FOREDRAGSHOLDERE:HEGE GRINDEM, HÅVARD MOKSNES, LARS ENGEBRETSEN, MARC STRAUSS,

MAREN STJERNEN, MAY ARNA RISBERG

ACL seminar 2016Ny kunnskap - bedre klinisk praksis

OSLO / 2016.01.15 /

/ SIDE 2EN DEL AV STAMINA GROUP

ACL seminar 2016 – Ny kunnskap - bedre praksis

TITTEL PÅ PRESENTASJONEN

• 08.30-08.45 Velkommen May Arna Risberg08.45-09.15 Konsekvenser av korsbåndskader May Arna Risberg09.15-09.45 Rekonstruksjon eller ikke: Nyeste forskning May Arna Risberg09.45-10.15 Rekonstruksjon eller ikke: Klinisk vurdering Marc Strauss10.15-10.30 Diskusjon10.30-10.45 Kaffe

• 10.45-11.00 Hvilket graft til hvilken pasient? Marc Strauss11.00-11.45 Gullstandard for rehabilitering Hege Grindem11.45-12.00 Diskusjon12.00-12.45 Lunsj UBC buffet

• 12.45-13.30 Tilbake til idrett - er pasienten klar? Hege Grindem og Håvard Moksnes13.30-14.15 Spesielle hensyn ved postoperative komplikasjoner og ved skader hos barn Håvard Moksnes14.15-14.30 Diskusjon14.30-14.45 Kaffe

• 14.45-15.15 Siste nytt fra det nasjonale korsbåndregistret Lars Engebretsen15.15-16.00 Forebygging av korsbåndskader og nye kneskader Maren Stjernen

/ SIDE 3EN DEL AV STAMINA GROUP

Utvikling av kompetanse på Nimi

Behandling av pasienter med ACL skade fra 2003 til 2016

• Mål om å være ledende innen ulike fagfelt også innen behandling og rehabilitering av ACL pasienter

• Mange års erfaring - utvikling av kompetanse

– Spesialister: idrettsfysioterapeuter, manuell terapeuter, ortopededer, fysikalsk medisinere

• Startet med forskning i 2003 (NAR) – integrerte klinikk og forsking

– Samarbeid nasjonalt og internasjonalt – Universitet i Delaware, Syd Danske Universitet og Australia

• Over 10 år senere kan vi vise at det vi gjør er landets beste og verdensledende!

/ SIDE 4EN DEL AV STAMINA GROUP

EditorialGrindem et al Aug 2015 BJSMTwo factors that may underpin outstanding outcomes after ACL rehabilitation

Over 10 år senere kan vi vise at det vi gjør er landets beste og verdensledende!

Norsk forskningssenter for AktivRehabilitering (NAR)

• Startet i 2003

• Forskningssamarbeid mellom– Nimi– Ortopedisk avdeling, Oslo Universitetssykehus– Idrettsmedisinsk seksjon, Norges Idrettshøgskole

• Eksterne forskningsmidler (fra 2003)– Helse Sør-Øst– National Institutes of Health (NIH), USA– Norges Forskningsråd– Syd Danske Universitet, Odense, Danmark– Helse og Rehabilitering

NIH R01HD041055

The Delaware-Oslo ACL Cohort Study

The Delaware-Oslo ACL Cohort Study

phd and postdoc students

ACL seminar 2016, Nimi

Professor og fysioterapeut May Arna Risberg PT, PhDNorsk forskningssenter for Aktiv Rehabilitering (NAR)

Ortopedisk avdeling, Oslo Universitetssykehus, Seksjon for idrettsmedisinske fag, Norges Idrettshøgskole og Nimi

Oslo University Hospital NIMINorwegian School Sport Sciences

Konsekvenser av ACL skadeKort- og langsiktige konsekvenser

• Norway

– ≈ 4000 ACL injuries in Norway each year

– ≈ 2000 go through ACL reconstruction (ACLR)

• Sweden

– ≈ 5000 ACL ruptures per year in Sweden

– ≈ 3000 go through ACL reconstructions

• Knee osteoarthritis (OA) after ACL injury 10-90%

• Post-traumatic OA accounts for 12% of all cases of OA

Anterior cruciate ligament (ACL)

Granan LP et al 2004, Lohmander LS et al 2007, Brown TD et al 2006, Øiestad et al 2010

Treatment after ACL injury

• 1990s - new surgical procedures and accelerated rehabilitation

• Surgery – “successful” treatment

– but

• recent studies suggests only about 60% make full recovery

• low return to sport rates ≈60%

• >50% develop OA as middle-aged

Shelbourne et al 1990, Biau DJ et al 2007, Oiestad BE et al 2010, Ardern CL et al 2011

We need to do better!

