– Written by Bruna Antunes, Elaine Zammit, Nicoletta Luchini, Mayolo Camacho, Qatar
DOES PREHAB HELP? PROBABLY
Anterior Cruciate Ligament (ACL) ruptures in athletic populations are commonly treated with surgical intervention which aims to restore knee stability and maximize capacity to allow athletes to return to their pre-injury level of activity. In preparation for the ACL Reconstruction (ACLR), athletes are often recommended to initiate a period of pre-surgical rehabilitation, often called PreHab. The goal of PreHab is to allow the athlete and injured knee time to recover from the initial injury and optimize the homeostasis and function of the knee prior to surgery. This is to reduce any complications in the initial post operative period while minimizing detraining which may influence the duration of rehabilitation and outcomes after surgery.
The benefits of undergoing PreHab is a topic of ongoing research as the evidence varies regarding the duration of the programme as well as its content. A systematic review on the effects of PreHab on surgical outcomes after ACLR has shown that PreHab including muscular strength, balance, and perturbation training offers a small benefit with regards to improved quadriceps strength and single leg hop scores three months after ACLR compared to no PreHab1.
Another comparison study concluded that the cohort treated with additional PreHab consisting of progressive strengthening and neuromuscular training, followed by a criterion-based postoperative rehabilitation program, had greater functional outcomes and return to play rates 2 years after ACLR2.
There are some non athletic populations who are not involved in activities that are demanding on knee stability who may choose to use the PreHab periods as an opportunity to better understand the suitability of progressing with a conservative approach. Prehab offers the possibility of improving the knee function and of potentially identifying copers3.
THE ROLE OF PREHAB IN ASPETAR
PreHab at Aspetar consists of a comprehensive rehabilitation programme that includes controlling the inflammatory signs (swelling, pain), ROM, strength, proprioception, and motor control. The programme is adapted to the clinical presentation of each individual. Some athletes may present with increased inflammatory signs such as knee joint effusion, pain, reduced range of motion (ROM) and/or quadriceps muscle atrophy, whereas others may present with controlled inflammatory signs and reasonable strength levels. It is also important that rehabilitation is focused both distal and proximal to the knee joint. Deficits in the plantar flexors and lumbo-pelvic region can impact neuromuscular performance and motor control in the post operative period and throughout rehabilitation4.
To better understand the clinical presentation on arrival at Aspetar, every athlete will be assessed in the Assessment and Movement Analysis Laboratory (AMAL). For more detailed information, refer to article on this journal “Individualizing the Testing Process”. Following the assessment in AMAL, the results are analyzed and then discussed with the athlete and their surgeon. The length, content and the goals of the rehabilitation programme are then defined according to the individual needs.
At Aspetar we have specific criteria for surgical readiness, that include:
· Full passive and active knee extension;
· More than 120 degrees of knee flexion;
· No/minimal oedema;
· No/minimal pain;
· Normal gait.
TYPICAL PRE-OPERATIVE PRESENTATION
Even though the Prehab programme is tailor made based on the results of the assessment for each athlete, the following are some common interventions that are included:
· Wall knee slides;
· Supine quads activation with/without muscle stim/Electromyography (EMG);
· Terminal quads extension in standing position with/without muscle stim;
· Low Load Blood Flow Resistance Training for the quadriceps;
· Banded hip external rotation in lunge position;
· Heel raise with banded peroneal/tibialis posterior;
· Forefoot dissociation on Blackboard®;
· Gait education;
· Game Ready®/Normatec®.
PREHAB IS NOT JUST PHYSIOTHERAPY
The elite sporting athlete will attend physiotherapy at Aspetar daily during the week in order to achieve the criteria for surgery in the shortest possible time (recreational athletes may attend less frequently and carry out more of the preparation independently depending on their other commitments). As well as attending physiotherapy there are a number of other components within the multidisciplinary team that are important and add benefit during the pre-operative period. Hydrotherapy can be very effective in the early stages post initial injury to help improve inflammatory signs, ROM limitations, or an altered gait pattern. For detailed information on the content of the Hydrotherapy programme please refer to article “Hydrotherapy” in this journal edition.
In addition, as well as minimizing the detraining of the lower limbs after injury we will look to maintain their cardiovascular capacity and upper limb and trunk strength with the assistance of the conditioning team. The benefits of this are both physical and psychological for the athlete. This is especially true when their normal training routine and environment has been disrupted now with injury. The importance and benefits of conditioning throughout the ACL rehabilitation process are discussed in the “Physical Conditioning” article in this journal.
