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effects of surgery through ROM and
muscle strengthening exercises while
ensuring that each activity is per-
formed without overstressing the ACL
grafts.435
Electromyog raphic biofeedback5j6 and
neuro mu scular electrical stimulation7.8
are two modalities used in the early
phases of rehab ilitation follow ing ACL
reconstruction to reduc e muscle atro-
phy and to facilitate strengthening.
The effectiveness of the se moda lities
in imprc~ving uadriceps femoris
mu scle fo rce in su bjects with ACL
reconstruction has been measured by
isokinetic dynomometry.6~7 hese
studies, however, applied feedback o r
neuro ml~ scular lectrical stimulation
during isometric q uadriceps femoris
exercises, and this approach may not
simulate functional activities.
We believe knee extension exercises
should b e designed to simulate func-
tional activities. Closed-chain kne e
extension has be en advocated as a
safe exe rcise for patien ts a fter ACL
reconstruction.9 The se exercises in-
volve applying resistance through the
terminal joint of a limb segment,
which restrains the joint's free move-
ment (eg, rising from a chair),
whereas open chain exercises in-
volve applying resistance to an
ex
tremity in a way that the distal joint is
free to move (eg, kicking into the
air).IO Although both of these forms of
exercise can address the physical
impairments of patients following ACL
reconstruction, research suggests that
closed-chain exercises are safer than
open-chain exercises because there is
less stre ss o n th e graft.11-13 Desp ite
this fact, som e subjects exp erience
increased pain a nd k nee effusion
following closed-chain exercises.14
Therefore, performing closed-chain
exercises in an env ironment in which
the forces around the knee joint are
reduced may aid in reducing knee
pain an d joint effusion.
Fkercises in water cou ld exp edite
rehabilitation because of the de-
creased stress on the joints, improved
circulation, and facilitated movement
that occur in water.15.16 Researchers
have analyzed limb movem ent in
water17-'9 and have co mp ared differ-
ent aquatic exerc ise devices,2&22 but
few studies have quantified gains in
muscular force that occur following
an aquatic exercise program. Bartow
and Diamond23 have concluded that
exercises performed using water as
resistance can increase the torque -
generating capabilities of the thigh
musculature in healthy subjects.
Gehlsen et a124 have made similar
conclusions in patients with multiple
sclerosis, but n o control gro up was
used for comparison.
NapoletanZ5 ound that in subjects
with ACL re constru ctions, unde rwater
treadmill ambulation in conjunction
with traditional rehabilitation was
BJ Tovin, I T , ATC, is StafT Physical Th erapis t, Physiotherap y Associates, 2770 Lenox Rd NE, Ste 102,
Atlanta, GA 30324 USA), and Director of Rehabilitation, Georgia Tech Athletic Association, Atlanta,
GA
30332.
Mr Tovin was a stude nt at Em ory University, Atlanta, GA, at the time this study was c om -
pleted in partial fulfillment of the req uirem ents for his Master of Medical Science deg ree . Address
all correspondence to Mr Tovin.
SL Wolf, PhD,
FT
AlTA, is Professor and Director of Research, Depar tme nt of Rehauilitation Medi-
cine, Professor, Division of G eriatrics, Departm ent of Internal Medicine, and Associate Professor,
Departm ent of Anatomy and Cell Biology, Emory University School of M edicine,
1441
Clifton d
NE, Atlanta, GA
30322.
BH Greenfield,
FT
CS, is Clinical Coordinato r of Education a nd Clinic Director, Physiotherapy Associ-
ates, Jonestm ro, GA 30236, and Clinical Instructor, D ivision of Physical Therapy, Emo ry University.
J C rouse, IT , is C linical Coordina tor of Physical Therapy, He althSouth, Atlanta, GA
30342.
BA Woodfin, MD, is Orth opae dic Surgeon, R esurgeons Ort hopa edics , and Team Physician, Georgia
Tech Athletic Association.
This study was approved by the Human Investigation Committee of Emory University and Pied-
mont Hospital.
This article
w s
submitted April
13 1993
and
w s
accepted Januaty
6 194.
more effective in retarding thigh atro-
phy than traditional rehabilitation
alone . Thigh atrophy, however, is only
o ne m easure of recovery. Whether
rehabilitation in water will be differ-
ent from traditional rehabilitation in
reducing knee joint laxity, enhancing
muscle force, and im proving func-
tional outcomes in subjects with intra-
articular ACL reconstructions is
uncertain.
The purpose of this study was to
determine whether exercises in a
po ol will lead to less joint effusion,
less thigh atrophy, increased ROM
and thigh musculature strength, and
less difficulty with activities of d aily
living in patients after intra-articular
ACL recon struction com par ed with
exercises on land.
An effort was mad e
to m atch specific exercises in both
groups s o that each program was
identical and only the rehabilitation
environment was manipulated.
ethod
Subjects
Twenty subjects (14 male, 6 female)
ranging in ag e from 16 to 44 years
@=29.0, SD=7.8) participated in this
study. All subjects had undergone
arthroscopically a ssisted intra-articular
ACL reconstruction using a bone-
patellar tendo n-bon e autograft, per-
formed by the same orthopedic sur-
ge on . Subjects w ho had prio r ACL
surgery to either knee o r who had a
meniscus repair at the time of surgery
were excluded from the study.
