ultimate knee rehabilitation

Knee Rehab Novel Concepts

& Application

B.KANNABIRAN

Existing

• Home Versus Supervised Therapy

• Home Exercise Versus Weight Machines

• Aquatic Therapy• Open Versus Closed

Chain Exercise• Progression Based on

Objective Criteria

What's new?

Functional

Approach

Critical Points EFFECTS OF INJURY ON PROPRIOCEPTION,

GAIT, AND DURATION OF INJURY

• A decrease in proprioception and kinesthesia occurs after anterior cruciate ligament (ACL) injury. Changes that occur within the joint affect normal recruitment and timing patterns of the surrounding musculature.

Critical Points EFFECTS OF INJURY ON PROPRIOCEPTION,

GAIT, AND DURATION OF INJURY• After ACL rupture, patients

walk with greater hamstring activity, a flexed knee, and minimal to no quadriceps electro myographic activity.

• Altered proprioception of the knee joint may last 1 to 3 yr after injury.

Critical Points EFFECTS OF INJURY ON PROPRIOCEPTION,GAIT, AND DURATION OF INJURY

• There is a significant decrease in muscle activation timing and recruitment order in the lower extremity in response to anterior tibial translation in ACL-deficient knees compared with uninjured controls.

ARTHROGENIC INHIBITION

Critical Points LOWER EXTREMITY MUSCLE STRENGTH

RECOVERY AFTER SURGERY

• Abnormal gamma loop function in quadriceps muscles from lack of normal sensory function (loss native ACL mechanoreceptors) in the reconstructed ACL.

• Non-optimal activation of muscles during voluntary contraction in ACL-deficient knees.

Developing a NeuromuscularRehabilitation program

• 1. The focus on functional movement

• 2. The principle of skill/ability level rehabilitation

• 3. The code for motor adaptation

….that ought to participate in this particular movement & accompany the stabilization of the body.

Neuromuscular exercises – do they exist?

• Peripheral plasticity – muscle, the acrobat of adaptation

• Neuromuscular rehabilitation is not just about exercising.

It is about providing cognitive sensory-motor challenges that will facilitate motor learning/adaptation.

A functional approachin KNEE Rehabilitation

• Functional movement is defined here as the

unique movement array of an individual.

• Functional rehabilitation of a person to recover their movement capacity by using

own movement repertoire (whenever possible)

A functional approachin KNEE Rehabilitation

• However, rehabilitation is likely to be less effective if the remedial movement patterns or tasks are outside the individual’s experience

(extra-functional).

A functional approachin KNEE Rehabilitation

Rehabilitation levels: skill and

ability level KNEE Rehabilitation

• The center of attention in this form of movement recovery is on the overall skill of performing the particular movement, which is loosely referred to as skill rehabilitation

The code for neuromuscularadaptation

“Simplified complexity” in tensional fields.Shaded circles represent tension created by

muscle groups

MOTOR COMPLEXITY MODEL

Neuromuscular Rehabilitation in Manualand Physical Therapies , Eyal Lederman 2010

The motor system as a process. Theinner circle represents processes occurring at

reflexive, sub-awareness level.

The comparator system identifies movementirregularities/errors.

Change in proprioceptive acuity

Damage to proprioceptive apparatus peripherally combined with nociception will result in unrefined motor output.

Experiences that contain the five code elements are more like to promote

adaptive changes within theneuromuscular system resulting in

movement and behavioural changes.

The transition from cognitive to autonomous phase during motor learning.

Throughout the transition some elements

will remain cognitive and autonomous.

ADAPTIVE CODE & PHYSICAL STIMULATION FOR PROPRIOCEPTION

To treat or not to treat

• Can the motor changes lead to further injury or progressive damage?

• The primary aim of neuromuscular rehabilitation is to help individuals to recover their control movement. It is unknown if rehabilitation would confer protective function against progressive tissue damage in the future.

