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Adaptation Strategies Post ACL Reconstruction
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10/19/2017 at 4:49:33 AM GMT
Posts: 62
Adaptation Strategies Post ACL Reconstruction

by Amanda Williamson, PT, DPT

Journal Club Template

Article Citation: Roper, JA, Terza, MJ, Tillman, MD, & Hass, CJ. (2016). Adaptation Strategies of Individuals with Anterior Cruciate Ligament Reconstruction. The Orthopedic Journal of Sports Medicine, 4(2), 2325967115627611. DOI: 10.1177/2325967115627611.

Clinical Question: How do motor control strategies utilized by individuals with anterior cruciate ligament reconstruction compare to healthy controls?

Search Engine: PubMED

Key words: motor control, proprioception, anterior cruciate ligament, reconstruction, ACLR

Study Design: Controlled laboratory study

Sample: 20 participants with anterior cruciate ligament reconstruction (ACLR) including 12 females and 8 males with a mean age of 20 (+/- 1) year and 20 healthy age- and sex-matched controls. Participants in the ACLR group were injured during noncontact (n=15) or contact (n=5) events and while performing varying activities (soccer, n=7; basketball, n=6; football, n=2; rugby, n=1; softball, n=1; cheerleading, n=1; gymnastics, n=1; lacrosse, n=1). Reconstruction was performed using autograft hamstring (n=8), patellar tendon (n=7), Achilles autograft (n=4), or hybrid allograft/autograft (n=1). Both groups reported 6 (+/- 3) hours of physical activity per week, were free from pain, and had not previously walked on a split-belt treadmill (SBT). All participants in the ACLR group were 36 (+/- 24) months post-surgery and were cleared to return to sporting activities by their doctor and physical therapist.

Intervention/procedure: Participants walked on the SBT under a series of learning, acclimation, and adaptation settings [Figure 1]. Participants began by walking at a self-selected comfortable speed while both belts moved together for 5 minutes to acclimate to the SBT. Participants then walked at a “slow” speed for 2 minutes and a “fast” speed for two minutes. For a second time, the participants walked at the “slow” speed for 2 minutes to re-establish baseline. Then, the belt under the nondominant limb in the controls (reconstructed limb in the ACLR group) sped up to the fast speed while the belt under the dominant limb in the controls (non-operative limb in the ACLR group) remained the same and the participant walked for 13 minutes under these conditions. This was followed by a “de-adaptation” phase in which the participants walked with both belts at the slow speed for 5 minutes. Participants then walked with the belt under the dominant limb in the controls (non-operative limb in the ACLR group) sped up to the fast speed while the bed under the non-dominant limb in the controls (reconstructed limb in the ACLR group) remained the same and again the participants walked for 13 minutes. This was then followed by a second “de-adaptation” phase.

Outcome Measures: Foot contacts, toe off, stride length, stance time, step length, fast step length (the step length calculated  at the heel strike of the fast leg), slow step length (the step length calculated at the heel strike of the slow leg), slow-double limb support (fast leg heel strike to slow leg to-off, and fast double-limb support (slow leg heel strike to fast leg toe off).

Data analysis: Differences in spatiotemporal gait parameters were analyzed utilizing three separate repeated-measure ANOVAs with Bonferroni correction for pairwise comparisons. The gait parameters analyzed include (1) asymmetry scores in adaptation (baseline, early, late) and between ACLR limbs when the ACLR limb was on the fast belt compared with when it was on the slow belt; (2) variables among conditions involved in adaptations (baseline, early, late) and between groups when the ACLR leg was on the fast belt versus when the control nondominant limb was on the fast belt; and (3) variables among conditions involved in adaptation (baseline, early, late) and between groups, when the ACLR limb was on the slow belt versus when the control nondominant limb was on the slow belt. In addition to the gait parameters, asymmetry scores during de-adapt 1 and de-adapt 2 were analyzed again using repeated-measure ANOVAs with Bonferroni correction. The adaptation patterns analyzed include (1) between limbs (ACLR fast, ACLR slow), (2) between groups for ACLR fast and control fast, and (3) between groups for ACLR slow and control slow.

Results: In measuring adaptation, double-support time asymmetry was significantly different between limbs during early and late adaptation for the ACLR group on the slow belt. Stride length asymmetry was greatest during late adaptation when compared with baseline and early adaptation between limbs of those with ACLR. Step length was significantly more asymmetric in the ACLR leg during early adaptation when compared with the control nondominant; additionally, double support time was significantly more asymmetric in the same group. During the fast-adapting protocol, stride length asymmetry was significantly greater during late adaptation in the ACLR group when compared in with control limbs. There were no differences in step length, double support time, stance time, or stride length when the ACLR limb was on the slow belt.

Conclusion: The control group adapted and stored new walking patterns equally in both the dominant and nondominant leg, regardless of which leg was placed on the fast or slow belt. Individuals in the ACLR group demonstrate impairments in both slow-adapting and fast-adapting measures depending on the limb/belt speed configuration. Future research should be conducted to investigate the neurophysiological mechanisms that may influence changes in the formation of motor patterns in individuals after ACL reconstruction.

Strengths: Terminology used for outcomes measures consistent with Ranchos terminology; strong experimental design and modification of variables

Limitations: While the study has identified differences in adaptation and learning to changes in the external environment, it does not explain which strategies might be used or whether these changes are due to impairments in motor control/motor learning or due to changes known in the post-operative patient including changes in strength and range of motion. Additionally, the inclusion criteria include a broad range of surgical approaches to ACL reconstruction in a relatively small sample size. There was also no mention of any functional measures being performed to assess the individual’s performance before participating. While the study specified that the individuals were clear to return to sport, there was a wide range of post-operative course from 12-46 months and there was no mention of what their post-operative rehab program included or for how long.

Application: The research serves as a pilot study to identifying impairments in measurements of motor control and learning in persons with ACLR and demonstrates the need for future research in the relationship of motor control and rehabilitation after orthopedic surgeries.

Appraisal: Level 4-

Last edited Thursday, October 19, 2017
11/2/2017 at 1:15:19 PM GMT
Posts: 11
One of the major issues that we have in our research is we define where the graft came from but do not go into further anthropomorphic and surgical measurements. From a surgical stand point we should know was this a single bundle, double bundle, was this the ACL the only structure reconstructed or surgically altered during the procedure, and what position the graft was tensioned through. I also personally feel like we would want to know more than male/female/age that we would want to know height/weight/femoral length to pelvic width/discharge measurements utilized.

From your article it appears to be paramount that once quad strength is within 80%, the concentration of rehabilitation should change from strength to proprioception during dynamic movement. Like you stated in the limitations they should have had some sort of functional measure prior to beginning the study. Additionally, it should have been noted whether the individual returned to their sport. Many times one of the pieces we miss in the rehabilitation process (especially if there was a traumatic event) is fear of returning to sport.

Thanks for listening/reading my two cents. Very nice job reviewing the article!

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