Procedure
During the preoperative visit, subjects
we re familiarized with the study and
postoperative rehabilitation protocols
we re ex plained. Each subject signed
an inform ed consent statemen t, writ-
ten to conform with the g uidelines of
Emory University and Piedmont Hos-
pital (Atlanta, Ga), and a que stionna ire
was adm inistered. Subjects were as-
signed to either a traditional rehabili-
tation (TR) group or a pool rehabilita-
tion (PR) group using the following
method of group assignment. The first
2 subjects were randomly assigned to
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able
1
Rehabilitation mgrams
Week 1 and Home Program Exercises Both Groups)
1. Wall slides: 25 repetitions
2. Active-assistive range of motion: 25 repetitions
3. Passive knee extension: 10 minutes
4. Hamstring muscle and calf stretching: 10 minutes each
5. Quadriceps femoris muscle sets
6. Straight leg raisesa: sets x 10 repetitions for hip flexion, abduction, adduction, and extension
7. Active knee flexiona: 3 sets x 10 repetitions
8. Toe raises: 3 sets x 10 repetitions
9. Partial wall squats usually added to the home program after first week): 3 sets x 10 repetitions
Week
2 8
Exercise Programs
Traditional Rehabilitation Group Pool Rehabilitation Group
1. Stationary cycling: 10 minutes
2. Gait training without brace, alternating forward and backward
ambulation: 10 min
3.
Side step-ups, front step-ups, step-downs: beginning with
3
sets
of 10 repetitions, progressing to 3 sets of 15 repetitions
4. Hip flexion, extension, abduction, adduction in standing using a
wall pulley with 4.54-kg 10-lb) plates: beginning with
3
sets of 10
repetitions, progressing to
3
sets of 15 repetitions
5. Knee flexion in sitting:
3
sets of 10 repetitions; boot: beginning
with 3 sets of 10 repetitions, progressing to 3 sets of 15 repetitions
1. Stationary cycling: 10 minutesb
2. Gait training without brace, alternating forward and backward
ambulation: 10 min
3.
Side step-ups, front step-ups, step-downs: beginning with
3
sets of
10 repetitions, progressing to 3 sets of 15 repetitionsC
4. Hip flexion, extension, abduction, adduction in standing using the
Hydrotone resistance boot: beginning with
3
sets of 10 repetitions
and progressing to
3
sets of 15 repetitions
5. Knee flexicn in standing using the Hydrotone resistance boot:
beginning with sets of 10 repetitions and progressing to 3 sets of
15 repetitions
Cuff weights were added to straight leg raises and knee flexion in increments of 0.91 kg (2 lb).
*stationary cycling in the p ool rehabilitation group used a ped dling device (see Fig. 1) rather than a stationary bicycle.
'Step-ups in the water were done with 20.32-cm (8-in) and 40.64-cm (16-in) steps.
one of the two groups using a coin
toss. The nex t 2 sub jects recruited
were placed in opposite groups of the
first 2 subjects. This proc ed ure was
continued for every 4 subjects until
20 subjects were recruited.
As
a result,
6
me n and 4 wom en were placed in
the PR grou p and 8 me n an d 2
women were placed in the TR group.
This method of grou p assignment was
used to evenly distribute subjects
between the two group s over time,
while also incorporating random
assignment to groups.
Week
Exercises for
Both
Oroups
During the first postoperative session,
patients in both group s were in-
structed in an identical progra m Tab.
I), which they performed at home
twice per day. The first wee k of post-
operative rehabilitation consisted of
three o r four treatment sessions in
which on e of the authors reviewed
the hom e program to en sure that the
exercises were d on e safely and inde-
pendently. T o facilitate passive kn ee
extension, each subject was posi-
tioned pro ne and the involved leg
from the su per ior third of the tibia
to the foo t) was placed off the side of
a treatmen t table o r be d, letting grav-
ity pull the knee into extension. Resis-
tance for the straight leg raises and
leg curls was ad ded using variable-
resistance cuff weights. Subjects initi-
ated each exercise, performing three
sets of 10 repetitions without weight
and progressing until they could per-
form th ree sets of 1 5 repetitions with-
ou t difficulty. Subjects then ad de d 0.9
kg 2 lb) to the cuff weight and re-
peated the p rogression starting with
thre e sets of 10 repetitions. This pro-
ced ure was continue d, and resistance
was added in 0.9-kg increments most
patients progressed their weight every
2-3 days). Subjects we re instruc ted
how to keep a log of their hom e
exercise
p r o g m , w hich w as check ed
by on e of the authors to help assess
compliance.
Weight earing
Gait training was also initiated on the
first postoperative session with axil-
lary crutches and a hinged knee
brace. The braces were locked in ull
extension for th e first 4 to 7 days, and
subjects were instructed to bea r as
much weight as
they could tolerate.
Subjects we re progressed from two
crutches to o n e crutch between the
4th and 7th postoperative days and
were usually off the crutch by the
10th postoperative day. The hinged
knee b race was unlocked at the be-
ginning of the 2nd week , permitting
90 degrees of knee flexion. The ROM
of the braces were increased to 120
degrees by the beginning of the 3rd
postoperative wee k, and subjects we re
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achieved a maximum height of 30.48
cm 12 in).
igure I
Pedalling device used
y
subjects in the water group
Rehabliltation rograms
out of the brace by the 6th postopera-
tive week.