Optimal functional activity

A functional approach

A functional approach

Merging the adaptive codewith rehabilitation Similarity spheres

Rehabilitation Similarity spheres

Context and specific injuryrehabilitation

(the amazing clinical shortcut)

Amazing clinical shortcut

Beyond the session: creatinga challenging environmentfor repair and adaptation

challenging environment

Complexity

• Complexity rules! Don’t become lost in the labyrinth of the neuromuscular system; look at the whole, not at minute details.

Creativity• Neuromuscular rehabilitation is a creative process;

it is not protocol-based. Every patient is different and presents with new challenges. You will forever have to problem-solve on your feet.

Clinical certainty is uncertainty

• The only clinical certainty is uncertainty – don’t fight it, learn to work with it. You will never know all the answers but you will be expected to provide expert care.

Finally Think movement not muscles.

• There is nothing like one brain to stimulate another.

• Make it fun, interesting and continuously challenging.

Functional approach composite abilities

Functional approach composite progression

Functional Approach Rehabilitation(Re–abilitation)

Functional Approach Rehabilitation (Re–abilitation)

Functional Approach Re-abilitation

Functional approachAdvanced composite workouts

Balance/postural stability challenge.

Balancing on the affected

side and drawing imaginary numbers from 0-10 with the

unaffected side.

Demonstration

challenge to balance/postural stability• Unexpected

challenge to balance/postural stability can be introduced by multidirectional perturbations provided by the practitioner.

The Future Trends in Rehabilitation/ RE-ABILITATION

• The Facility• Influence of Technology• Recognizing the importance of progressing

rehabilitation objectively and preventing the detrimental effects of immobilization, but also protecting the integrity of healing tissue.

Take Home

• One is the restoration of neuromuscular control almost immediately after surgical procedures to the knee joint to prevent deafferentation of the joint.

• The progression of the patient must be increased gradually, and therefore, it is the responsibility of the therapist to find a balance between a detrimentally slow progression and advanced techniques prematurely that could have dangerous results.

• Teamwork• Goals• Communication• Motivation• Compliance• Reinforcement• Managing Complications• Optimizing Results• Rehabilitation Protocols• Healing Tissue Should Never Be Overstressed• Preventing the Detrimental Effects of Immobilization• Cardiopulmonary Conditioning• Program Based on Current Research & creativity

Refereces •Hole CD, Smit GH, Hammond J, et al. Dynamic control and conventional strength ratios of the quadriceps and hamstrings in subjects with anterior cruciate ligament deficiency. Ergonomics 2000;43(10):1603–1609.• Patel RR, Hurwitz DE, Bush- Joseph CA, et al. Comparison of clinical and dynamic knee function in patients with anterior cruciate ligament deficiency. Am J Sports Med 2003;31(1):68–74.• St Clair Gibson A, Lambert MI, Durandt JJ, et al. Quadriceps and hamstrings peak torque ratio changes in persons with chronic anterior cruciate ligament deficiency. J Orthop Sports Phys Ther 2000;30(7):418–427.• Konishi Y, Ikeda K, Nishino A, et al. Relationship between quadriceps femoris muscle volume and muscle torque after anterior cruciate ligament repair. Scand J Med Sci Sports 2007; 17(6):656–661.• Berchuck M, Andriacchi TP.Gait adaptations by patientswho have a deficient anteriorcruciate ligament. J BoneJoint Surg Am1990;72A:871–877.• Thambyah A, Thiagarajan P,Goh Cho Hong J. Knee jointmoments during stair climbing of patients with anterior cruciate ligament deficiency. Clin Biomech (Bristol, Avon)2004;19(5):489–496.• Robon MJ, Perell KL, Fang M,et al. The relationship betweenankle plantar flexor muscle moments and knee compressive forces in subjects with andwithout pain. Clin Biomech(Bristol, Avon) 2000;15(7):522–527.• Shrader MW, Draganich LF, Pottenger LA, et al. Effects of knee pain relief in osteoarthritis on gait and stair-stepping. Clin Orthop Relat Res 2004; (421):188–193.• Mu¨ndermann A, Dyrby CO, Hurwitz DE, et al. Potentialstrategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: reduced walking speed. Arthritis Rheum 2004;50(4):1172–1178.