E D IT O R IA L
Journal of Sport Rehabilitation, 2014, 23, 169-170 http://dx.doi.org/10.1123/JSR.2014-0246 © 201 4 Human Kinetics, Inc.
Current Concepts in Cartilage Management and Rehabilitation Despite the abundance of clinical and scientific research focused on improving and further developing surgical treatment options for articular cartilage pathology, an ideal treatment algorithm for individual patients is still lacking. The development of evidence-based rehabilita tion programs has largely lagged behind the emergence of new surgical treatments, in part due to the challenge in evaluating both a new surgical treatment and a modi fied rehabilitation strategy at the same time. Traditional articular cartilage rehabilitation has been based on a “do no harm” philosophy and largely on basic-science and animal data. While this strategy is not wrong, as cartilage repair procedures become the standard of care, high-quality scientific investigations of rehabilitation and its effect on outcomes are key to ensuring that patients achieve the highest possible levels of function. A number of areas require further research and clini cal implementation in order to enhance patient outcomes of cartilage repair. Specifically, in this special issue investigations regarding the influence of varied individual patient and surgical factors on the rehabilitative process, accelerated pathways of postoperative care, and criteria for determining whether an individual is safe to return to his or her chosen sport or other activities postoperatively are presented. In addition, existing clinical tools employed in the evaluation of surgical outcome and patient physical activity levels are analyzed in the context of cartilage rehabilitation. Much of the work presented in the following pages simply underscores the need for continued research into cartilage repair and restoration rehabilitation. The first step to investigating rehabilitation prior to and following articular cartilage procedures is to enhance the documentation of existing rehabilitation strategies. The need for improved reporting of postoperative reha bilitation is clearly evidenced in the pages of this special issue. In addition, these authors observed how the inclu sion of a rehabilitation clinician in the research team can enhance the reporting of rehabilitation. Investigators must move beyond simply publishing the prescribed rehabilitation protocol and instead begin to document the actual rehabilitation characteristics as experienced by the patients (time to full weight bearing, continuous passivemotion machine use, strength asymmetries at baseline and standard postoperative time points, duration of formal rehabilitation, patient compliance, criteria for progres sion, etc) in the same manner as disease characteristics (defect size, defect location, body-mass index, history of
previous surgeries, etc) are currently documented. The documentation of this information will verify what truly is standard clinical practice and also allow the examina tion of associations between rehabilitation practices and patient outcomes. These associations can then serve as a foundation for more in-depth controlled investigations. In many regions of the world the documentation of these characteristics will require improved communication and cooperation between the treating surgeon and the rehabilitation clinician; this improved relationship may in itself improve patient care and outcomes. In addition to improving the reporting of rehabilita tion practice, the documentation of clinical outcomes must continue to expand. At present, clinical trials evaluating patient outcome after cartilage surgery employ patient-reported outcome tools that were not necessarily developed for cartilage-repair patients. Furthermore, we often find ourselves comparing varied research outcomes that report results using different outcome tools. There remains a need for the development of a cartilage-specific patient outcome instrument that addresses the factors that are of greatest interest to the patient. In addition, the potential influence of current patient activity level and desired activity level on outcome scores should also be considered. Instruments that require successful comple tion of running or jumping activities to achieve maximum scores may not be applicable to all cartilage patients and certainly are not applicable at all stages of rehabilitation. Along these same lines, it is clear from the work presented in this issue that current physical activity instruments are not adequate, given their failure to assess frequency, duration, and intensity across the broad continuum of physical activity that may be relevant to articular cartilage patients. There needs to be collaboration for future devel opment of valid and reliable instruments that are more appropriate for use in cartilage-repair patients. We also need to remember that the patient is the most important person, and what drives their individual requirement for cartilage-repair surgery and postoperative goals remains unique to them; therefore, the potential for qualitative research to further develop or supplement both of these types of outcomes should not be overlooked. In addition to documenting patient-reported out comes and physical activity levels, there is a need for the documentation of standardized performance measures. In the following pages, performance measures take many forms including biomechanical analysis of kinematics and kinetics, a 3-repetition-maximum of a straight-leg
