Compare and Contrast each rhetorical situations
Assignment #1 Description: Exploratory Essay
Purpose: The exploratory essay is designed to introduce you to writing and research in your academic discipline and to emphasize the relevance of scholarship to our everyday lives. For this assignment you will need to select a popular media OR trade publication article AND an academic journal article reporting on the same/similar topic to compare and contrast in terms of their rhetorical situation and style.
Audience: A beginning college student/researcher in your discipline.
Process: This assignment requires you to complete the following steps:
Step 1. Find a popular media or trade publication article (print or online) focused on a topic pertaining to your academic discipline.
Step 2. Read the article and identify any possible keywords from it you can use to search for an academic journal article about the same topic. *Consult with your instructor if you think you need to find an academic journal article on a related topic because you are unable to find one about the same topic.
Step 3. Use the library resources, such as your subject guide, to find an academic journal article about the same topic as your popular media or trade publication article. Select an article published recently (within the last 5 years preferably, but no more than the last 10 years); you want to be aware of what your academic discipline is researching and writing about now.
Step 4. Read the academic journal article and popular media or trade publication article you selected in Step 1, analyzing them for rhetorical situation and style.
Step 5. Draft your essay, comparing and contrasting your two articles in terms of their purpose, content, and style. Refer to the handout Article Analysis Guide for detailed information about how to draft your essay.
Format: The exploratory essay should be approximately 3-4 typed and double-spaced pages (the required title page and bibliography page do not count toward this requirement), conform to formatting guidelines (12 pt. Times New Roman font, 1 margins, proper heading, etc.), and use APA style or the documentation style of your field.
Assessment: 10 % of your final course grade
Due Date: The rough draft is due —. The final draft is due —. ACL REHAB (T SGROI AND J MOLONY, SECTION EDITORS)
ACL Rehabilitation Progression: Where Are We Now?
John T. Cavanaugh1 & Matthew Powers1
Published online: 8 August 2017
# Springer Science+Business Media, LLC 2017
Abstract
Purpose of Review With the increase of publications available
to the rehabilitation specialist, there is a need to identify a
progression to safely progress the patient through their post-
operative ACL reconstruction rehabilitation program.
Rehabilitation after ACL reconstruction should follow an
evidence-based functional progression with graded increase
in difficulty in activities.
Recent Findings Clinicians should be discouraged not to use
strict time frames and protocols when treating patients follow-
ing ACL reconstruction. Rather, guidelines should be follow-
ed that allow the rehabilitation specialists to progress the pa-
tient as improvements in strength, edema, proprioception,
pain, and range of motion are demonstrated. Prior to returning
to sport, specific objective quantitative and qualitative criteria
should be met. The time from surgery should not be the only
consideration.
Summary The rehabilitation specialist needs to take into ac-
count tissue healing, any concomitant procedures,
patellofemoral joint forces, and the goals of the patient in
crafting a structured rehabilitation program. Achieving sym-
metrical full knee extension, decreasing knee joint effusion,
and quadriceps activation early in the rehabilitation process
set the stage for a safe progression. Weight bearing is begun
immediately following surgery to promote knee extension and
hinder quadriceps inhibition. As the patient progresses
through their rehabilitative course, the rehabilitation specialist
should continually challenge the patient as is appropriate
based upon their goals, their levels of strength, amount of
healing, and the performance of the given task.
Keywords Knee . Cruciate . Rehabilitation . Progression .
Guideline . Criteria
Introduction
Over 200,000 anterior cruciate ligament (ACL) injuries occur
in the USA annually [1]. It is estimated that more than half of
these injuries undergo surgical reconstruction [2]. Following
ACL reconstruction (ACLR), under the direction of the ortho-
pedic surgeon, the rehabilitation specialist is charged with the
responsibility of returning the patient to their pre-injury level
of function. Post-operative rehabilitation programs have
changed dramatically over the past couple of decades. Strict
protocols based on time elapsed from surgery have been re-
placed by criteria based guidelines (Table 1). These guidelines
follow a progression where selective criteria are met prior to
advancement in the program. This paper will discuss the pro-
gression of rehabilitation following ACL reconstruction.
A functional progression was defined by Kegerreis [3] as
an ordered sequence of activities enabling the acquisition or
reacquisition of skills required for the safe and effective per-
formance of athletic endeavors. In other words, the patient
needs to master a simple activity before advancing to a more
demanding activity. Programs are individualized, where some
patients will be ready to advance sooner than others.
Biological factors such as graft revascularization and matura-
tion as well as fixation techniques are also considered to en-
sure a safe progression through the ACLR rehabilitation
program.
