Clinical Practice Guidelines - Academy Of Orthopaedic .
Clinical Practice GuidelinesJournal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 3, 2017. For personal use only. No other uses without permission.Copyright 2017 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.DAVID S. LOGERSTEDT, PT, PhD DAVID SCALZITTI, PT, PhD MAY ARNA RISBERG, PT, PhDLARS ENGEBRETSEN, MD KATE E. WEBSTER, PhD JULIAN FELLER, MDLYNN SNYDER-MACKLER, PT, ScD MICHAEL J. AXE, MD CHRISTINE M. MCDONOUGH, PT, PhDKnee Stability and MovementCoordination Impairments:Knee Ligament SprainRevision 2017Clinical Practice Guidelines Linked to theInternational Classification of Functioning,Disability and Health From the Orthopaedic Sectionof the American Physical Therapy AssociationJ Orthop Sports Phys Ther. 2017;47(11):A1-A47. doi:10.2519/jospt.2017.0303SUMMARY OF RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3METHODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4CLINICAL GUIDELINES:Impairment/Function-Based Diagnosis. . . . . . . . . . . . . . . . . . . A7CLINICAL GUIDELINES:Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A17CLINICAL GUIDELINES:Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A22AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . . A25REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A26REVIEWERS: Roy D. Altman, MD Paul Beattie, PT, PhD John DeWitt, DPT James M. Elliott, PT, PhD Amanda Ferland, DPTG. Kelley Fitzgerald, PT, PhD Sandra Kaplan, PT, PhD David Killoran, PhD Joanna Kvist, PT, PhD Robert Marx, MD, MScLeslie Torburn, DPT James Zachazewski, DPTFor author, coordinator, contributor, and reviewer affiliations, see end of text. 2017 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, andthe Journal of Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to thereproduction and distribution of this guideline for educational purposes. Address correspondence to Brenda Johnson, ICF-Based Clinical Practice Guidelines Coordinator,Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: icf@orthopt.org47-11 CPG Knee 3.indd 110/18/2017 2:26:08 PM
Knee Ligament Sprain: Clinical Practice Guidelines Revision 2017Summary of Recommendations*Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 3, 2017. For personal use only. No other uses without permission.Copyright 2017 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.DIAGNOSIS/CLASSIFICATIONA Physical therapists should diagnose the International Classification of Diseases (ICD) categories of Sprain and strain involving collateral ligament of knee, Sprain and strain involvingcruciate ligament of knee, and Injury to multiple structures of knee,and the associated International Classification of Functioning, Disability and Health (ICF) impairment-based categories of knee instability (b7150 Stability of a single joint) and movement coordinationimpairments (b7601 Control of complex voluntary movements), using the following history and physical examination findings: mechanism of injury, passive knee laxity, joint pain, joint effusion, andmovement coordination impairments.DIFFERENTIAL DIAGNOSISThe clinician should suspect diagnostic classifications associated with serious pathological conditions when the individual’s reported activity limitations and impairments of body functionand structure are not consistent with those presented in the Diagnosis/Classification section of this guideline, or when the individual’ssymptoms are not resolving with intervention aimed at normalizationof the individual’s impairments of body function.BEXAMINATION – OUTCOME MEASURES: ACTIVITY LIMITATIONSAND SELF-REPORTED MEASURESClinicians should use the International Knee DocumentationCommittee 2000 Subjective Knee Evaluation Form (IKDC2000) or Knee injury and Osteoarthritis Outcome Score (KOOS), andmay use the Lysholm scale, as validated patient-reported outcomemeasures to assess knee symptoms and function, and should usethe Tegner activity scale or Marx Activity Rating Scale to assess activity level, before and after interventions intended to alleviate thephysical impairments, activity limitations, and participation restrictions associated with knee ligament sprain. Clinicians may use theAnterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) instrument as a validated patient-reported outcome measure to assesspsychological factors that may hinder return to sports before and after interventions intended to alleviate fear of reinjury associated withknee ligament sprain.BEXAMINATION – PHYSICAL PERFORMANCE MEASURESClinicians should administer appropriate clinical or fieldtests, such as single-legged hop tests (eg, single hop fordistance, crossover hop for distance, triple hop for distance, and6-meter timed hop), that can identify a patient’s baseline status relative to pain, function, and disability; detect side-to-side asymmetries;assess global knee function; determine a patient’s readiness to returnto activities; and monitor changes