1. Hva er konsekvensene etter ACL skade?

– Hva vet vi om kort – og langtidsresultater?

• Hva er utfordringene?

2. Hvordan kan vi bruke ny kunnskap til å bedre pasientenesfunksjon på kort og lang sikt?

– Kunnskapsbasert informasjon – hvilken informasjon og rådgir vi pasientene ? ( følger pasientene rådene?)

– Øvelses- og treningstiltak

– Kirurgiske tiltak

Hvordan kan ny kunnskap gi bedre klinisk praksis?

• Smerter og hevelse

• Laxitet – økt translatorisk glidning

• ROM deficits

• Quadriceps dysfunksjoner

• Dynamisk instabilitet

• Nevromuskulære dysfunksjoner

• Biomekaniske forandringer –ledd belastnig

• Artrose

• Funksjonsproblemer i dagliglivet

• Funksjonsproblemer i sport

• Psykososiale konsekvenser

• Livskvalitet

• Tilleggsskader

– Menisk

– Sideligamenter

– Bruskskader

Konsekvenser av ACL skade

6 mnd 1 år 2 år 10-15 år

20

30

40

50

60

70

80

90

100

110

120

Isolert

Kombinert

aa

ab

abab

a

Qu

adri

cep

s st

ren

gth

(%

)

Quadriceps styrke over tid (% forskjell)

Oiestad et al 2010

Quadriceps dysfunctionafter ACL injury

• Pronounced both after injury and surgery

• Persistent over time– quadriceps inhibition

• Associated with long-term development of knee OA

Risberg et al 1999, Keays et al 2003, 2010; Tsepis et al 2006, de Jong et al. 2007; Ageberg et al 2007, Palmieri-Smith et al 2008,

Oiestad et al 2010, 2014

Maximizing quadriceps strength

Target muscle atrophy

• Strength training: dose-response

• Both CKC and OKC exercises

– OKC exercises: time postoperatively, ROM and resistance

• Both concentric and eccentric exercise

– Progression of strengthening exercises

– Plyometric exercises

Target muscle inhibition

• Efferent signals – Exercises+ Neuromuscular electrical stimulation (NMES)

• Neuromuscular exercises including perturbation exercises

Optimize rehabilitation program

Palmierri-Smith et al 2008

Gjør vi dette?

Neuromuscular electrical stimulation (NMES)Systematic reviews:

Risberg et al 2004, Wright et al 2008,

Kim KM et al 2010

>14 RCTs on NMES after ACLR

High intensity NMES significantly improve quadriceps muscle strength after ACLR

Imoto AM et al 2011

Kim KM et al 2010

Hamstrings weakness

• Less pronounced than quadriceps weakness

• Less persistent over time

• Mainly a concern postoperatively: hamstring graft

• Do not overlook!

Keays et al 2003, Tsepis et al 2006, Ageberg et al 2007, Heijne et al 2010, Lautamies et al 2008

Knee injuries

Posttraumatic knee OA

• 40-50 % of patients with knee OA come from previous injury– 12% of the overall prevalence of symptomatic OA is attributable to

posttraumatic OA

• Knee OA occur at an earlier age - from the 40-50 age decade

• Oiestad et al 2010 (10-15 years after ACL reconstruction)

– 74% tibiofemoral OA• Isolated ACL: 62% (symptomatic: 32%)

• Combined injuries: 80% (symptomatic: 46%)

Øiestad et al 2009, 2010

ENROLLMENT 1990-1997 at the time of ACL Reconstruction

BASELINE: n=258

Excluded n=48Not found n=19Declined to participate n=16Living abroud n=8 Pregnant n=2Died n=1

Lost to follow-up (n=42)

Involved knee • Isolated injury (n= 62)• Combined injury (n=106)

• Contralateral knee Uninjured (n=121) Injured (n=47)

20 year: n=168 (80%)