This article is part of the Topical Collection on ACL Rehab
* John T. Cavanaugh
[emailprotected]
1 Sports Rehabilitation & Performance Center, Hospital For Special
Surgery, 535 East 70th Street, New York, NY 10021, USA
Curr Rev Musculoskelet Med (2017) 10:289296
DOI 10.1007/s12178-017-9426-3
mailto:[emailprotected]
http://crossmark.crossref.org/dialog/?doi=10.1007/s12178-017-9426-3&domain=pdf
Table 1 Anterior cruciate ligament (BTB) rehabilitation guideline
Post-operative phase I (weeks 02)
Goals:
Emphasis on full passive extension
Control post-operative pain/swelling
Range of motion 0 90
Early progressive weight bearing
Prevent quadriceps inhibition
Independence in home therapeutic exercise program
Precautions:
Avoid active knee extension 40 0
Avoid ambulation without brace locked at 0
Avoid heat application
Avoid prolonged standing/walking
Treatment strategies:
Towel extensions, prone hangs, etc.
Quadriceps re-education (quad sets with EMS or EMG)
Progressive weight bearing
PWB WBAT (patella tendon) with brace locked at 0 with crutches
Patella mobilization
Active flexion/active-assisted extension 90 0 exercise
SLRs (all planes)
Brace locked at 0 for SLR (supine)
Short crank ergometry
Hip progressive resisted exercises
Proprioception board/balance system (bilateral weight bearing)
Leg press (bilateral/80 5 arc) (if ROM >90)
Upper extremity cardiovascular exercises as tolerated
Cryotherapy
Home therapeutic exercise program: evaluation based
Emphasize patient compliance to home therapeutic exercise program
and weight bearing precautions/progression
Criteria for advancement:
Ability to SLR without quadricep lag
ROM 0 90
Demonstrate ability to unilateral (involved extremity) weight bear
without pain
Post-operative phase 2 (weeks 26)
Goals:
ROM 0 130
Good patella mobility
Minimal swelling
Restore normal gait (non-antalgic)
Ascend 8 stairs with good control without pain
Precautions:
Avoid descending stairs reciprocally until adequate quadriceps control
and lower extremity alignment
Avoid pain with therapeutic exercise and functional activities
Treatment strategies:
Progressive weight bearing/WBAT (patella tendon) with crutches brace
opened 0 50, if good quadriceps control (good quad set/ability to
SLR without lag or pain)
D/C crutches when gait is non-antalgic
Brace changed to MD preference (OTS brace, patella sleeve, etc.)
Standard ergometry (if knee ROM >115)
Leg press (90 0 arc)
AAROM exercises
Mini squats/weight shifts
Proprioception training: prop board/balance system/contralateral
Theraband exercises
Initiate forward step-up program
Stairmaster
Aquaciser (gait training) if incision benign
SLRs (progressive resistance)
Hamstring/calf flexibility exercises
Hip/hamstring PRE
Core stabilization exercises
Retrograde incline treadmill ambulation
Active knee extension to 40
Home therapeutic exercise program: Individualized
Criteria for advancement:
ROM 0 125
Table 1 (continued)
Normal gait pattern
Demonstrate ability to ascend 8 step
Good patella mobility
Post-operative phase 3 (weeks 614)
Goals:
Restore Full ROM
Demonstrate ability to descend 8 stairs with good leg control
without pain
Improve ADL endurance
Improve lower extremity flexibility
Protect patellofemoral joint
Precautions:
Avoid pain with therapeutic exercise and functional activities
Avoid running and sport activity till adequate strength development
and MD clearance
Treatment strategies:
Progress squat program
Initiate step down program
Leg press
Lunges
Isometric isotonic knee extensions 9040
Advanced proprioception training (perturbations)
Agility exercises (sport cord)
Retrograde treadmill ambulation/running
Quadriceps stretching
KT 1000 knee ligament arthrometer exam at 3months
Home therapeutic exercise program: evaluation based
Criteria for advancement:
ROM to WNL
Ability to descend 8 stairs with good leg control/alignment
without pain
Functional progression pending KT1000 and functional
assessment
Post-operative phase 4 (weeks 1422)
Goals:
Demonstrate ability to run pain free
Maximize strength and flexibility as to meet demands of activities
of daily living
Isokinetic test 85% limb symmetry
Precautions:
Avoid pain with therapeutic exercise and functional activities
Avoid sport activity till adequate strength development and MD
clearance
Treatment strategies:
Start forward running (treadmill) program when 8 step down
satisfactory
Continue LE strengthening and flexibility programs
Advance agility program/sport specific
Start plyometric program when strength base sufficient
Isotonic knee extension (full arc/pain and crepitus free)
Isokinetic training (fast moderate velocities)
Home therapeutic exercise program: Individualized
Criteria for advancement:
Symptom-free running
Isokinetic test 85% limb symmetry
Lack of apprehension with plyometric and agility activities to date
Post-operative phase 5return to sport (weeks 22?)