in the patient’s status throughoutthe course of treatment.BEXAMINATION – PHYSICAL IMPAIRMENT MEASURESBa2 When evaluating a patient with ligament sprain over an episode of care, clinicians should use assessments of impair-ment of body structure and function, including measures of kneelaxity/stability, lower-limb movement coordination, thigh musclestrength, knee effusion, and knee joint range of motion.INTERVENTIONS – CONTINUOUS PASSIVE MOTIONClinicians may use continuous passive motion in the immediate postoperative period to decrease postoperative pain afteranterior cruciate ligament (ACL) reconstruction.CINTERVENTIONS – EARLY WEIGHT BEARINGClinicians may implement early weight bearing as tolerated(within 1 week after surgery) for patients after ACLreconstruction.CINTERVENTIONS – KNEE BRACINGCClinicians may use functional knee bracing in patients withACL deficiency.Clinicians should elicit and document patient preferencesin the decision to use functional knee bracing following ACLreconstruction, as evidence exists for and against its use.DClinicians may use appropriate knee bracing for patients withacute posterior cruciate ligament (PCL) injuries, severe medial collateral ligament (MCL) injuries, or posterolateral corner (PLC)injuries.FINTERVENTIONS – IMMEDIATE VERSUS DELAYED MOBILIZATIONClinicians should use immediate mobilization (within 1 week)after ACL reconstruction to increase joint range of motion,reduce joint pain, and reduce the risk of adverse responses of surrounding soft tissue structures, such as those associated with kneeextension range-of-motion loss.BINTERVENTIONS – CRYOTHERAPYBClinicians should use cryotherapy immediately after ACLreconstruction to reduce postoperative knee pain.INTERVENTIONS – SUPERVISED REHABILITATIONClinicians should use exercises as part of the in-clinic supervised rehabilitation program after ACL reconstruction andshould provide and supervise the progression of a home-based exercise program, providing education to ensure independentperformance.BINTERVENTIONS – THERAPEUTIC EXERCISESWeight-bearing and non–weight-bearing concentric and eccentric exercises should be implemented within 4 to 6 weeks,2 to 3 times per week for 6 to 10 months, to increase thigh musclestrength and functional performance after ACL reconstruction.Anovember 2017 volume 47 number 11 journal of orthopaedic & sports physical therapy47-11 CPG Knee 3.indd 210/18/2017 2:26:08 PM
Knee Ligament Sprain: Clinical Practice Guidelines Revision 2017Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 3, 2017. For personal use only. No other uses without permission.Copyright 2017 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.Summary of Recommendations* (continued)INTERVENTIONS – NEUROMUSCULAR ELECTRICAL STIMULATIONINTERVENTIONS – NEUROMUSCULAR RE-EDUCATIONA Neuromuscular electrical stimulation should be used for 6 to8 weeks to augment muscle strengthening exercises in patients after ACL reconstruction to increase quadriceps musclestrength and enhance short-term functional outcomes.Neuromuscular re-education training should be incorporatedwith muscle strengthening exercises in patients with kneestability and movement coordination impairments.A*These recommendations and clinical practice guidelines are basedon the scientific literature published prior to December 2016.List of AbbreviationsACL: anterior cruciate ligamentACL-RSI: Anterior Cruciate Ligament-Return to Sportafter InjuryADLs: activities of daily livingAPTA: American Physical Therapy AssociationCI: confidence intervalCPG: clinical practice guidelineEQ-5D: EuroQol-5 DimensionsHRQoL: health-related quality of lifeICC: intraclass correlation coefficientICD: International Classification of DiseasesICF: International Classification of Functioning, Disabilityand HealthIKDC 2000: International Knee DocumentationCommittee 2000 Subjective Knee Evaluation FormJOSPT: Journal of Orthopaedic & Sports PhysicalTherapyKOOS: Knee injury and Osteoarthritis Outcome ScoreKQoL-26: Knee Quality of Life 26-item questionnaireLCL: lateral collateral ligamentMCL: medial collateral ligamentMDC: minimal detectable changeMRI: magnetic resonance imagingNLR: negative likelihood ratioNMES: neuromuscular electrical stimulationOR: odds ratioPCL: posterior cruciate ligamentPLC: posterolateral cornerPLR: positive likelihood ratioPROs: patient-reported outcomesQoL: quality of lifeRCTs: randomized controlled trialsSANE: single assessment numeric evaluationSF-12: Medical Outcomes Study 12-Item Short-FormHealth SurveySF-36: Medical Outcomes Study 36-Item Short-FormHealth SurveyTSK-11: Tampa Scale of KinesiophobiaIntroductionAIM OF THE GUIDELINESThe Orthopaedic Section of the American Physical TherapyAssociation (APTA) has an ongoing effort to create evidencebased clinical practice guidelines (CPGs) for orthopaedicphysical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disabilityand Health (ICF).125The purposes of these clinical guidelines