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raise, assorted force-plate measures, and isokinetic strength testing. Which of these or other functional tests are most appropriate for evaluating cartilage patients remains unclear. What is clear from all of these evalu ations is that significant deficits in patient function that cannot be detected by patient-reported outcomes alone remain postoperatively, even as many as 5 years after cartilage repair or restoration. Future assessment of clinical outcomes must be multidimensional and include patient-oriented outcome measures, physical activity assessment, and functional performance evaluation to fully assess the ability of surgical intervention and subsequent rehabilitation to enhance or restore patient function and quality of life. There is a plethora of cartilage methods available to patients, including restorative (ie, osteochondral auto grafts and allografts) and reparative (marrow stimulation and chondrocyte implantation) procedures. As is the case with other knee surgeries and orthopedic procedures, ongoing development of new and varied surgical methods brings improvements. While some cartilage-repair meth ods have always been amenable to “keyhole” surgical approaches, we have seen the more recent introduction of cartilage-repair methods undertaken through arthroscopic approaches (such as chondrocyte implantation) that in the past were only attainable through a more invasive arthrotomy. Similarly, new single-stage cell-based procedures and “off the shelf’ products are being inves tigated to simplify technology previously only available in 2-stage procedures. With time, it will be interesting to see how the ongoing development of arthroscopic cartilage-repair approaches accessible to all areas of the knee, along with the development of cell-based 1-stage procedures, alters (or reaffirms) the clinical reasoning of employing a particular cartilage-repair method for a certain individual. A persistent issue for patients undergoing cartilagerepair methods is the relatively conservative nature of rehabilitation through the early postoperative phases in order to allow the safe adherence and/or growth of maturing repair tissue. From a clinician perspective, there is a need to implement rehabilitation strategies that are as “aggressive” as possible to maintain, and eventually restore, limb strength and function, without jeopardizing
the repair process. While a “recipe” type approach to rehabilitation after cartilage repair is not possible given the wide array of factors that combine to influence the postoperative environment, further work and better understanding of how varied surgical and patient-specific factors do influence individual patient progression and rehabilitation protocols are still required to better enable an individualized approach. Unfortunately, research in the field of cartilage repair will continue to be limited by what surgical procedures and funding are available to the research group. For example, available cartilage-repair options are based on geographical location and regulatory implications. To date, the need of industry to establish the safety and efficacy of their surgical devices and biologies has largely driven clinical research pertaining to cartilage repair, limiting researchers’ ability to investigate the effect of variations in rehabilitation strategies or timelines. In addi tion, the enrollment of primarily “ideal patients” (young, low body-mass index, neutral alignment, no evidence of osteoarthritis, no patellofemoral defects, no prior failed cartilage procedures, limited concomitant procedures, etc) in many of the clinical trials published to date may limit the generalizability of some results to the actual clinical populations on which cartilage-repair and -res toration procedures are being performed. Therefore, it is imperative that clinical outcomes continue to be examined in real-world settings to further investigate what patient or surgical factors may alter both rehabilitation strategies and overall outcome. Future trials need to be developed with a team approach and should include surgeons, clinicians, and established researchers to investigate the overall best course of patient care presurgically, at the time of surgery, and postsurgery. The papers presented in this special edition, “Current Concepts in Cartilage Management and Rehabilitation,” highlight some of the most current procedures, reha bilitation approaches, and research standards that, with continued refinement, will result in improved outcomes for patients. Jennifers. Howard, PhD, ATC; Jay R. Ebert, PhD; and Karen Hambly, PhD, MCSP Guest Editors
Copyright of Journal of Sport Rehabilitation is the property of Human Kinetics Publishers, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Journal of Sport Rehabilitation, 2014, 23, 169-170 http://dx.doi.org/10.1123/JSR.2014-0246 © 201 4 Human Kinetics, Inc.
