caused by rotation/translation of the knee with foot planted; often non-contact • Physical Exam: • • • • Effusion and decreased ROM common Lachman and/or anterior drawer: increased anterior translation of tibia Lachman is very sensitive and specific Pivot shift • KT-1000 1 9/13/2016 • Should be done at initial assessment • Utility: rule out fractures, evaluate physes • Obtain 4 views: AP, lateral, tunnel, sunrise • Associated fractures may include: • Segond fx: lateral tibial condyle avulsion • Lateral femoral condyle impaction • Tibial spine avulsion • In practice, insurance likely requires radiographs prior to advanced imaging Segond fracture • Sensitivity and specificity generally 95+% • A number of articles describe similar accuracy for clinical evaluation • MRI is most useful for confirming the diagnosis and defining associated injuries • In practice it is necessary prior to surgical intervention 2 9/13/2016 • ACL may appear thick with increased intra-substance signal on T2 images • May see complete rupture with lack of fiber continuity, or possible avulsion type rupture • Bone bruise pattern: posterior lateral tibial plateau and lateral femoral condyle • Assess for associated injuries: menisci, articular cartilage MRI: ACL rupture • Starts from the time we suspect ACL tear clinically • Discuss the importance of attaining normal knee motion and maintaining quad strength pre-operatively • May need pre-op physical therapy • Protection: brace, crutches, weight bearing status? • Consider the emotional impacts • Know some timelines for your surgeons 3 9/13/2016 • Graft choice depends on several factors • Patient age, skeletal maturity • Surgeon experience • In adolescents the most common options are autograft hamstrings or cadaver graft • Hamstrings obtained from ipsilateral knee 4 9/13/2016 Management of Adolescent ACL Injuries: Treatment Outside of the Operating Room Post Operative Physical Therapy Kyle Sela, PT, DPT, SCS, OCS PT Sports Medicine Coordinator, St. Luke’s Health System Boise, ID Disclosures • None to report AAOS Guidelines • Bottom Line Up Front • Moderate evidence to support the following post-operative physical therapy guidelines • • • • Accelerated vs non-accelerated rehab programs Unrestricted and immediate range of motion (ROM) vs delayed Immediate weight bearing vs delayed Early, but limited range during open kinetic chain (OKC) exercises vs delayed and full motion • Early closed kinetic chain (CKC) exercises vs delayed 1 9/13/2016 Accelerated vs Nonaccelerated • Recommendations based off of 2 studies (Beynnon 2005, 2011) • • • • BTB Grafts were used for all subjects Non-adolescent populations: 18-50 years of age Randomized into 2 groups Accelerated program progressed subjects over 19 weeks • Exercises thought to produce increased sheer on the graft were initiated earlier • Nonaccelerated program lasted 32 weeks • Followed out to 24 months • Results • No differences in almost all outcome measures • Knee laxity, activity level, pain, ADLs, quality of life, articular cartilage biomarkers • Increased quad strength in accelerated group at 3 month follow up only • 1 re-tear (6 months out, nonaccelerated group) • Aggressive vs nonaggressive hamstring autograft (Christensen 2013) • No difference between groups (only followed to 24 weeks) Unrestricted and Immediate Extension ROM • Early active extension after anterior cruciate ligament reconstruction does not result in increased laxity of the knee. (Isberg 2006) • 22 BTB Subjects • Randomized into 2 groups • Full passive or active extension immediately vs delayed • Follow up at 6 months and 2 years • Results • No difference between groups in any outcome measure • Laxity • Self reported scores • Hop testing Early but limited motion during OKC strengthening • OKC in restricted range 90-45° shown to be safe (Fleming 2005, Escamilla 1998) • Early OKC exercises in hamstring autograft may increase laxity (Heinji 2007) • Early vs late start of OKC in both BTB and HS ACLR (4 groups) • Early hamstring group demonstrated significantly increased AP laxity • No other differences between groups were found (strength, pain, function) • Best time to implement safe OKC exercises? (Fukuda 2013) • Early start (4 weeks) vs Late start (12 weeks) • Restricted motion at knee extension machine from 45-90 • Results • No difference in knee joint laxity • Earlier group had quicker return of quad strength • No difference in function 2 9/13/2016 Future Research in Post-Op Therapy • Shift focus from differences in early rehab to later rehab guidance • Identify optimal return to play, duty or work measures and benchmarks to guide rehab • Improve long term tracking of ACLR patients • What is re-tear or contralateral tear rate in specific populations • Better describe those who re-tear vs those who don’t • Repeat functional testing in “graduates” to identify regression • Is there