15 YEAR: n=210

Risberg MA et al 2016, AJSM in press

Øiestad PhD 2011

Methods – prospective cohortFollow-ups: 6 months, 1 and 2 years• Clinical exam• KT-1000 knee arthrometer tests• Cincinnati score• VAS for pain and Global Function• Isokinetic muscle strength tests• Single leg hop tests• Tegner activity scale

Follow-ups: 15 and 20 years • Clinical exam• KT-1000 knee arthrometer tests• Isokinetic muscles strength tests• KOOS ( Pain, Symptoms, ADL, Sport, QoL)• VAS for pain and Global Function• Tegner activity scale• Radiographic TFOA and PFOA

Risberg MA et al 2016, AJSM in press

Radiographic assessments• Tibiofemoral joint

– Synaflexer frame

• Patellofemoral joint

– Skyline view

• Radiographic and symptomatic OA– Kellgren & Lawrence (KL) grade 0-4

• Grade ≥2= OA

– Symptomatic OA

• Knee pain during the last 4 weeks and KL grade 2, 3 or 4

Synaflexer

Kellgren &Lawrence 1957, Kothari et al 2004, Felson et al 2011, Schiphof D et al 2008, Peat et al 2006

Skyline view

Patient characteristics20 years follow-up , n=168

Variables Mean (SD) Age (years) 45 (9)Females, number (%) 76 (42)Body Mass Index 27 (4)Time between injury and surgery (months) 28 (52)Time between surgery and 20 years follow-up (years) 18 (2)VAS at rest (mm) (0-10) 0.8 (1.5)VAS during or after activity (mm) (0-10) 2.1 (2.3)Tegner, median (min-max) (0-10) 4 (0-9)

Results

Risberg MA et al 2016, AJSM in press

Additional injuries

• At the 20 year follow-up

– 64% combined injuries (involved)

– 28% injuries to contralateral knee

• New injuries between 15 and 20 years

– 13% injuries/included surgical procedures

• 50% involved side

• 50% contralateral side

Risberg MA et al 2016, AJSM in press

Tibiofemoral OA15 and 20 years – isolated and combined injuries (involved side)

56%

41%

16%

11%

Risberg MA et al 2016, AJSM in press

Tibiofemoral OA15 and 20 years – isolated and combined injuries (involved side)

15 years isolated

15 years combined

20 years combined

20 years isolated

56%

41%

16%

11%

Those with meniscus injuries have more knee OA and worse function

Risberg MA et al 2016, AJSM in press

Patellofemoral OA15 and 20 years – isolated and combined injuries (involved side)

15 years isolated

15 years combined

20 years combined

20 years isolated

28%

16%

7%

10%

Those with meniscus injuries have more knee OA and worse function

Risberg MA et al 2016, AJSM in press

Tibiofemoral (TF) OA and patellofemoral (PF) OARadiographic and Symptomatic

Joint OA cutoff 15 years 20 years Change (%)TFOA KL2+ 30% 42% 12%

Symp TFOA KL2+ 15% 24% 9%

PFOA KL2+ 13% 21% 8%

Symp PFOA KL2+ 7% 14% 7%

Results

Risberg MA et al 2016, AJSM in press

KOOS score – 15 to 20 yearsIsolated and combined injuries

Only between 2-6 points change from 15 to 20 years

*

*p<0.01

*

*

Risberg MA et al 2016, AJSM in press

*

Quadriceps muscle strength

9%

*p<0.0001

*

**

*

10%

Risberg MA et al 2016, AJSM in press

8% *

**

*

*p<0.0001

Quadriceps and hamstrings muscle strength

Risberg MA et al 2016, AJSM in press

10%

Kliniske implikasjoner

• Fortsett med quadriceps trening til man har TESTET at den er normalisert

• "Isolerte" ACL skader "klarer seg bra"

• Kombinerte skader utvikler mer artrose (også patellar artrose)– Implementer kunnskapsbasert treningsprogram for artrose!

– Unngå meniskreseksjon/kirurgi ved degenertiv menisk – dette er tidlig artrose og skal behandles først med trening!

• Unngå overvekt – økt risiko for artrose

1. Hva er konsekvensene etter ACL skade?– Quadricepsdysfunksjoner – kort og lang sikt

– Langtidskonsekvenser: artrose

2. Hvordan kan vi bruke ny kunnskap til å bedre pasientenesfunksjon på kort og lang sikt?

– Kunnskapsbasert informasjon• Risikofaktorer for artrose: menisk, svak quadricepsmuskulatur,

vridningsidretter

• Lite artrose/lite problemer hos de med "isolert" ACL skade

– Øvelses- og treningstiltak• Ta pasienten inn til oppfølging!