During the second through the eighth
postope~ztiveweeks, the TR group
performed a land rehabilitation pro-
gram and the PR group performed a
similar program in the water Tab.
1 .
Both programs were performed three
times per week in the same sequence.
Subjects in the TR group warmed up
with 10 minutes of stationary cycling,
followed by 10 minutes of gait train-
ing alternating forward and backward
walking) and 5 minutes of passive
stretching. The PR group warmed up
with the same exercises, but used a
pedalling device underwater Fig. 1)
instead of a stationary bicycle.
Subjects in the TR group initiated
closed-chain exercises on a 5.08-cm
2-in) step. Three sets of 10 repeti-
tions were performed, progressing to
three sets of 15 repetitions. When
subjects could perform three sets of
15 repetitions comfortably at a given
height, the height was increased by
5.08 cm and they started with three
sets of 10 repetitions again. Subjects
usually advanced every two or three
sessions and continued the same
exercise progression while the height
of the step was increased in incre-
ments of 5.08 cm. Subjects usually
Hydrotone International Inc, 3535NW 58th St, Ste 1000 Oklahoma City OK 73112.
Subjects in the PR group initiated
closed-chain exercises on a 20.32-cm
8-in) step. Subjects began with three
sets of 10 repetitions and progressed
until they could d o three sets of 15
repetitions without difficulty. This
progression usually occurred within 1
week of rehabilitation in the water.
Between the second and third weeks,
subjects were advanced to a 40.64-cm
16-in) step in chest-deep water and
the progression format was repeated.
Between the fourth and eighth weeks,
subjects used the 40.64-cm step in
waist-deep water to reduce the force
of buoyancy on body weight, thereby
increasing resistance. Exercises in
waist-deep water progressed in the
same manner. If subjects were able to
perform three sets of 15 repetitions
on the 40.64-cm step in waist-deep
water without difficulty, they were
positioned o n a 40.64-cm step in
thigh-deep water for maximal resis-
tance and the sequencing format was
repeated.
The next group of exercises consisted
of standing hip flexion, extension,
abduction, adduction, and knee flex-
ion strengthening. The TR group
performed these exercises using pul-
leys that contained a stack of 4.5-kg
10-lb) plates. Subjects initiated each
exercise with a weight they could
lift
comfortably for three sets of 10 repe-
titions and progressed until they
could perform three sets of 15 repeti-
tions without difficulty. Another 4.5-kg
plate was then added, and the exer-
cise was repeated with three sets of
10 repetitions.
Hip strengthening and knee flexion
exercises were done using a Hydro-
tone exercise boot* Fig. 2). Exercises
consisted of three sets of 10 repeti-
tions for hip flexion-extension,
abduction-adduction, and knee flex-
ion. Because this study did not intend
to quantify the amount of resistance
in the water or to increase the surface
area of the Hydrotone boot, subjects
were instructed to move their in-
volved legs through the water as fast
as they could.As symptoms decreased
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ware (version 5.1)* were used to
calculate and record peak torque (in
Flgure 2 ydrotone resistance boot used y subjects in the water group
and muscle performance improved,
subjects increased the speed and
created more resistance.
Data Collection
Arthrometric measurements
Joint
laxity was measured preoperatively
and at 8 weeks following surgery.
Measurements were made by one of
two physical therapists (BJT and JC)
using a KT-1000 knee arthrometer.'
This device has the highest diagnostic
accuracy of five different arthrometric
de~ices.~6nterior drawer testing was
performed with the knee flexed 30
degrees. Anterior displacement of the
tibia on the femur was measured (in
millimeters) during 6.8-kg (15-lb) and
9.1-kg (20-lb) Lachman tests. Greater
forces were not used in fear of over-
stressing the graft during this critical
period of graft healing. The testers
maintained 100% agreement, within
0.5 mm, both with a prior reliability
study and throughout this study.
Muscle performance
measurements Isometric and isoki-
netic peak knee torques were mea-
sured at the end of the eighth week
of rehabilitation and compared be-
tween groups. An electromechanical
dynamometer and LIDO@AC+ soft-
+Medrnetric,San Diego. CA
$Loredan Biomedical Inc, 2121-B 2nd St, Ste 107, Davis, CA 95616.
elcro USA Inc, 406 Brown Ave, Manchester,
NH
03108.
foot-pounds), and gravity-corrected
measurements were obtained. Accord-
ing to the manufacturer, the dyna-
mometer's accuracy is self-calibrated
through the computer software pack-
age. One tester, who was blind to
group assignment, performed all the
testing.
During the testing session, subjects
were positioned with their hips in 80
to 90 degrees of flexion. The hips and
tested limb were stabilized with Vel-
cro@ straps across the pelvis and
over the thigh. Subjects were in-
structed to grasp the handrails during
the test. The axis of rotation of the
dynamometer was aligned with that of
the knee, and the lever arm pad was
placed 7.62 cm (3 in) below the tibial
tubercle. Subjects were allowed a
short period of familiarization at each
speed.