Goals:
Lack of apprehension with sport specific movements
Maximize strength and flexibility as to meet demands of
individuals sport activity
Isokinetic test 90% limb symmetry
Hop test 90% limb symmetry
Acceptable quality movement assessment
290 Curr Rev Musculoskelet Med (2017) 10:289296
Range of Motion
Following ACLR, achieving full knee extension range of mo-
tion (ROM) should be achieved as soon as possible. Extension
loss results in abnormal joint arthrokinematics at both the
tibiofemoral and patellofemoral joints. This in turn leads to
abnormal articular cartilage contact pressures and quadriceps
inhibition [4, 5, 6].
Achieving full extension should ideally be achieved preop-
eratively. McHugh, et al. [7] found that patients with knee
extension loss were 5 more likely to have extension loss
issues after surgery.
Treatment strategies employed to achieve full extension
include low load prolonged stretching (Fig. 1) and calf
stretching. Patellofemoral joint mobilizations in a superior di-
rection are utilized to encourage extension ROM [8] Sleeping
in a post-operative brace locked at 0 extension is utilized to
encourage extension and discourage the formation of a flexion
contracture during the night hours. Full extension is one of
several important criteria to meet to safely progress the patient
off their crutches after surgery.
ROM exercises to facilitate flexion begin immediately after
ACLR. ROM flexion goals of 120 should be met 4 weeks
following surgery and full symmetrical flexion achieved by
12 weeks. Treatment strategies begin with active-assisted
ROM exercises off the side of a plinth or bed (Fig. 2).
Treatment strategies employed to further progress gains in
flexion ROM include wall slides, active-assisted ROM sitting
or on a step, and one half moon movement on a stationary
bicycle. A short crank ergometer (Fig. 3) is utilized allowing
patients to cycle earlier in the rehabilitative process and thus
facilitate gains in flexion ROM [9]. Fleming and colleagues
[10] demonstrated relatively low ACL peak strain values
in vivo during stationary cycling.
Table 1 (continued)
Precautions:
Avoid pain with therapeutic exercise and functional activities
Avoid sport activity till adequate strength development and MD
clearance
Treatment strategies:
Continue to advance LE strengthening, flexibility, and agility
programs
Advance plyometric program
Brace for sport activity (MD preference)
Monitor patients activity level throughout course of rehabilitation
Reassess patients complaints (i.e., pain/swelling dailyadjust
program accordingly)
Encourage compliance to home therapeutic exercise program
KT 1000 knee ligament arthrometer exam, isokinetic test, hop
test(s), quality movement assessment at 6months
Home therapeutic exercise program: Individualized
Criteria for discharge:
Isokinetic and functional hop test(s)90% limb symmetry
Acceptable quality movement assessment
Lack of apprehension with sport specific movements
Flexibility to accepted levels of sport performance
Independence with gym program for maintenance and progression
of therapeutic exercise program at discharge
Adapted from Anterior Cruciate Ligament Reconstruction Cavanaugh
JT, Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician
Cioppa-Mosca J, Cahill JB, Cavanaugh JT, Corradi-Scalise D, Rudnick
H, Wollf AL, (eds) Elsevier Publishers pp.425438, 2006
Fig. 1 Passive low load prolonged stretching utilizing a rolled towel
under the ankle
Fig. 2 Active-assisted knee flexion/extension
Fig. 3 Short crank bicycle
Curr Rev Musculoskelet Med (2017) 10:289296 291
Inferior-guided patellofemoral joint mobilizations are uti-
lized to encourage gains in knee flexion [8]. When 120 of
knee flexion is demonstrated, quadriceps stretching off the
side of a plinth (Fig. 4) and eventually in a prone position is
introduced to the patients program. Soft tissue massage can
be of particular benefit throughout the progression to restore
full symmetrical flexion ROM.
Post-operative Weight Bearing
Weight bearing progression following ACLR is dictated by
graft selection and surgeon preference. Advanced fixation
techniques such as cancellous screw bone-to-bone fixation
allow for immediate post-operative weight bearing.