are to: Describe evidence-based physical therapy practice, in-cluding diagnosis, prognosis, intervention, and assessment of outcome for musculoskeletal disorders commonlymanaged by orthopaedic and sports physical therapists Classify and define common musculoskeletal conditionsusing the World Health Organization’s terminology related to impairments of body function and body structure,activity limitations, and participation restrictions Identify interventions supported by current best evidenceto address impairments of body function and structure,activity limitations, and participation restrictions associated with common musculoskeletal conditionsjournal of orthopaedic & sports physical therapy volume 47 number 11 november 2017 47-11 CPG Knee 3.indd 3a310/18/2017 2:26:08 PM
Knee Ligament Sprain: Clinical Practice Guidelines Revision 2017Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 3, 2017. For personal use only. No other uses without permission.Copyright 2017 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.Introduction (continued) Identify appropriate outcome measures to assess changesresulting from physical therapy interventions in bodyfunction and structure as well as in activity and participation of the individual Provide a description to policy makers, using internationally accepted terminology, of the practice of orthopaedicphysical therapists Provide information for payers and claims reviewers regarding the practice of orthopaedic physical therapy forcommon musculoskeletal conditions Create a reference publication for orthopaedic physicaltherapy clinicians, academic instructors, clinical instructors, students, interns, residents, and fellows regardingthe best current practice of orthopaedic physical therapySTATEMENT OF INTENTThese guidelines are not intended to be construed or toserve as a standard of medical care. Standards of care aredetermined on the basis of all clinical data available for anindividual patient and are subject to change as scientificknowledge and technology advance and patterns of careevolve. These parameters of practice should be consideredguidelines only. Adherence to them will not ensure a successful outcome in every patient, nor should they be construed as including all proper methods of care or excludingother acceptable methods of care aimed at the same results.The ultimate judgment regarding a particular clinical procedure or treatment plan must be made based on clinicianexperience and expertise in light of the clinical presentationof the patient, the available evidence, available diagnosticand treatment options, and the patient’s values, expectations, and preferences. However, we suggest that significantdepartures from accepted guidelines should be documentedin the patient’s medical records at the time the relevant clinical decision is made.MethodsContent experts were appointed by the Orthopaedic Sectionof the APTA to conduct a review of the literature and to develop an updated “Knee Stability and Movement CoordinationImpairments: Knee Ligament Sprain” CPG as indicated bythe current state of the evidence in the field. The aims of therevision were to provide a concise summary of the evidencesince publication of the original guideline and to develop newrecommendations or revise previously published recommendations to support evidence-based practice. The authors ofthis guideline revision worked with research librarians withexpertise in systematic reviews to perform a systematic searchfor concepts associated with ligament injuries and instabilitiesof the knee for articles published since 2008 related to classification, examination, and intervention strategies consistentwith previous guideline development methods related to ICFclassification.70 Briefly, the following databases were searchedfrom 2008 to December 2016: MEDLINE (PubMed; 2008to date), Scopus (Elsevier; 2008 to date), CINAHL (EBSCO;2008 to date), SPORTDiscus (EBSCO; 2008 to date), Coch rane Library (Wiley; 2008 to date). (See APPENDIX A for fullsearch strategies and APPENDIX B for search dates and results,available at www.orthopt.org.)The authors declared relationships and developed a conflictmanagement plan, which included submitting a Conflict ofInterest form to the Orthopaedic Section, APTA, Inc. Articlesa4 that were authored by a reviewer were assigned to an alternatereviewer. Funding was provided to the CPG development teamfor travel and expenses for CPG development training. TheCPG development team maintained editorial independence.Articles contributing to recommendations were reviewedbased on specified inclusion and exclusion criteria with thegoal of identifying evidence relevant to physical therapistclinical decision making for adult persons with knee stability and movement coordination impairments/knee ligamentsprain. The title and abstract of each article were reviewedindependently by 2 members of the CPG development teamfor inclusion (see APPENDIX C for inclusion