Isometric testing consisted of three
maximal 5-second repetitions with the
knee flexed 85 degrees
t
measure
knee extension torque and three
maximal 5-second repetitions with the
knee flexed 60 degrees
t
measure
knee flexion torque. Subjects were
given a 30-second rest period be-
tween repetitions. The highest torque
value was recorded.
Isokinetic testing consisted of three
separate contractions at 90/s with a
30-second rest period between repeti-
tions. Isokinetic extension was tested
from 80 to 40 degrees of knee flex-
ion, and isokinetic flexion was tested
from 0 to 70 degrees of knee flexion.
Isohnetic extension was done sepa-
rately from isokinetic flexion to pre-
vent possible shearing during changes
in direction. The maximum peak
torque for the three repetitions was
recorded for each of the four tests.
U
subjects were tested in the same
order.
Passlve range of motion
measurements
Passive range of
motion (PROM) measurements for
knee flexion and extension were
taken by one of the two physical ther-
apists using a standard plastic goni-
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able 2
Results
o
Analysis
o
Variance
o
Dzferences in Joint Laxity Measurements
During a
6.8-kg 15-lb)
Lachmun Test
Source
df SS S
Between subjects
Groups (A) 1 21 OO 21 OO 3.43 082
Error
17 104.08 6.12
Within subjects
Weeks (B) 1 50.84 50.84 8.39 .01
A x B 1 0.003 0.003 0.00 984
Error 17 103.05 6.06
om eter (17.78 cm [7 in] long with a
360 scale and 1 increments). The
testers maintained 100% agreement,
within 5 degrees, both with a prior
reliability study an d thro ugh out this
study.
Passive range of m otion was m ea-
sured at the beginning of each treat-
ment session at 2, 4, 6, and 8 weeks
postoperatively. Subjects we re al-
lowed a 3-minute warm-up, which
consistell of self-stretching within
their available ROM. Both m easure -
ments were taken with subjects posi-
tioned supine . Knee extension mea-
surements we re taken with a towel
roll und er the hee l of the involved
extremity. Knee flexion m easurements
were taken with the h ip maintained at
90 degrees of flexion, while the heel
was moved toward the buttocks. End-
range was determ ined by applying
overpressure until firm resistance was
met. The maximum value of three
measurements was recorded.
Girth
measurements
Girth mea-
surements were taken by on e of the
two physical therapists during the
preoperative visit and at 2, 4, 6, and 8
weeks following surgery. Measure-
ments were taken at the mid-patella
level and 15.24 cm (6 in) above th e
mid-patella using a standard tape
measure (increments of 0.3175 cm
[ hn]) with subjects positioned su-
pine with their thigh musculature
relaxed. 'These measurement locations
were used to document changes in
knee joint e h s io n and thigh muscu-
lar atrophy. The testers maintained
100% agreem ent, within 0.636 cm
Y4
in), both with a prior reliability study
and throughout this study.
Functional questlonnalre A func-
tional questionnaire was administered
at the en d of the eighth postoperative
week. The questionnaire consisted of
a Lysholm scale,27 which quantifies
the functional use
of
the knee joint
using a scale of 0 to 1 00. This rating
system is a self-report of the subject's
perceived ability of activities such as
walking, stair climbing, and squatting
and is an accepted method of evaluat-
ing functional impairment.27,28 igher
scores indicated bette r functional use
with fewer symptoms.
Data Management and Analysis
Side-to-side differences in joint laxity
measurements were calculated and
used to com pare the values between
groups prior to surgery and 8 weeks
following surgery. Mean differences
we re com pared using an analysis of
variance (ANOVA). A Tukey's pair-wise
comp arison was used for within-
group comparisons, and a Bonferroni
pair-wise compa rison was used for
between-group comparisons.
Measurements of isometric and isoki-
netic peak torq ue for the quadriceps
femoris and hamstring m uscles we re
normalized to the values of the unin-
volved contralateral musculature and
expressed as a percentage. The mean
peak torque percentage and the mean
Lysholm score were com pared b e-
tween group s using a Student's test.
The ROM measurements for weeks 2,
4, 6, and 8 we re analyzed using a
two-way ANOVA (groups
X
weeks) for
repeated measures. A Tukey's pair-
wise comparison post hoc test for
significance was us ed for within-
gro up com parisons, and a Bonferroni
pair-wise comparison was u sed for
between-group comparisons.
Girth measurements were calculated
from m easurements of girth at mid-
patella and 15.24 cm above m id-
patella. Mean differences we re com-
pared at 2, 4, 6, and 8 weeks using
tests identical to those undertaken for
ROM. Th e alp ha level of significance
was set at .05.
Results
Results of the ANOVAs for joint laxity
measurem ents, presented in Tables 2
and 3, sho wed n o significant differ-
ence between groups (F=3.43, 4.04;
df=l l;P= .08 , .06), indicating that
neither program induced more laxity
than the oth er. A significant effect for
time did exist at both the 6.8-kg
(F=8.39, df=l P=.01) and 9.1-kg
forces (F=24.0,
df
1 P=.0001), indi-
cating that both g roups h ad sign&-
cantly less joint laxity at 8 weeks after
surgery compared with before
surgery.