sufficient evidence to support Neuromuscular Electrical Stimulation (NMES)? • Seems promising in ACLR and other post-op populations (Erlandson 2014) • Rehab trends to keep an eye on in the literature • Blood Flow Restriction Training (BFR) • Force plates for training and evaluation References • Beynnon, B. D., Uh, B. S., Johnson, R. J., Abate, J. A., Nichols, C. E., Fleming, B. C., ... & Roos, H. (2005). Rehabilitation After Anterior Cruciate Ligament Reconstruction A Prospective, Randomized, Double-Blind Comparison of Programs Administered Over 2 Different Time Intervals. The American journal of sports medicine, 33(3), 347-359. • Beynnon, B. D., Johnson, R. J., Naud, S., Fleming, B. C., Abate, J. A., Brattbakk, B., & Nichols, C. E. (2011). Accelerated Versus Nonaccelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction A Prospective, Randomized, Double-Blind Investigation Evaluating Knee Joint Laxity Using Roentgen Stereophotogrammetric Analysis. The American journal of sports medicine, 39(12), 25362548. • Christensen, J. C., Goldfine, L. R., & West, H. S. (2013). The effects of early aggressive rehabilitation on outcomes after anterior cruciate ligament reconstruction using autologous hamstring tendon: a randomized clinical trial. J Sport Rehabil, 22(3), 191-201. • Erlandson, A. K., & Lauber, C. A. (2014). Neuromuscular electrical stimulation compared to exercise alone for regaining strength in patients post anterior cruciate ligament surgery: A critically appraised topic. Journal of Athletic Medicine• Volume, 2(3). • Fleming, B. C., Oksendahl, H., & Beynnon, B. D. (2005). Open-or closed-kinetic chain exercises after anterior cruciate ligament reconstruction?.Exercise and sport sciences reviews, 33(3), 134-140. • Fukuda, T. Y., Fingerhut, D., Moreira, V. C., Camarini, P. M. F., Scodeller, N. F., Duarte, A., ... & Bryk, F. F. (2013). Open Kinetic Chain Exercises in a Restricted Range of Motion After Anterior Cruciate Ligament Reconstruction A Randomized Controlled Clinical Trial. The American journal of sports medicine, 41(4), 788-794. • Heijne, A., & Werner, S. (2007). Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surgery, Sports Traumatology, Arthroscopy, 15(4), 402414. • Isberg, J., Faxén, E., Brandsson, S., Eriksson, B. I., Kärrholm, J., & Karlsson, J. (2006). Early active extension after anterior cruciate ligament reconstruction does not result in increased laxity of the knee. Knee surgery, sports traumatology, arthroscopy, 14(11), 11081115. 3 9/12/2016 Management of Adolescent ACL Injuries: Bracing Opal Griffin, LAT, ATC St. Luke’s Health System, Boise ID Sports Medicine: Outreach Athletic Training Disclosers: Presenter: Opal Griffin, LAT, ATC With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (and/or spouse/partner) and any for-profit company in the past 24 months which could be considered a conflict of interest. All images that are included are for clarification purposes only, not a suggestion of the “best brace” or the type that was specifically tested. Prophylactic Bracing: Ortho Guidelines from the AAOS (5, 6) Limited evidence supports Preventative braces might not be prescribed Studies showed no reductions in ACL injuries with Bracing Only tested American HS and Collegiate FB players. Future Research Would this be different in other papulations? Female Soccer has the highest rate of ACL injury per the AAOS Greater population size? Younger population? 1 9/12/2016 Postoperative Functional Bracing: Ortho Guidelines from the AAOS (1, 2, 3) Moderate evidence does not support routine use not proven effective when compared to neoprene knee sleeve and no bracing. Routine use cannot be supported There was lack of efficacy following ACL reconstruction.. Types of Braces Studied (examples) Functional Bracing Neoprene sleeve Postoperative Functional Bracing: 2015 Review published in Sports Health (4) Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines Postoperative bracing did NOT improve: pain, swelling, range of motion or safety “Eleven studies… no study demonstrated a clinically significant or relevant improvement in safety, range of motion including extension, or other outcome measures.7,15,19,25,27,31,36,43,47,50,57,67” Supported by 17 studies that the MOON group considered to be level 1 or 2 evidence 2 9/12/2016 Postoperative Bracing: Exception Meniscal Injury with about half of all ACL injuries. Per the AAOS. Meniscal repair requires support post surgically. References: Functional knee braces after ACLR 1. Birmingham TB, Bryant DM, Giffin JR et al. A randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. Am J Sports Med 2008;36:648655. 2. McDevitt ER, Taylor DC, Miller MD et al. Functional bracing after anterior cruciate ligament reconstruction: a prospective, randomized, multicenter study. Am J Sports Med 2004;32:1887-1892. 