and exclusion criteria, available at www.orthopt.org). Full-text review was thensimilarly conducted to obtain the final set of articles for contribution to the recommendations. The team leader (D.S.L.)provided the final decision for discrepancies that were notresolved by the review team (see APPENDIX D for a flow chart ofarticles and APPENDIX E for articles included in recommendations by topic, available at www.orthopt.org). For selected relevant topics that were not appropriate for the developmentof recommendations, such as incidence and imaging, articleswere not subject to systematic review and were not includedin the flow chart. Evidence tables for this CPG are availableon the Clinical Practice Guidelines page of the OrthopaedicSection of the APTA website (www.orthopt.org).november 2017 volume 47 number 11 journal of orthopaedic & sports physical therapy47-11 CPG Knee 3.indd 410/18/2017 2:26:08 PM
Knee Ligament Sprain: Clinical Practice Guidelines Revision 2017Methods (continued)This guideline was issued in 2017 based on the publishedliterature up to December 2016. This guideline will be considered for review in 2021, or sooner if new evidence becomesavailable. Any updates to the guideline in the interim periodwill be noted on the Orthopaedic Section of the APTA website, www.orthopt.orgJournal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 3, 2017. For personal use only. No other uses without permission.Copyright 2017 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.Individual clinical research articles were graded according to criteria adapted from the Centre for Evidence-BasedMedicine, Oxford, United Kingdom for diagnostic, prospective, and therapeutic studies.91 In 3 teams of 2, each reviewer independently assigned a level of evidence and evaluatedthe quality of each article using a critical appraisal tool. SeeAPPENDICES F and G (available at www.orthopt.org) for thelevels of evidence table and details on procedures used forassigning levels of evidence. The evidence update was organized from highest level of evidence to lowest level. Anabbreviated version of the grading system is provided below.IIIIIIVVEvidence obtained from systematic reviews, high-quality diagnostic studies, prospective studies, or randomized controlled trialsEvidence obtained from systematic reviews, lesser-quality diagnostic studies, prospective studies, or randomized controlledtrials (eg, weaker diagnostic criteria and reference standards,improper randomization, no blinding, less than 80% follow-up)Case-control studies or retrospective studiesCase seriesExpert opinionGRADES OF EVIDENCEThe strength of the evidence supporting the recommendationswas graded according to the previously established methodsfor the original guideline and those provided below. Eachteam developed recommendations based on the strength ofevidence, including how directly the studies addressed thequestion on knee stability and movement coordination impairments/knee ligament sprain population. In developing theirrecommendations, the authors considered the strengths andlimitations of the body of evidence and the health benefits, sideeffects, and risks of tests and interventions.GRADES OF RECOMMENDATIONBASED ONSTRENGTH OF EVIDENCEStrong evidenceABModerateevidenceA preponderance of level I and/or level IIstudies support the recommendation.This must include at least 1 level I studyA single high-quality randomized controlledtrial or a preponderance of level II studiessupport the recommendationWeak evidenceA single level II study or a preponderance oflevel III and IV studies, including statementsof consensus by content experts, support therecommendationConflictingevidenceHigher-quality studies conducted onthis topic disagree with respect to theirconclusions. The recommendation isbased on these conflicting studiesTheoretical/foundationalevidenceA preponderance of evidence from animalor cadaver studies, from conceptual models/principles, or from basic science/benchresearch supports this conclusionExpert opinionBest practice based on the clinicalexperience of the guidelinesdevelopment teamCDLEVELS OF EVIDENCEIGRADES OF RECOMMENDATIONBASED ONSTRENGTH OF EVIDENCEEFGUIDELINE REVIEW PROCESS AND VALIDATIONIdentified reviewers who are experts in knee ligament injurymanagement and rehabilitation reviewed the content andmethods of this CPG for integrity, accuracy, and to ensurethat it fully represents the condition. Any comments, suggestions, or feedback from the expert reviewers were deliveredto the authors and editors to consider and make appropriate revisions. These guidelines were also posted for publiccomment and review on the orthopt.org website, and a notification of this posting was sent to the members of the Orthopaedic Section, APTA, Inc. Any comments, suggestions,and feedback gathered from public commentary were sentto the authors and editors to consider and make appropriaterevisions in the guideline. In addition, a