The ACL injury typically results in a drastic reduction in exercise for our athletes, and a significant shift in the types of training they will perform. In preparation for this, our athletes are also referred to the Nutrition team for an assessment of their dietary needs and provision of strategies to optimize their recovery. The sports nutritionist will evaluate the athlete’s body composition and adjust the diet to the phase of rehabilitation and individual needs. ACL injury can also have a major psychological impact on the athlete. Athletes commonly present with kinesiophobia (fear of movement) and acquired fear avoidance strategies such as maintaining a flexed knee during the stance phase of gait. Lack of knee confidence and fear of movement are related to lower levels of perceived physical function by the patient5. They may also have altered mood and low motivation as they deal with the short term consequences of the injury. Therefore review by our Psychology team can identify any flags that may be barriers to successful outcome and can provide them with strategies to cope through this period. Therefore, the PreHab programme is tailored to the needs of each athlete, both physical and psychological, to prepare them for their surgery – not a generic “one size fits all” recipe.
PREPARING FOR THE UNCERTAINTIES
As well as preparing the athlete for surgery during this time there is also the opportunity to prepare them for the initial post surgery period, educating them on what to expect and what the process will be immediately afterwards. It is also a great opportunity for the athlete to ask questions such as:
· When can I stop using crutches?
· For how long will I have pain?
· When can I start driving?
· When can I start the Hydrotherapy programme?
· How often will I attend physiotherapy?
Answering questions helps reduce anxiety in our athletes regarding these uncertainties, facilitate their short term goal setting and better prepares them for the post-surgery routine. Together with the surgeon, it is important to discuss the different procedures for ACLR (hamstrings graft, bone-to-bone, quadriceps graft etc.) and their specifications. There might also be a need to explain additional rehabilitation considerations such as range of motion limitations for a time defined by the surgeon in case of additional interventions such as meniscal repairs. The surgeon may also impose weight bearing restrictions, from non-weight bearing to partial weight bearing, in case of concomitant cartilage intervention and/or meniscal repairs. Patients will always compare themselves to gauge their progress, so it’s crucial to explain these factors before an athlete starts wondering “why am I using crutches and my friend is walking without them?”
At Aspetar, the patients are also provided with education and information regarding what to expect in their early post-op care. Patients are educated regarding the importance of starting an exercise programme after the surgery in order to increase the blood flow, maintain the ROM allowed, improve quads control and activation and maintain good transfer mobility and gait control. In this line, the patients are provided with educational material that includes an infographic explanatory leaflet and a QR code that provides access to a video with possible post-op needs and explanations (see leaflet and QR).
The process of guiding our athletes back to their desired level of activity can and should begin immediately after the initial injury has occurred and the pre-operative phase can play a vital role in post-surgical outcomes. It is key to individualize PreHab to the needs of the athlete and take a multidisciplinary approach to support them through what can be a challenging period for them.
Bruna Antunes P.T.
Physiotherapist
Elaine Zammit P.T.
Physiotherapist
Nicoletta Luchini P.T.
Senior Physiotherapist
Mayolo Camacho P.T.
Physiotherapist
Aspetar Orthopedic and Sports Medicine Hospital
Doha,Qatar
Contact: bruna.antunes@aspetar.com
References
1. Carter HM, Littlewood C, Webster KE, Smith BE. The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review. BMC Musculoskeletal Disorders 2020;21(647).
2. Failla MJ, Logerstedt DS, Grindem H, Axe MJ, Risberg MA, Engebretsen L, et al. Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction? A Comparative Effectiveness Study Between the MOON and Delaware-Oslo ACL Cohorts. Am J Sports Med 2016;44(10),2608-2614.
3. Smith TO, Postle K, Penny F, McNamara I, Mann CV. Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament versus non-operative treatment. The Knee 2014;462-470.
4. Buckthorpe M, Gokeler A, Herrington L, Hughes M, Grassi A, Wadey R, et al. Optimizing the Early-Stage Rehabilitation Process Post-ACL Reconstruction. Sports Medicine 2023.
5. Hart HF, Culvenor AG, Guermazi A, Crossley K. Worse knee confidence, fear of movement, psychological readiness to return-to-sport and pain are associated with worse function after ACL reconstruction. Physical Therapy in Sport 2020;41:1-8.
Header image by Olimpiadas Especiales América Latina