Presentation in International Sports Physiotherapy Congress (@FSPACongress) in Helsinki 6/2017

1. ACL Rehabilitation
Some perspectives of using DBC Knee Concept
Juha Koistinen
Sports Physiotherapist (Cert.), OMT
Clinic Owner - Liikuntafysio
Consultant - Sports Academy of Helsinki Capital Region, Urhea.

2. Aim of this session
• To provide a short demonstration of
post-surgery ACL process in the
DBC Concept Clinic Sello
• To bring up some functional criteria
to follow the process (not based only
timeline)
• To introduce clinical outcome (within
the process)

3. Tools to provide systematic approach
• DBC Medical Background + Knee treatment manual
• Treatment devices and facilities
• CIS = Clinical information system (software)
• Process documentation
• Outcome measurement
• Quality Assurance
• Exercise library

4. Basic knee process
PRE-INFORMATION AND
BASELINE ASSESSMENT
• Pre-information
questionnaire (inc. IKDC)
• Clinical assessment and
tests
• Clinical reasoning =>
• Diagnosis and functional
patterns
• [RBDS, FABQ
questionnaires if
needed]
TREATMENT PLAN
• Assessment summary
report
• Goals
• # of treatment visits
• Frequency
• Content:
• Active treatment
• CBA, manual
therapy, pain
management if
needed
TREATMENT
• Evidence based clinical
practice
• 3-15-25 visits
• Small group training,
with pain treatment as
necessary
• Progress checks – for
treatment plan
adjustments
OUTCOME ASSESSMENT
• Questionnaires
• Clinical assessment
• Severity of
deconditioning
• Individual summary
Report
• Progress or outcome
measures to evaluate
against the baseline
measures
FOLLOW UP
• Questionnaires
• Clinical assessment
• Severity of
deconditioning
• Individual summary
Report
• Continued activity to
maintain treatment
results
- Elite vs. recreational athlete -
- Training the athlete not just the injury!-

5. CIS - Pre-information

6. Process documentation

7. IKDC Functional Scale
Grade symptoms at the highest activity level at which you think you could
function without significant symptoms, even if you are not actually performing
activities at this level.
• What is the highest level of activity that you can perform without significant
knee pain?
• What is the highest level of activity you can perform without significant
swelling in your knee?
• What is the highest level of activity you can perform without significant
giving way in your knee?
• What is the highest level of activity you can participate in on a regular
basis?

8. IKDC Functional Scale
• Very strenuous activities = Jumping or pivoting as in basketball
or soccer
• Strenuous activities = Heavy physical work, skiing or tennis
• Moderate activities = Moderate physical work, running or jogging
• Light activities = Walking, housework or yard work
• Unable to perform any of the above activities.

9. IKDC Functional Scale
How does your knee affect your ability to:
1. Go up stairs
2. Go down stairs
3. Kneel on the front of your knee
4. Squat
5. Sit with your knee bent
6. Rise from a chair
7. Run straight ahead
8. Jump and land on your involved leg
9. Stop and start quickly
• Not difficult at all
• Minimally difficult
• Moderately difficult
• Extremely difficult
• Unable to do

10. Treatment options
• Surgical + reconditioning
• Hamstring autograft - STG
• Patellar tendon autograft - BTB
• (Allograft)
• Non-surgical = reconditioning

11. Surgical options
PATELLAR TENDON AUTOGRAFT
Pitfalls:
• Postoperative pain behind the
kneecap
• Pain with kneeling
• Slightly increased risk of
postoperative stiffness
• Low risk of patella fracture
HAMSTRING TENDON AUTOGRAFT (STG)
• Single or double bundle techniques
• With double bundle graft better rotational
stability, functional result seems to be
equal
• Fewer problems with anterior knee pain or
kneecap pain after surgery
• Less postoperative stiffness problems, faster
recovery
• Negative affects of hamstring function (e.g.
sprinters), neural irritation

12. Postop ACL Reconditioning Stages
Pre-surgery
˜1-4 wks
Acute stage
˜1-2 wks
Initial stage
˜8 wks
Intermediate stage
˜6-7 wks
Intensive stage
˜8 wks
Functional stage
˜10 wks
RETURN TO PARTICIPATION
RETURN TO
SPORTS
RETURN TO
PERFORMANCE

13. Process benchmarking
STAGE ELEMENT TEST GOAL
Presurgery
Acute
Initial
Intermediate
Intensive
Functional
Range of motion Active knee extension-flexion
Effusion Swipe test, ballotable patella
Patellar movement Gliding / soft tissue tightness
Harvest site Palpation -
Strength and activation
Circumference 5 & 15 cm +VMO
Isometric extension
Isometric flexion
OLHD, CMJ jump height
Functional task
Gait symmetry, stride length
Two leg squat
One leg squat
Cycling
Running
Activities index IKDC (9 questions: 0-4)
Current function Self reporting (Q’s from IKDC)

14. Exercise categories
• Adjuncts of exercise (GameReady,
Compex, mobilizations etc.)
• Cardio exercises
• Mobility exercises
• Muscle performance exercises
• Muscle activation exercises
• Open kinetic chain exercises
• Closed kinetic chain
• Functional exercises
• Balance (static / dynamic)
• Gait
• Running (Antigravity treadmill Alter
G)
• Coordination, muscle specific
coordination drills
• Eccentric training (YoYo)
• Plyometrics
RESPECT GRAFT
RESPECT CARTILAGE
RUNNING FOR RUNNING SAKE?

15. ACL Protocol (26 wks)
• Pre-surgery session (baseline, 1:1)
• 5-7 treatment & progress check sessions (1:1)
• 2 test sessions (12, 26 wks)
• Altogether 8-10 sessions (1:1)
• Small group sessions 2-3 times/week (1:3 or 1:6)
• Altogether 75+ rehab sessions & other S&C sessions

16. Post-surgery ACL Results
0
22,5
45
67,5
90
Pain 24h Pain last wk Pain last 6 wks Trouble 24h Trouble last wk Trouble last 6 wks Knee index
19%/
100%
70%/
100%

17. INITIAL STAGE

18. INITIAL STAGE

19. INITIAL STAGE

20. INITIAL STAGE

21. INITIAL STAGE

22. INITIAL STAGE

23. INITIAL STAGE

24. INITIAL STAGE

25. INTERMEDIATE STAGE

26. INTERMEDIATE STAGE

27. INTERMEDIATE STAGE

28. INTERMEDIATE STAGE

29. INTERMEDIATE STAGE

30. INTERMEDIATE STAGE

31. Thank you!
Kiitos!