Comparison of quadriceps femoris
and hamstring m uscle isometric and
isokinetic peak torque percentages
(Tab. 4) between g roups revealed no
significant differences for isometric
knee flexion, isometric knee exten-
sion, and isokinetic k nee extension
peak to rqu e percentages. The isoki-
netic knee flexion peak torq ue per-
centa ge, how ever, was significantly
higher for the TR group @=96.4,
SD=13.5) than for the PR group
@
81.7, SD=11 .1) (P =.01).
Passive range of motion measure-
ments were recorded at weeks 2, 4 , 6 ,
and 8 . Table 5 shows that there were
n o significant differences between
groups at each measurement period
(F=0.38, df=l P=.546). As expected,
there was a significant effect for time
(F= 116.49, df=3, P=. 000 1), implying
that kne e joint PROM for b oth g roups
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between the baseline measurement
and the second postoperative week,
Table 3 Results of Analysis of Variance of Differences in Joint Laxity Measurements
During a 9.1-kg (20-lb)Lachrnan Test
but no difference existed between
groups. Mean Lysholrn scores were
significantly higher in the PR group
Source
f
SS MS
@=92.2, SD=4.31) than in the TR
group @=82.4, SD=12.36) (P=.03)
Between subjects
Groups A)
Error
17 156 20
Within subjects
Weeks B)
1 123 73
A x B 1 0 25
Error
17 87 64
improved over the weeks.
At
2
weeks following surgery, the first
PROM measurement showed that
both groups had an average of 117
degrees of knee PROM. Both groups
showed progressive increments over
time, averaging 20 degrees between
weeks 2 and 4, 8 degrees between
weeks 4 and 6, and 4 more degrees
between weeks 6 and 8. Mean knee
PROM for both groups at the end of
the 8-week program was 150 degrees.
Post
ho analysis revealed that gains
in PROM were significant for both
groups only during the first 6 weeks.
No significant differences were noted
between groups. There was no signifi-
cant groupx time interaction, indicat-
ing that change in PROM over time
was not dependent on assignment.
Girth measurements taken at mid-
patella and 15.24 cm above mid-
patella were compared between
knees to determine mean differences
(Tab. 6). Between-group analysis
showed that the PR group had less
girth than the TR group for each mid-
patella measurement, but the differ-
ence was significant only at 8 weeks.
No significant difference between
groups was noted (F=2.09, df=
1
P=.l66). A time effect was shown
(F=23.45, df=4, P=.0001), as both
groups had a significant increase in
girth at mid-patella between the base-
line measurement and the second
postoperative week. Additionally, both
groups showed a significant decrease
in girth at mid-patella after the second
week, but only until week 4 At 15.54
cm above mid-patella, both groups
had significant decreases in girth
Lysholm scale measurements showed
that the PR group scored significantly
higher than the TR group at 8 weeks,
indicating that this group had fewer
problems with activities of daily living.
Increased pain, based on the subjects
self-report, and knee swelling during
activities of daily living were primarily
responsible for lower scores in the
TR group. The results of the laxity
and girth measurements may offer
possible reasons why the PR group
had higher Lysholm scores.
At 8 weeks following surgery, both
groups had less than 3 mm of differ-
ence in joint laxity between the in-
volved and uninvolved knees for both
the 6.8- and 9.1-kg Lachman tests.
Neither program induced knee joint
laxity, as a laxity difference of 5 3 mm
is considered normal.29 Although
between-group comparisons revealed
no significant difference, the within-
group means at the end of 8 weeks
indicated that the TR group had
greater than 1.5 mm more laxity for
both tests than the PR group. The
inability to detect a significant differ-
ence between groups may have been
due to insufficient sample size. This
result may be d ue to the increased
stresses on the knee joint during
Table 4 Means and Standard Deviations for Group Peak Torque Recovery at the
rehabilitation on land with
Eighth Postoperative Week (Percentage of Nonoperative Limb s Peak Torque)
in water.l5 Increased knee joint laxity
in the surgical knee at 8 weeks could
lsometrlc Peak lsoklnetlc Peak
have resulted in increased knee joint
Torque Percentage Torque Percentage
effusion, which may have led to the
07s) 901s)
lower Lysholm scores.
Group SD SD
Girth measurements taken at 15.24
kg
above mid-patella showed no signs-
Traditional rehabilitation n=9 )
cant difference between groups for
Flexion
85 1 9 1 96 4 13 5
atrophy of the thigh musculature.
Extension
43 1 11 6 56 1
9.2 Within-group comparison, however,
Pool rehabilitation n=10)
revealed that both groups followed
Flexion
83 7 10 6
81 7 1 l l the same significant changes from the
Extension
42 8 12 7 50 6 18 1
presurgical measurement until the
eighth postoperative week. Both
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in greater circumferential
measurements.
Table
5
Results of Analysis of Variance of Dgerences Between Groups in Recovey
of Range of Motion
Source
f
SS S
P
Between subjects
Groups A) 1 132.61 132.61 0.38 546
Error 18 6287.63 349.31
Within subjects
Weeks B) 3 13277.84 4425.95
1
16.49 .0001
A X B 3 48.24 16.08 0.42 737
Error 54 2051.66 37.99
groups experienced the greatest
change between the presurgical mea-
surement and the second postopera-
tive week, with the greatest decrease
in girth occurring at the fourth post-
operative week. Thigh musculature
atrophy is commonly observed d uring
the acutt: postsurgical period due to
muscle inhibition that takes place
from the increased joint effusion and
increased pa in . DeA ndrade e t a13O
have shc~wn hat with increased kn ee
joint effu sion, th ere is less muscle
output
as
measured by electromyo-
graph ic activity.