3. Risberg MA, Holm I, Steen H, Eriksson J, Ekeland A. The effect of knee bracing after anterior cruciate ligament reconstruction. A prospective, randomized study with two years' follow-up. Am J Sports Med 1999;27:76-83. 4. Wright R, Haas, A, Anderson, J et al. and MOON Group. Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines. Sports Health 2015;7:239-243. Prophylactic knee bracing 5. Sitler M, Ryan J, Hopkinson W et al. The efficacy of a prophylactic knee brace to reduce knee injuries in football. A prospective, randomized study at West Point. Am J Sports Med 1990;18:310-315. 6. Deppen RJ, Landfried MJ. Efficacy of prophylactic knee bracing in high school football players. J Orthop Sports Phys Ther 1994;20:243-246. Questions… Thank you for joining us! 3 9/13/2016 Return to Sport after ACL Reconstruction: How Objective is your Decision? Mark V. Paterno PT, PhD, MBA, SCS Coordinator of Orthopaedic and Sports Physical Therapy Acting Scientific Director Division of Occupational Therapy and Physical Therapy Associate Professor, Division of Sports Medicine Cincinnati Children’s Cincinnati, OH Objectives 1. Review current evidence regarding RTS after ACL reconstruction 2. Discuss current criteria used to determine readiness to RTS. 3. Identify potential opportunities to improve RTS decision making in this population 1 9/13/2016 CLINICAL QUESTION: When is it safe to return to sports (RTS) after ACL Reconstruction? 1. What is “safe”? 2. What are the functional demands of the sport? RTS: When is it safe? 1. Incidence of 2nd ACL injury after ACLR and RTS Ipsilateral Graft Re-tear (Wright et al JBJS 2011) Contralateral ACL Injury (Wright et al JBJS 2011) 2. Incidence of Secondary Injury after ACLR and RTS 3. Incidence of Osteoarthritis after ACLR and RTS 50-100% of patients develop OA after ACL injury Lohmander et al 2004 2 9/13/2016 RTS: When are you able to return to your prior level of function? What factors are necessary to insure success: • Strength • Balance/Postural Stability • Mechanical Stability/Functional Stability • Power • Endurance • Agility • Etc…. ACL Return to Sport: Systematic Review Kvist J. “Rehabilitation Following Anterior Cruciate Ligament Injury: Current Recommendations for Sports Participation.” Sports Med 2004: 34(4): 269280. 34 articles between 1998-2003 ACL Return to Sport: Systematic Review- Kvist Sports Med 2004 Outline of criteria reported: • • • • 13/34 assessed isokinetic strength 25/34 used jump testing 14/34 reported some clinical criteria (i.e. ROM, knee stability etc.) 4/34 had no assessment of strength or performance 3 9/13/2016 ACL Return to Sport: Systematic Review- Barber-Westin et al 2011 Systematic Review (n=264) • 40% : no criteria • 13% : objective criteria Current Return to Sport Measures 1. 2. 3. 4. Time from surgery Strength Knee Laxity Functional Performance Testing Single Hop X-Hop Triple Hop Timed Hop Current Return to Sport Measures “…low correlations between various hop test scores and self-reported measures of function may indicate that neither of these methods can stand alone as an adequate assessment of knee function.” Fitzgerald GK et al “Hop Tests as Predictors of Dynamic Knee Stability” JOSPT 2001 4 9/13/2016 Return to Sport Assessment: What are we missing? 1. Patient reported outcomes 2. Assessment of movement quality 3. Patient readiness to return to activity RTS: Patient Reported Outcomes 1. Patient Reported Quality of Life Measure 2. Region Specific Assessment • IKDC: Zwolski et al AJSM 2015 • KOOS: Wasserstein et al Osteo Cart 2015 (MOON Data) • Others RTS: Assessment of Movement Quality 5 9/13/2016 RTS: Assessment of Movement Quality “Biomechanical Measures during Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury after ACL Reconstruction and Return to Sport” Paterno et al AJSM 2010 RTS: Predictors of 2nd ACL Injury Paterno et al AJSM 2010 RTS: Patient Readiness to RTS 1. Fear of Reinjury/Lack of Confidence • Lentz et al JOSPT 2012: Athletes who RTS had lower level of kinesiophobia • Lentz et al AJSM 2015: Athletes who did not RTS due to fear of reinjury was older, lower quad strength and lower IKDC 2. Other Factors 6 9/13/2016 Summary 1. Limited evidence exists regarding RTS decision making after ACLR 2. Current criteria used to determine readiness to RTS may not identify those at high risk for injury or likely to maintain pre-injury level of function 3. Future work needs to better identify critical factors to use to determine readiness to safely return to sport Thank you!! Mark V. Paterno PT, PhD, MBA, SCS Cincinnati Children’s mark.Paterno@cchmc.org @mvpaternopt 7
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.4 Linearized : No Modify Date : 2016:09:14 16:05:05-04:00 Creator : PDFMerge! (http://www.pdfmerge.com) Create Date : 2016:09:14 16:05:05-04:00 Producer : iText® 5.5.8 ©2000-2015 iText Group NV (ONLINE PDF SERVICES; licensed version) Page Count : 23EXIF Metadata provided by EXIF.tools