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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

8/10/2019 Phys Ther 1994 Tovin 710 9

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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

8/10/2019 Phys Ther 1994 Tovin 710 9

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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

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

8/10/2019 Phys Ther 1994 Tovin 710 9

11/13

collection; and Piedmont Hospital for

use of their facilities.

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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