Thigh girth began to increase after
the fourth postoperative week, an d
the involved extremity was within
1.90 cm 0.75 in) of the contralateral
extremity by the eighth postoperative
week for both g roups. Increases in
thigh girth at this time may be attrib-
uted
t
several factors. As postopera-
tive joint effusion and pain decrease
while ROM increases, th e thigh mu s-
culature can b e exercised through a
gre ate r ROM. As exercises are p er-
formed mo re vigorously, muscle
tissue begins t hypertrophy, resulting
-
able 6 . Results of Analysis of Variance of Dzffwences Between Groups for Girth
Measurenzents at Mid-patella and 40 62 m 6 in) Above Mid-patella
Source f SS S
P
Mid-patella
Between subjects
Groups A)
Error
Within sl~bjects
Weeks B)
A x B
40.64 cm above m id-patella
Betweeri subjects
Groups A) 1 0.006 0.006 0.01 933
Error 17 15.53 0.80
Within S L J ~ ~ ~ C ~ S
Weeks B)
A X B
Error
Girth me asurem ents taken at mid-
patella showed that the girth for the
PR group was consistently less at each
time pe riod, but these differences
w er e significant on ly at 8 weeks.
As
discussed e arlier, the increased ginh
in the TR group m ay have bee n
cause d by th e joint effusion resulting
from greater stress o n the joint d ur-
ing land exercises co mp ared with
water exercise s. This increased joint
effusion m ay have l ed to lowe r Ly-
sholm scores.
Within-group comparison reveals that
mid-patella ginh measurements
changed similarly for both groups;
that is, measurements at this location
we re inversely related to the mea-
surem ents taken at 15.24 kg above
mid-patella. The greatest increa se in
girth was noted between the presurgi-
cal measurement and the second
postoperative week, suggesting the
increased joint effusion that typically
occurs following surgery. These re-
sults indicate that as joint effusion
decreases, m uscle girth increases,
with th e transition occurring around
4
to weeks following surgery.
Between-group comparison for peak
torque percentages PTPs) showed
that the
TR
group had a significantly
higher PTP for the hamstring muscles
at 90/s, indicating that the traditional
rehabilitation approach was m ore
effective than th e po ol rehab ilitation
approach for strengthening the ham-
string muscles. This result may have
occurred for two reasons. First, resis-
tance in the water was partially deter-
mined by the speed of l imb move-
ment, which was controlled by each
subject.16 Sub ject effort can b e affected
by pain and motivation. Therefore,
subjects may not have generated
enough resistance to facilitate maxi-
mal strengthening. Hamstring m uscle
exercises in the TR gro up were d on e
using weights, so resistance was not
self-paced. Second, there is a differ-
enc e in the type of muscle contrac-
tion that o ccurs o n land. Empirical
evidence suggests that an e ccentric
muscle contraction is important for
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8/10/2019 Phys Ther 1994 Tovin 710 9
10/13
restoring muscle perf0rman ce.3~This
type of contraction is more likely to
occur on land than in water due to
increased gravitational forces.
In both g roups, there w as equal effec-
tiveness in restoring quadriceps femo-
ris muscle strength. These results also
show ed that greate r joint effusion in
the TR gro up did not significantly
affect peak torque muscle perfor-
mance. A possible reason for this
finding is that all subjects were tested
in the range of 85 to 40 degrees of
knee flexion, rather than at the end -
range whe re joint effusion has be en
shown to s e c t muscle perfonnance.30
The mean PTPs for both group s are
similar to those repo rted for oth er
subjec ts with ACL reconstru ctions.5
Oth er studies,7,8 how ever, have d em -
onstrated higher peak to rque values.
Two possible explanations for lower
PTPs in this study are the type of
quadriceps fem oris muscle strength-
ening a nd m ethodological factors.
Type of Quadriceps Femoris
Muscle Strengthenlng
The method of quadriceps femoris
muscle strengthening in both groups
focused on closed-chain exercises,
which may not have provided enough
isolated stimulus to the quadriceps
femoris muscle to facilitate maxim um
strength gains. Previous studies,7.8
which demonstrated higher strength
gains, applied n euromuscular electri-
cal stimulation d uring open-chain
knee extension exercises. Both
groups in this study may have bene -
fited from isolated kne e extension
exercises through a limited ROM (90
to 40 of knee flexion to ens ure graft
protection), as recent research find-
ings indicate that closed-chain exer-
cises alone may not be enough to
facilitate maximum muscle perfor-
mance as m easured by isokinetic
dynamometry.32
Methodological Factors
Changing the m ethodology may have
resulted in higher mean PTPs. Per-
forming three 5-second isometric
quadriceps femoris m uscle contrac-
tions resulted in d on or site pain (the
anatomical site at which the central
third of the patellar ten don was surgi-
cally removed for use as an a u-
tograft) in so me subjects in both
group s, which may have altered the
rema ining tests. Anterior kn ee p ain is
com m on in th e early ph ases of ACL
rehabilitation if a patellar tendon
autograft is used. Testing isom etrically
and at slow speeds increases the joint
reaction forces aro und the patella, but
usually is a better indicator of
strength. Although strength testing in
this study provided adequate graft
protection, testing at faster speeds first
and slower speeds at the end of the
testing session might have resulted in
better PTP scores. The testing pro ce-
du re in this study did n ot take these
factors into account because at the
time the study was proposed, n o
published research had incorporated
isokinetic testing at 8 w eeks, using
only subjects with patellar tendon
autografts.