Following ACLR with an autologous bone-patellar tendon-
bone (BTB) graft weight bearing is at first partial (50%) uti-
lizing crutches and subsequently progressed to weight bearing
as tolerated (WBAT) on successive days. This progression
allows the knee joint to acclimate to increased loads.
Ambulating in water, e.g., underwater treadmill (Fig. 5) can
be utilized to gradually apply increased load through the knee
joint and assist in the development of a normal gait pattern.
Walking in chest-deep water results in a 60 to 75% reduction
in weight bearing, while walking in waist-deep water results in
a 40 to 50% reduction in weight bearing [11, 12].
A post-operative brace is initially locked at 0 for ambula-
tion to protect the harvest site. The brace is opened when
quadriceps control is demonstrated by the ability of the patient
to straight leg raise (SLR) without a quadriceps lag or com-
plaints of pain. Crutches are then discontinued upon meeting
the criteria of demonstrating a normal non-antalgic gait.
A significant decrease in patellofemoral pain has been re-
ported when an immediate progressive weight bearing guide-
line is utilized [13]. ACLRs utilizing hamstring or allografts
are progressed at a slower rate secondary to the decreased
strength of soft tissue fixation and biological considerations,
respectively. Weight bearing may be delayed following
ACLRs with concomitant articular cartilage or meniscus re-
pair procedures.
Strengthening
Re-establishing quadriceps control is an early goal of post-
operative ACLR rehabilitation. Controlling post-operative ef-
fusion assists in discouraging quadriceps inhibition. Spencer
et al. [14] identified that mechanoreceptors in the joint capsule
respond to changes in tension and in turn inhibit motor nerves
supplying the quadriceps muscles. Therapeutic interventions
utilized include the use a commercial cold with compression
device (Fig. 6), quadriceps setting with a towel under the knee,
and weight bearing with the appropriate amount of load.
Should a patient have difficulty eliciting a quadriceps contrac-
tion, a biofeedback unit or an electrical muscle stimulator can
be used in conjunction with the quadriceps setting exercise to
Fig. 4 Quadricep stretching off the side of a plinth
Fig. 5 Underwater treadmill (Hudson Aquatic Systems LLC, Angola,
IN)
Fig. 6 Gameready cold/compression device
292 Curr Rev Musculoskelet Med (2017) 10:289296
better facilitate a quadriceps contraction. Numerous studies
[1517] have demonstrated an earlier return of quadriceps
strength after ACLR with the use of electrical stimulation.
As quadriceps activation is demonstrated, a key observation
in order to progress the patient is seeing the patient perform a
straight leg raise without the assistance of the post-operative
brace without any complaints of pain or quadriceps lag. When
this criteria is met, the post-operative brace can be opened to
allow normal knee range of motion during ambulation.
Crutches are continued at this point until a non-antalgic gait
is demonstrated. Closed kinetic chain exercises including leg
press and squats inside a pain free arc of motion are introduced
as these activities have been shown to minimize stress to the
ACL [1821, 22, 23]. Limited evidence now demonstrates
that open kinetic chain (OKC) exercises inside a 900 arc of
motion may not compromise graft laxity.[2426]. Mikkelsen
et al., randomized 44 ACLR (BTB) patients to either a closed
chain rehabilitation only program and a closed chain program
that added open chain exercises 6 weeks post-operatively. At
6-month follow up, KT-1000 knee ligament arthrometer
values showed no significant difference in knee laxity be-
tween the groups. A significant increase in quadriceps
strength in the open chain group was also identified. With
the demonstration of 0130 ROM, OKC exercise progres-
sion begins with multiangle quadriceps isometrics inside a
9040 arc of motion (Fig. 7). Isometric exercises are
progressed to isotonic exercises using progressive resistance
(PRE). At 3 months, post-operatively isotonic exercise is
allowed throughout a full arc of motion and progressed to
isokinetic exercises utilizing moderate-fast speeds.
Throughout this progression, the rehabilitation specialist
should closely monitor the patellofemoral joint for crepitus
and complaints of pain.
Neuromuscular Training
After ACLR, surgery afferent information is altered, which
results in a disruption in the pathway between the patients
center of gravity and base of support [27]. Improving neuro-
muscular reaction time to imposed loads enhances dynamic
stabilization around the knee and thus protects the static re-
constructed tissue from overstress or re-injury [28]. As soon as
the patient achieves 50% weight bearing, neuromuscular/
balance training is initiated on a dynamic balance system
(Fig. 8) or proprioception device (foam cushion, rocker board,
etc.). Balance activities are then increased progressively to
include unilateral weight bearing, use of multiplanar support
surfaces, and perturbation training [29]. Activities should at-
tempt to eliminate or alter sensory information from the visual,
vestibular, and somatosensory systems so as to challenge the
other systems.
