What is prehabilitation and why is it important?
Preoperative rehabilitation or prehabilitation refers to a program that involves physically and mentally preparing the patient before surgery with the aim of reducing complications and speeding up subsequent recovery.
Anterior cruciate ligament (ACL) reconstruction is a very common treatment following a tear. This intervention involves an extensive and prolonged postoperative rehabilitation process (between 9-12 months) to ensure a complete recovery and return to the level of sporting activity prior to the injury.
Patients who arrive better prepared, both psychologically and physically, for the reconstruction show better postoperative outcomes. Among the preoperative factors associated with better results are greater quadriceps strength and a full passive knee extension range, optimism, and self-efficacy. These findings reinforce the importance of prehabilitation, which has been associated with better function and level of sporting activity reported by the patient compared to no or limited prehabilitation.
What should preoperative rehabilitation be like?
A prehabilitation program before the ACL reconstruction surgery aims primarily to improve the preoperative functionality of the knee, in order to optimise the postoperative outcomes.
Specific functional objectives of prehabilitation:
- Absence of effusion in the affected knee – joint effusion inhibits the activation of the quadriceps, making it difficult to perform the strength work necessary to achieve the other preoperative objectives.
- Full active and passive range of motion – a lack of full extension of the knee prior to surgery is an important risk factor for a lack of extension postoperatively.
- Quadriceps strength symmetry of 90% - a reduction greater than 20% in quadriceps strength has negative consequences on the self-reported outcome two years after surgery.
Prehabilitation can begin as soon as the tear is diagnosed, and follows the same principles as the acute and intermediate phases of postoperative rehabilitation. It is important to specifically work on full passive extension and quadriceps strength, as these are the two factors most associated with worse outcomes after surgery.
When the patient has full range of motion, shows no effusion, and is able to jump on one leg with confidence, prehabilitation can progress to strength training with high loads and plyometric exercises. This type of work is safe in this phase and its benefits last up to 2 years after surgery.
It is important to note that, to this day, there is no clear consensus on what the optimal content, frequency, or duration of a prehabilitation program should be. However, guided by the functional objectives described above, an effective prehabilitation can be designed and postoperative outcomes can be optimized. An individualized program should be proposed, adapting to the presentation and evolution of each patient.
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