linical lmpllcatlons
Although a primary goal in the reha-
bilitation of pa tients with ACL recon -
structions is the restoration of quadri-
ceps femoris muscle performance, the
means of achieving this goal must
avoid overstressing the graft and in-
creasing joint e h s io n . Addttionally, to
expedite recovery, patients must toler-
ate the rehabilitation program . Som e
patients find postoperative exercises
too uncomfortable because of age,
low presurgical activity level, o r low
pain tolerance, and progression d ur-
ing the early phases of rehabilitation
is limited.
Exercises in water may make the total
rehabilitation program m or e tolera-
ble. Although a co mp lete aquatic
exercise program m ay be unneces-
sary, augmen ting a land program with
pool exercises may permit loading
the joint to a g reater deg ree. For
patients who are unable to tolerate
traditional e xercises o n land, water
can be
used to facilitate progression
to m ore aggressive exercises. In this
study, a water environm ent was m ost
beneficial for facilitating closed-chain
exercises, such as gait training and
step-ups, and the land pulleys ap-
peared to b e mo st beneficial for ham-
string muscle and hip strengthening.
Isolated qua driceps femo ris muscle
contractions in a safe range using
open-chain exercises may have bene-
fited both groups.
Patients using a pool for rehabilitation
are l ikely to tolerate an even m ore
aggressive rehabilitation program than
that presented in this study. In this
study, however, exercises in both
group s had to b e carefully matched to
ens ure that the main effect between
rehabilitation programs was du e to
the environ men t. The PR gro up cou ld
have performed more advanced exer-
cises, but varying the e xercises would
have ma de interpretation of results
unclear becau se differences between
groups could have then been attrib-
uted to the environment, exercises, or
interaction between the two.
Although traditional exercises have
been the treatment choice of most
clinicians, the results of this study
suggest that a rehabilitation program
for patients with intra-articu lar ACL
reconstructions performed in a pool
is mo re effective in re ducin g joint
effusion and facilitating recovery o f
lower-extremity function as indicated
by Lysholm scores. The results also
suggest that rehabilitation in water is
equally effective as on land for restor-
ing knee ROM an d quadriceps fem o-
ris muscle strength, but not as effec-
tive in restoring hamstring muscle
strength. Clinicians wh o wish to allow
maximal weight bearing may find the
adjunct of aquatic exercises useful.
Future studies should analyze the
effectiveness of a program that com-
bines traditional and water exercises,
using larger samp le sizes and a
longer follow-up period.
cknowledgments
We thank Lynn Snyde r-Mackler, ScD,
PT, for assisting with p repara tion of
this manuscript; Roberto Infante, PT
and the staff at Resurgeons Ortho-
paedics for their assistance with data
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8/10/2019 Phys Ther 1994 Tovin 710 9
11/13
collection; and Piedmont Hospital for
use of their facilities.
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32 Reynolds NL, Worrell TW, Perrin DH. Effect
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Correction
I n C o m p a r i s o n
of the
Effects
of
Ex erc i se inW a t e rand on Landon
t h e Reh ab i l i t a t i o n of Pat ien ts With
In t r a -a r t icu l a r An te r io r Cru c i a t e
L ig am en t Reco n s t ru c t i o n s by
To v inet al in theAu g u s t1994
i s su e ,an i n c o r r e c t u n i t of m e a s u r e
m e n t
for
g i r t h
is
s h o w n
on
p ag es
7 1 6and 717 and an i n c o r r e c t m e t
r i c c o n v e r s i o n
is
p r e s e n t e d
in
T a b l e6. Thed i s c u s s i o n and the
t a b l e s h o u l d
be
c o r r e c t e d
to
reflect
t h a t t h i g h g i r t h m e a s u r e m e n t s in
t h a t s t u d y were t ak en at m id -p a t e l l a
a n d at 1524 cm 6 in)a b o v emid-
patel la .TheJ o u r n a l r e g r e t sthe
e r r o r s .
no chest painandnorm al corona ry arter
ies (group
3).
The TENSwas set to deliver 300-milli-
second constant-current pulsesat 150 Hz.
Elect rodes wer e p laced20 cmapartat
the site
of
the most inte nse pain
for
sub
jectsingroups 1 and 2, andoverthe
per icard ium
for
subjects
in
g ro u p
3. In
tensity was adapted individuallytojust
below
the
level that produc ed pain
(10-60 mA). Coronary angiography was
performed
for
m easu rem en t
of
b lood
flow velocityandd iameterof the left
an ter ior descending
and
circumflex arter
ies during diastole. After determining
TENS intensity,
the
stimulator was tu rned
off and baseline valuesof resting blood
flow velocity, heart rate (HR), meanand
systolic blood pressures (BP), arterial
d iameters ,andaort ic norep ineph rineand
epinephrine concentrat ions were deter
mined. Transcutaneous electrical nerve
stimulation treatmentwasthen givenfor
5 minutes ,andm easu rem en ts w ereim
mediately repeated.