Continued Progression
As range of motion and strength is demonstrated, the patient is
instructed in a progressive step-up program, first mastering 6
steps advancing to normal stair height 8 steps. As further
strength is demonstrated, a forward step down program is
introduced (Fig. 9).
Fig. 7 Isometric Knee Extension at 60 knee flexion Fig. 8 Dynamic balance system (Biodex Corporation, Shirley, NY)
Curr Rev Musculoskelet Med (2017) 10:289296 293
After 3 months post-op, if ROM is within normal limits and
sufficient strength is demonstrated via a pain-free 8 step down
without deviation, a running program is started. Backward run-
ning is preceded by forward running, as retrograde running has
been shown to generate lower patellofemoral joint compression
forces than forward running [30]. An Alter G treadmill (Alter G,
Inc., Fremont, CA) (Fig. 10) is utilized to incrementally add load
during a forward running progression. A running program is
progressed with an emphasis on speed over shorter distances
vs. slower distance running.
Plyometric training is then incorporated only if full ROM, an
adequate strength base and flexibility, is demonstrated.
Plyometric training should follow a progression with its compo-
nents of speed, intensity, load, volume, and frequency being
monitored and progressed accordingly. Activities should begin
with simple drills and advance to more complex exercises (e.g.,
double leg jumping vs. box drills). Agility and deceleratory train-
ing are important interventions to include in the later phases of
rehabilitation in preparation for return to sport.
Return to Sport
When to return to sport following ACLR is a controversial
issue. Pinczewski et al. [31] reported that one in four patients
undergoing an ACLR will suffer a second tear within 10 years
of their first. Paterno et al. [32] reported an incidence rate of a
second ACL injury within 2 years after returning to sports was
nearly 6 greater then healthy controls.
More and more surgeons and rehabilitation specialists are
utilizing numerous forms of assessment in determining an
athletes readiness to return to play. Subjective rating scales,
knee laxity testing, isokinetic testing, functional hop testing,
balance testing, and qualitative movement assessment
(Fig. 11) are utilized to provide evidence in the decision mak-
ing process. Acceptable scores on these assessments are re-
quired to safely return the athlete to sport. Following dis-
charge from a formal rehabilitation program, volume of ath-
letic exposures needs to be modified.
Several studies have demonstrated deficits in muscular
strength, kinesthetic sense, balance, and force attenuation
6 months to 2 years following reconstruction [32, 3335].
Return to sport 6 months following ACLR, therefore is no longer
the expected norm.
Fig. 10 Unweighted treadmill (AlterG Inc., Fremont, CA)
Fig. 9 Forward step down exercise off an 8 step
Fig. 11 Quality movement assessment of a single leg squat exercise
294 Curr Rev Musculoskelet Med (2017) 10:289296
Summary
Rehabilitation following ACL reconstruction has shifted from a
paradigm based on protocols to a progression based program with
gradient increases in difficulty. It is the rehabilitation specialists
responsibility to consider the forces placed on the healing ACL
graft and patellofemoral contact pressures generated during spe-
cific exercises and activities. Early in the rehabilitative process,
the focus needs to be on gaining full knee extension, decreasing
edema, and developing quadriceps strength. Therapeutic exer-
cises should progress in difficulty often being performed in a
variety of positions and settings. Neuromuscular training should
be implemented into the rehabilitation program as early as
deemed appropriate and progressed accordingly throughout the
rehabilitative process. ACLR rehabilitation progression should be
based on objective criteria and not just time frames. In order to
achieve a successful outcome the rehabilitation specialist must
continually assess the patient and select exercises that challenge
the patient properly. When the patient is ready to return to sports,
objective criteria must be met in order to reduce the risk of further
injury. This transition is now considered to take place at greater
than 6 months. Exposure/volume to athletic activity needs to be
controlled in the post-rehabilitation period.
Compliance with Ethical Standards
Conflict of Interest Both authors declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any of
the authors. Additional informed consent was obtained from all individual
participants for whom identifying information is included in this article.
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Papers of particular interest, published recently, have been
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296 Curr Rev Musculoskelet Med (2017) 10:289296
ACL Rehabilitation Progression: Where Are We Now?
Abstract
Abstract
Abstract
Abstract
Introduction
Range of Motion
Post-operative Weight Bearing
Strengthening
Neuromuscular Training
Continued Progression
Return to Spor
