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Nawasreh Z1, Marmon A2, Logerstedt D3, Snyder-Mackler L4
1Jordan University of Science and Technology (JUST), Dept. Rehabilitation Sciences, Irbid, Jordan, 2University of Delaware, Newark, United States, 3University of the Sciences in Philadelphia, Department of Physical Therapy, Philadelphia, United States, 4University of Delaware, Department of Physical Therapy, Newark, United States
Background: Anterior cruciate ligament (ACL) rupture is a common sports injury resulting in knee instability, strength deficits, and abnormal gait pattern. These impairments affect activities of daily-living and challenge patients participating in sports activities. Manual perturbation training, a neuromuscular exercise, is the gold standard of care for patients with ACL rupture who opt for non-surgical management. It improves knee functional performance and mitigates abnormal gait patterns in patients with an ACL-deficient knee. However, the manual perturbation is not widely used in the clinical setting as it is time- and labor-intensive for therapists. Further, it is subjected to variations between therapists since it is administered manually. Therefore, administering perturbation training mechanically may be less variable and reduce the time and labor associated with manual training. However, the effectiveness of administering perturbation training on a mechanical device after ACL rupture has not been investigated.
Purpose: To investigate whether perturbation training administered on a mechanical device provides effects similar to manual perturbation training on clinical measures and knee biomechanics in patients with an ACL-deficient knee. We hypothesize that mechanical perturbation would induce an effect similar to that of manual training on knee functional performance and biomechanics.
Methods: Eighteen Level I/II patients with ACL ruptures participated in this preliminary study. Nine patients received mechanical (Mechanical) and 9 patients received manual perturbation training (Manual). The mechanical perturbation training was administered on a device with a moveable plate that provides multidirectional translations and bidirectional rotation at three amplitudes and velocities, similar to those in manual training. The manual training involved providing purposeful manipulations of support surfaces in three conditions (rockerboard, rollerboard, and rollerboard and platform) by a physical therapist. Patients completed performance-based testing (quadriceps strength and single-legged hop tests), patient-reported questionnaires (Knee Outcome Survey-Activities of Daily Living Scale, Global Rating Score (GRS), International Knee Documentation Committee 2000 (IKDC-2000)) and 3-dimentional gait analysis before (pre-test) and after (post-test) training. A 2X2 ANOVA was used for statistical analysis (Mean+SD).
Results: No significant group-by-time interaction was found for all measures (p>0.18). Significant main effects of time were found for IKDC2000 (Pre-test:69.10+10.95, Post-test:75.14+7.19), knee excursion during weight-acceptance (Pre-test:16.01+3.99o; Post-test:17.28+3.99o) and mid-stance (Pre-test:14.78+4.13o; Post-test: 16.92+4.53o), and knee flexion moment (Pre-test:0.43+0.11 Nm/kg*m; Post-test:0.48+0.11 Nm/kg*m) (p0.04). After accounting for pre-testing groups' differences, mechanical group scored significantly higher on triple-hop limb symmetry index (LSI) (Mechanical:96.73+6.65%; Manual:84.97+6.83%) and 6-meter timed-hop LSI (Mechanical:102.07+9.50%; Manual:91.21+9.42%) (p0.047) compared to manual group.
Conclusion(s): The mechanical perturbation training induced effects similar to manual training; both training modes were equally effective at improving patients' perception of knee function and increasing knee excursion and flexion moment during walking after ACL rupture. The mechanical group scored higher on triple and 6-meter timed hop LSIs after training, even with controlling for baseline groups' differences.
Implications: Administering perturbation training using mechanical device has the potential to be used as a treatment intervention for patients with an ACL rupture. Utilizing mechanical perturbation in the ACL-rehabilitation program may help minimizing the time and effort of therapists. Additionally, mechanical perturbation will standardize training that can be used widely in the rehabilitation clinics.
Keywords: outcomes after ACL injury, mechanical perturbation training, Knee biomechanics
Funding acknowledgements: National Institutes of Health (NIH/ Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (grant number 5R44HD068054).
Purpose: To investigate whether perturbation training administered on a mechanical device provides effects similar to manual perturbation training on clinical measures and knee biomechanics in patients with an ACL-deficient knee. We hypothesize that mechanical perturbation would induce an effect similar to that of manual training on knee functional performance and biomechanics.
Methods: Eighteen Level I/II patients with ACL ruptures participated in this preliminary study. Nine patients received mechanical (Mechanical) and 9 patients received manual perturbation training (Manual). The mechanical perturbation training was administered on a device with a moveable plate that provides multidirectional translations and bidirectional rotation at three amplitudes and velocities, similar to those in manual training. The manual training involved providing purposeful manipulations of support surfaces in three conditions (rockerboard, rollerboard, and rollerboard and platform) by a physical therapist. Patients completed performance-based testing (quadriceps strength and single-legged hop tests), patient-reported questionnaires (Knee Outcome Survey-Activities of Daily Living Scale, Global Rating Score (GRS), International Knee Documentation Committee 2000 (IKDC-2000)) and 3-dimentional gait analysis before (pre-test) and after (post-test) training. A 2X2 ANOVA was used for statistical analysis (Mean+SD).
Results: No significant group-by-time interaction was found for all measures (p>0.18). Significant main effects of time were found for IKDC2000 (Pre-test:69.10+10.95, Post-test:75.14+7.19), knee excursion during weight-acceptance (Pre-test:16.01+3.99o; Post-test:17.28+3.99o) and mid-stance (Pre-test:14.78+4.13o; Post-test: 16.92+4.53o), and knee flexion moment (Pre-test:0.43+0.11 Nm/kg*m; Post-test:0.48+0.11 Nm/kg*m) (p0.04). After accounting for pre-testing groups' differences, mechanical group scored significantly higher on triple-hop limb symmetry index (LSI) (Mechanical:96.73+6.65%; Manual:84.97+6.83%) and 6-meter timed-hop LSI (Mechanical:102.07+9.50%; Manual:91.21+9.42%) (p0.047) compared to manual group.
Conclusion(s): The mechanical perturbation training induced effects similar to manual training; both training modes were equally effective at improving patients' perception of knee function and increasing knee excursion and flexion moment during walking after ACL rupture. The mechanical group scored higher on triple and 6-meter timed hop LSIs after training, even with controlling for baseline groups' differences.
Implications: Administering perturbation training using mechanical device has the potential to be used as a treatment intervention for patients with an ACL rupture. Utilizing mechanical perturbation in the ACL-rehabilitation program may help minimizing the time and effort of therapists. Additionally, mechanical perturbation will standardize training that can be used widely in the rehabilitation clinics.
Keywords: outcomes after ACL injury, mechanical perturbation training, Knee biomechanics
Funding acknowledgements: National Institutes of Health (NIH/ Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (grant number 5R44HD068054).
Topic: Robotics & technology; Musculoskeletal: lower limb; Human movement analysis
Ethics approval required: Yes
Institution: University of Delaware
Ethics committee: Nicole Farnese-McFarlane
Ethics number: 535813-9
All authors, affiliations and abstracts have been published as submitted.