panel of consumer/patient representatives and external stakeholders, such asclaims reviewers, medical coding experts, academic educators, clinical educators, physician specialists, and researchers, also reviewed the guideline and provided feedback andrecommendations that were given to the authors and editors for further consideration and revisions. Last, a panel ofconsumer/patient representatives and external stakeholdersand a panel of experts in physical therapy practice guideline methodology annually review the Orthopaedic Section,APTA’s ICF-based Clinical Practice Guideline Policies andprovide feedback and comments to the Clinical PracticeGuideline Coordinator and Editors to improve the APTA’sguideline development and implementation processes.DISSEMINATION AND IMPLEMENTATION TOOLSIn addition to publishing these guidelines in the Journal ofOrthopaedic & Sports Physical Therapy (JOSPT), these guidelines will be posted on CPG areas of both the JOSPT and theOrthopaedic Section, APTA websites for free access, and willjournal of orthopaedic & sports physical therapy volume 47 number 11 november 2017 47-11 CPG Knee 3.indd 5a510/18/2017 2:26:08 PM
Knee Ligament Sprain: Clinical Practice Guidelines Revision 2017Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 3, 2017. For personal use only. No other uses without permission.Copyright 2017 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.Methods (continued)be submitted for posting on the Agency for Healthcare Research and Quality website (www.guideline.gov). The implementation tools planned to be available for patients, clinicians,educators, payers, policy makers, and researchers, and the associated implementation strategies, are listed in the TABLE.The primary ICF body structure codes associated withknee stability and movement coordination impairmentsare s75011 Knee joint, s75002 Muscles of thigh, s75012Muscles of lower leg, and s75018 Structure of lower leg,specified as ligaments of the knee.CLASSIFICATIONThe primary ICF activities and participation codes associated with knee stability and movement coordination impairments are d2302 Completing the daily routine and d4558Moving around, specified as direction changes while walking or running.The primary International Classification of Diseases 10threvision (ICD-10) codes and conditions associated withknee stability and movement coordination impairments areS83.4 Sprain and strain involving (fibular)(tibial) collateral ligament of knee, S83.5 Sprain and strain involving(anterior)(posterior) cruciate ligament of knee, and S83.7Injury to multiple structures of knee, Injury to (lateral)(medial) meniscus in combination with (collateral)(cruciate) ligaments.The primary ICF body function codes associated with theabove-noted ICD-10 conditions are b7150 Stability of asingle joint and b7601 Control of complex voluntarymovements.TABLEMobile app of guideline-based exercises for patients/clientsand health care practitionersClinician’s quick-reference guideRead-for-credit continuing education unitsEducational webinars for health care practitionersMobile and web-based app of guideline for training of healthcare practitionersPhysical Therapy National Outcomes Data RegistryLogical Observation Identifiers Names and Codes mappingNon-English versions of the guidelines and guidelineimplementation tools ORGANIZATION OF THE GUIDELINEFor each topic, the summary recommendation and grade ofevidence from the 2010 guideline are presented, followed bya synthesis of the recent literature with the correspondingevidence levels. Each topic concludes with the 2017 summaryrecommendation and its updated grade of evidence.Planned Strategies and Tools to Support the Disseminationand Implementation of This Clinical Practice GuidelineTool“Perspectives for Patients”a6A comprehensive list of codes was published in the previousguideline.70StrategyPatient-oriented guideline summary available on www.jospt.organd www.orthopt.orgMarketing and distribution of app using www.orthopt.org andwww.jospt.orgSummary of guideline recommendations available on www.orthopt.orgContinuing education units available for physical therapists and athletic trainersthrough JOSPTGuideline-based instruction available for practitioners on www.orthopt.orgMarketing and distribution of app using www.orthopt.org and www.jospt.orgSupport the ongoing usage of data registry for common musculoskeletalconditions of the head and neck regionPublication of minimal data sets and their corresponding Logical ObservationIdentifiers Names and Codes for the head and neck region on www.orthopt.orgDevelopment and distribution of translated guidelines and tools to JOSPT’sinternational partners and global audience via www.jospt.orgnovember 2017 volume 47 number 11 journal of orthopaedic & sports physical therapy47-11 CPG Knee 3.indd 610/18/2017 2:26:08 PM