• Styrketrening som forebygging

• Styrketrening som symptomlindring og bedre funksjon ved begynnendeartrose

Hvordan kan ny kunnskap gi bedre klinisk praksis?

ACL seminar 2016, Nimi

Professor og fysioterapeut May Arna Risberg PT, PhDNorsk forskningssenter for Aktiv Rehabilitering (NAR)

Ortopedisk avdeling, Oslo Universitetssykehus, Seksjon for idrettsmedisinske fag, Norges Idrettshøgskole og Nimi

Oslo University Hospital NIMINorwegian School Sport Sciences

Rekonstruksjon eller ikke: Nyeste forskning

Dessverre ikke ett "enkelt" svar!

Som all annen behandling:

Bruk forsknings-kunnskapen som grunnlag i vurderingen av hver enkelt pasient

Rekonstruksjon eller ikke?

ACL injured individuals are different - also regarding prognosis -

• Injury mechanisms

• Types of injury (meniscus, cartilage)

• Risks for development and progression of OA

• Functional disabilities– Muscular strength – quadriceps

– Neuromuscular function – dynamic stability

– Pain and symptoms

• Return to sport

• Other factors?

The neuromuscular system

So there is no ONE treatment that is best for all ACL injured

Treatment options

1. ACL reconstruction (ACLR) + rehabilitation (Rehab)2. Prehab + ACLR + Rehab3. Rehab alone

Evidence and clinical implications

Evidence

Surgery versus rehab alone?Prehab?Type of rehab programs?

Evidence

Surgery versus rehab alone?Prehab?Type of rehab programs?

Surgery or no surgery for ACL injured?

No significant differences between groups

Knee OA 20 years after ACL injury

ACLRPain SymptomsK&L= 2

ACL injuryNo surgeryNo painK&L=0

0

10

20

30

40

50

60

Surgery No surgery

Meuffels2010

Neuman2008

Kessler2008

Meunier2007

Lohmander2004

Fink

Knee OA > 10 years after ACLROiestad et al Systematic review 2009

Surgical vs nonsurgical treatmentCohorts – comparative studies

• Roos H et al 1995

• Fink C et al 2001

• Myklebust G et al 2003

• von Porat A et al 2004

• Swirtun LR et al 2006

• Meunier A et al 2007

• Neuman P et al 2008

• Kostogiannis et al 2008

• Kessler MA et al 2008

• Ageberg E et al 2008

• Meuffels et al 2009

• Moksnes & Risberg 2009

• Grindem et al JBJS 2014

Grindem et al JBJS 2014

The Delaware-Oslo ACL Cohort

Post-rehab testing

Late surgery

n=21

ACL injured n=141

n=2

Baseline testing

Average 2 months after injury

ACL injured included n=143

5 weeks rehab program*

n=141

Nonsurgical

n=43

Surgical n=79

2 years follow-up n=41 n=87 n=13n=2

Pre-rehab testing ACL injured n=141

?Continued Rehab

Postop Rehab

55%45%

30% 70%

Ongoing 5 years follow-up with radiographs

* Eitzen et al 2010

Grindem et al JBJS 2014

DecisionSurgical or non-surgical treatment?

• Operative (n=79)

– 77% - wanted to participate in Level I sports

– 15% - patient preference

– 7% - dynamic instability

– 1% - missing

• Delayed surgery (n=21)

– Dynamic instability

• Level I sports – 62%

• Level II sports – 29%

• ADL - 9%

• Nonoperative (n=64)

– 66% - good knee function, did not want Level I sports

– 34% - patient preference, wanted to try Level I sports

After 2 years: 70%

After 2 years: 30%

Grindem et al JBJS 2014

?