In 10
patients
in
each
g ro u p ,thestudy was repeated after co ro
nary blood flow returned
to
baseline
values. Results were compared usingthe
Wilcoxon matched-pairs test .
Resting coronary blood flow velocity
increased
and
aor tic ep ine phrine
de
creased significantly ingroups 1 and 2,
after TENS treatment. Heart rate, mean
or
systolic BP, blood norepinephrine,and
ar terial d iameters we re
not
altered
by
TENSin any group. Results were highly
reproducib le. There
was a
v ariability
in
responses toTENSingroups 1 and 2that
was independent ofthreshold stimulation
and siteofelectro de placem ent, suggest
ing individual differences
in
sensitivity
to
neurostimulation. Thelackofany
changes
in
g ro u p
3
(patients with heart
transplant) maybe associated with car
diac denervation
or
heterogenous rein-
nervation, immunosuppression therapy,
or higher baseline valuesofHR.
The authors suggested thatthe increase
in coronary blood flow velocity after
TENSin patients with chest painis due to
dilationat themicrocirculatory level. This
m ay be theresultof local productionof
vasodilatory substances, reductionin
local sympathetic activity,
or
both.
Carol J Weaver PhD
T
West Virginia University
Morgantoum
WVa
Validation offaNon Invasive
MethodofMeasuringtheSurface
Curvature
of
the Erect Spine
RaineS,Twomey LT (SchoolofPhysio
therapy, Curtin University
of
T echnology,
Perth, Western Australia, Australia),
Jour-
nal of Manual
and
Manipulative Ther-
apy.
1994;2:11-21.
The authors introduced
a
noninvasive
methodformeasurementofspinal curva
tures, examined
the
amount
of
measure
ment errorforthis method,anddeter
mined
the
validity
of
this m ethod
by
comparisons with radiographs.Theauthors
offered
an
alternative
to
measurement
methods usingamodified Cobb technique
that reflected changes
in the
angulation
of
the superiorandinferior vertebraein a
particular region without consideration
of
the shapeofthe curve. This method used
photographs, from whichthespinal curves
were manually digitizedandthen calcu
latedby acomputer.
Fifteen volunteer subjects from an outpa
tient scoliosis clinic were used inthis
study.Thenoninvasive measurem ent
method involved identifying with adhe
sive dots theC-7, T-6, T-12, L-2,and the
left posterior superior i l iac spine. This
was followedby theapplicationof a con
tinuous foam marker (1.27
cm in
width
and2.54 cm in depth) placed alongthe
subject 's spine.
The
adhesive dots w ere
then transferredto thefoam marker,
delineating
the
b o rd er s
of
four regions:
upper thoracic, lower thoracic, upper
lumbar ,
and
lower lumbar . Through
a
s tandard ized procedure,a profile photo
graph was takenas the subject stood over
the cen terof agraphlex platformand
directly behind a plum line.Thecontours
of the cont inuous m arkerand theindi
vidual spinal level markers were manu
ally digitized,and thespinal c urvature
was calculated through the use of a
GTCO digitizer, twocomputers ,and
custom-designed software. This measure
ment process involved2hoursof time
per subject.
The measurement errordue to theman
ual digitization was determined
by
exam
ining repeated trialsof manual tracings
over known curves that were designed to
simulate spinal curvatures. Thiswas
found to be less than 0.02%inrelationto
the mean surface curvature (-0.000010
to -0 .000041 rad /mm). This degreeof
error was foundto be similar throughout
the different regionsof the curve.
The validity
of
this technique
was
studied
by comparing the measurements taken
from
the
photographs wi th m easure
ments taken from theradiographs. Trac
ings were taken from
the
curves defined
by
the
posterior vertebral bodies
and
from
the
spinous processe s. These trac
ings were manually digitizedandcom
puter calculated
by the
same m eans
as
the photographs. These radiographic
curves were then compared wi ththe
photographic, surface curvesfor each
subject. A Pears on Product-M oment Cor
relation Coefficient was used for analysis
of the results.Theresults we re varied,
ranging from r=.37 tor= .8 4 .Thecorre
lations betwee nthesurface measurem ents
an d
the
radiographs improved
if
the sur
face measurement was compared withthe
posterior vertebral body measurem ent
in
the thoracic spine (r=.70-.84),and ifthe
surface measurement was compared with
the spinous process measurementin the
lumbar spine (r=.65-.67). This discrepancy
was explainedby theauthorsintermsof
variations
in the
radiographic anatomy of
these two spinal regions.
The authors concluded that this noninva
sive measurement techniquewasableto
provide
a
reasonable indication
of the
curvatureof the underlying vertebral
co lumn.
The
auth ors sug gested that this
mathematically derived curvature
of
the
surface contour
of
the spine
is a
m o re
precise method than themodified Cobb
method. They speculated about modifica
tionsin thetesting cond itions thatmay
improve thecorrelat ions betw eenthe
surface measurem entsand theradio
graphic measurements .
Karen Maloney Backstrom PT OCS
Univ of Colorado
Denver Colo
84 1165
P h ys ic a l T h e r a p y / V o l u m e 74,N u m b e r 1 2 / D e c e m b er1994