Knee Ligament Sprain: Clinical Practice Guidelines Revision 2017CLINICAL NCEJournal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at on November 3, 2017. For personal use only. No other uses without permission.Copyright 2017 Journal of Orthopaedic & Sports Physical Therapy . All rights reserved.2010 SummaryApproximately 80 000 to 250 000 injuries occur to the anterior cruciate ligament (ACL) per year in the United States,with about 100 000 ACL reconstructions performed annually, the sixth most common orthopaedic procedure in theUnited States. Approximately 70% of all ACL injuries arenoncontact in nature and 30% are contact injuries. The incidence of posterior cruciate ligament (PCL) injury is 0.65%to 44% of all ligamentous knee injuries. The most commoncauses for PCL injury are motor vehicle accidents and athletics. The incidence of medial (tibial) collateral ligament(MCL) lesions is 7.9% of all athletic injuries. Injury to thelateral (fibular) collateral ligament (LCL) is the least common of all knee ligament injuries, with an incidence of 4%.Two of the most common multiligament knee injuries involvethe MCL and the ACL, and the posterolateral corner (PLC)and the ACL or the PCL. A comprehensive description of theincidence of ligamentous injuries of the knee was publishedin the 2010 guidelines.70In intermediate follow-up studies, the incidencerate of ipsilateral ACL graft rupture ranged from3% to 9%, and that of contralateral ACL injuryranged from 3% to 20.5%.88,126 Female athletes after ACL reconstruction and returning to sport are 4.5 times more likelyto sustain an ACL injury within 24 months compared to female controls.87,88 A systematic review of studies with a minimum of 5 years of follow-up after ACL reconstructionreported an ipsilateral ACL graft rupture rate ranging from1.8% to 10.4% (pooled, 5.8%) and a contralateral ACL injuryrate ranging from 8.2% to 16.0% (pooled, 11.8%).127IIIn a case-control study by Webster et al,122 the incidence of second ACL injury was 4.5% to the ACLgraft (ipsilateral) and 7.5% to the contralateralACL. The incidence of second ACL injury was highest in patients who were under 20 years of age at primary surgery(29% to either knee), with an odds ratio (OR) of 6.3 for ipsilateral graft rupture and an OR of 3.1 for contralateral ACLinjury. Returning to high-risk sports involving cutting andpivoting increased the odds of ipsilateral graft rupture by 3.9fold and of contralateral ACL rupture by 4.9-fold.IIIEVIDENCE UPDATEA systematic review of ACL injuries and/or surgeryreported that the annual incidence rates of nationalpopulations in different countries ranged from0.01% to 0.05% (median, 0.03%), or 8 to 52 per 100 000person-years (median, 32 per 100 000 person-years).78 Incidence rates for military groups and professional athletes aresubstantially higher, and rates for amateur athletes are moderately higher than national-population incidence rates.78IOf increasing interest is the rate of second ACL injury. A systematic review with meta-analysis by Wiggins et al123 reported the overall second ACL injuryrate to be 15% (8% to the ipsilateral ACL graft, 7% to the contralateral ACL). Patients younger than 25 years had a secondACL injury rate of 21%. Athletes younger than 25 years whoreturned to sports had a second ACL injury rate of 23%.IA systematic review and meta-analysis by Gornitzky et al39 reported the overall ACL injury incidencerate to be 0.062 injuries per 1000 exposures in UShigh school athletes. Compared to boys, girls had a relativeIIrisk rate of 1.57 injuries per exposure, despite a greater number of ACL injuries in boys. In girls, the highest per-seasoninjury risk levels (incidence rate by number of exposures perseason) were seen in soccer (1.11%), basketball (0.88%), andlacrosse (0.53%). In boys, the highest injury risk levels perseason were seen in American football (0.80%), lacrosse(0.44%), and soccer (0.30%).In a population-based epidemiologic study in Sweden, young men aged 21 to 30 years had the highestincidence rate of ACL injuries at 225 per 100 000inhabitants (95% confidence interval
Clinical Practice Guidelines DAVID S. LOGERSTEDT, PT, PhD DAVID SCALZITTI, PT, PhD MAY ARNA RISBERG, PT, PhD LARS ENGEBRETSEN, MD KATE E. WEBSTER, PhD JULIAN FELLER, MD LYNN SNYDER-MACKLER, PT, ScD MICHAEL J. AXE, MD CHRISTINE M. MCDONOUGH, PT, PhD Knee Stability an
What is a clinical practice guideline? APA defines two main types of guidelines: 1. Professional practice guidelines-"recommendations to professionals concerning their conduct and the issues to be considered in particular areas of clinical practice" (APA, 2002 ). 2. Clinical practice guidelines-"provide specific recommendations about
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Nov 01, 2013 · ADA Clinical Practice Guidelines Handbook 2013 November 1, 2013 Page 7 Legal Affairs. Collaborating organizations will be expected to abide by the evidence-based process as stated in this handbook. 1.2.4 End-users ADA Clinical Practice Guidelines are primarily intended to be used by