Patient reported outcome (PRO)

IKDC2000

0

20

40

60

80

100

Baseline 6 weeks 2 years

Nonsurgical

Surgical

0

50

100

150

200

250

300

Baseline 6 weeks 2 years Healthy

Nonsurgical

Surgical

Isokinetic quadriceps strength

Grindem et al JBJS 2014

Time p<0.001Group*time p=0.650

Time p<0.001Group*time p=0.664

Re-injuries - 2 yearssurgically and non-surgically treated ACL injury

Non-surgical

(n=43)

Surgical

(n=100)

Index knee:

ACL re-rupture - 8 (8.0 %)

Meniscus 4 (9 %) 13 (13 %)

Med/Lat/Patella Cartilage 2 (5%) 7 (7 %)

MCL - 1 (1 %)

Patella subluxation - 1 (1%)

Contralateral knee:

ACL rupture 1 (2%) 2 (2%)

Lateral meniscus - 1 (1%)

Medial collateral ligament - 1 (1%)

16% 34%

Higher risk of knee re-injury in surgically treated, but not after adjusting for age and preinjury sport participation (Level I sports)

Grindem et al JBJS 2014

• Current evidence is insufficient to base clinical decision-making

• Current evidence indicate that ACL injured individuals should receive non-operative interventions before surgical intervention is considered

Smith TO et al 2014

Summary – EvidenceSurgery or rehab alone

• No significant differences in knee function or knee OA in surgically compared to non-surgically treated ACL injured– Non-surgically treated

• Significantly older

• Better knee function at baseline

• Meniscus injuries after non-surgical treatment – No more meniscus injuries

• Frobell et al 2010, 2013, – More injuries after ACLR, but no significant differences adjusting for age and

pre-injury sport participation • Grindem et al 2014

– 3.5 fold increase of meniscus tear at ACLR in those who underwent surgery more than 12 months after injury

• Snoeker BA et al 2013 – not adjusted for sport participation

Evidence

Surgery versus rehab alone?Prehab?Type of rehab programs?

Preoperative rehab (prehab) prior to ACLR

• Preoperative quadriceps strength is an important predictor of the functional outcome of the knee joint after ACLR (Eitzen I et al

2010)

• 4 prehab studies– 5 week progressive rehab program (Eitzen I et al 2010)

– Perturbation training (Hartigan E et al 2009)

– Home-based physiotherapy (Keays SL et al 2006)

– 6 weeks strength and neuromuscular program (Shaarani SR et al 2013)

Prehab programs improve function and postop results

The Delaware-Oslo ACL Cohort Study

2010

p<0.001 for all subscales

Patients who underwent progressive preoperative rehabilitation showed superior results both preoperatively and 2 years postoperatively compared to patients in the control group

Grindem H et al BJSM 2014

Editorial Aug 2015 BJSM

Two factors that may underpin outstanding outcomes after ACL rehabilitation

• Progressive rehabilitation - Prehab

• Patient education, set goals and TEST them!

Our treatment algorithm

• Start active rehabilitation early after injury, including patient education

• Prehab

• Include functional testing

• After early rehab decide on operative treatment or continue non-operative/active rehab

– teamwork: patient, PT and surgeon

• Delay return to sport – get knee function and performance back!

• Make sure you test it!

Physical therapist

Orthopaedic surgeon

Patient

Post injury

Rehab• Tests• Phase 1,2

Tests / Screen

Our ACL treatment algorithm

Rehab• Phase 3

•Milestones

•Criteria

Returnto SportRTS

tests

PostopRehab• Phase 1,2,3• Milestones• Criteria

Returnto Sport

RTS tests

Take home messages

• Non-operative treatment is not the best choice for all ACL-injured patients

• But it can be!

• Use a treatment algorithm

• Include prehab and evidence based guidelines for rehab

• Address quadriceps muscle dysfunctions

• Remember muscle strength and functional tests before return to sport

1. Rekonstruksjon eller ikke?– Ingen signifikante forskjeller mellom disse to behandlingene MEN

• All behandling MÅ tilpasses den enkelte pasient sine dysfunksjoner og mål

– Bruk en behandlingsalgoritme

• Start med et preop progressivt reningsprogram!

• Pasientene blir godt kjent med nødvendige treningstiltak

• Funksjonsvurderingen blir bedre

• Optimalisering av funksjon FØR operasjon gir bedrelangtidsresultater etter kirurgi

2. Ca 30% av pasientene klarer seg meget bra (etter 2 år) utenrekonstruksjon når de har vært igjennom den beskrevnebehandlingsalgoritmen

Hvordan kan ny kunnskap gi bedre klinisk praksis?

Acknowledgements

• NIH Grant # 5 R37 HD 037985 -11

• The South-Eastern Norway Regional

Health Authority

• The Norwegian Research Council

Oslo University Hospital

Norwegian School of Sport Sciences

NIMI

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