Current Concepts in Cartilage Management and Rehabilitation Despite the abundance of clinical and scientific research focused on improving and further developing surgical treatment options for articular cartilage pathology, an ideal treatment algorithm for individual patients is still lacking. The development of evidence-based rehabilita tion programs has largely lagged behind the emergence of new surgical treatments, in part due to the challenge in evaluating both a new surgical treatment and a modi fied rehabilitation strategy at the same time. Traditional articular cartilage rehabilitation has been based on a “do no harm” philosophy and largely on basic-science and animal data. While this strategy is not wrong, as cartilage repair procedures become the standard of care, high-quality scientific investigations of rehabilitation and its effect on outcomes are key to ensuring that patients achieve the highest possible levels of function. A number of areas require further research and clini cal implementation in order to enhance patient outcomes of cartilage repair. Specifically, in this special issue investigations regarding the influence of varied individual patient and surgical factors on the rehabilitative process, accelerated pathways of postoperative care, and criteria for determining whether an individual is safe to return to his or her chosen sport or other activities postoperatively are presented. In addition, existing clinical tools employed in the evaluation of surgical outcome and patient physical activity levels are analyzed in the context of cartilage rehabilitation. Much of the work presented in the following pages simply underscores the need for continued research into cartilage repair and restoration rehabilitation. The first step to investigating rehabilitation prior to and following articular cartilage procedures is to enhance the documentation of existing rehabilitation strategies. The need for improved reporting of postoperative reha bilitation is clearly evidenced in the pages of this special issue. In addition, these authors observed how the inclu sion of a rehabilitation clinician in the research team can enhance the reporting of rehabilitation. Investigators must move beyond simply publishing the prescribed rehabilitation protocol and instead begin to document the actual rehabilitation characteristics as experienced by the patients (time to full weight bearing, continuous passivemotion machine use, strength asymmetries at baseline and standard postoperative time points, duration of formal rehabilitation, patient compliance, criteria for progres sion, etc) in the same manner as disease characteristics (defect size, defect location, body-mass index, history of
previous surgeries, etc) are currently documented. The documentation of this information will verify what truly is standard clinical practice and also allow the examina tion of associations between rehabilitation practices and patient outcomes. These associations can then serve as a foundation for more in-depth controlled investigations. In many regions of the world the documentation of these characteristics will require improved communication and cooperation between the treating surgeon and the rehabilitation clinician; this improved relationship may in itself improve patient care and outcomes. In addition to improving the reporting of rehabilita tion practice, the documentation of clinical outcomes must continue to expand. At present, clinical trials evaluating patient outcome after cartilage surgery employ patient-reported outcome tools that were not necessarily developed for cartilage-repair patients. Furthermore, we often find ourselves comparing varied research outcomes that report results using different outcome tools. There remains a need for the development of a cartilage-specific patient outcome instrument that addresses the factors that are of greatest interest to the patient. In addition, the potential influence of current patient activity level and desired activity level on outcome scores should also be considered. Instruments that require successful comple tion of running or jumping activities to achieve maximum scores may not be applicable to all cartilage patients and certainly are not applicable at all stages of rehabilitation. Along these same lines, it is clear from the work presented in this issue that current physical activity instruments are not adequate, given their failure to assess frequency, duration, and intensity across the broad continuum of physical activity that may be relevant to articular cartilage patients. There needs to be collaboration for future devel opment of valid and reliable instruments that are more appropriate for use in cartilage-repair patients. We also need to remember that the patient is the most important person, and what drives their individual requirement for cartilage-repair surgery and postoperative goals remains unique to them; therefore, the potential for qualitative research to further develop or supplement both of these types of outcomes should not be overlooked. In addition to documenting patient-reported out comes and physical activity levels, there is a need for the documentation of standardized performance measures. In the following pages, performance measures take many forms including biomechanical analysis of kinematics and kinetics, a 3-repetition-maximum of a straight-leg
169
170
Howard, Ebert, and Hambly
raise, assorted force-plate measures, and isokinetic strength testing. Which of these or other functional tests are most appropriate for evaluating cartilage patients remains unclear. What is clear from all of these evalu ations is that significant deficits in patient function that cannot be detected by patient-reported outcomes alone remain postoperatively, even as many as 5 years after cartilage repair or restoration. Future assessment of clinical outcomes must be multidimensional and include patient-oriented outcome measures, physical activity assessment, and functional performance evaluation to fully assess the ability of surgical intervention and subsequent rehabilitation to enhance or restore patient function and quality of life. There is a plethora of cartilage methods available to patients, including restorative (ie, osteochondral auto grafts and allografts) and reparative (marrow stimulation and chondrocyte implantation) procedures. As is the case with other knee surgeries and orthopedic procedures, ongoing development of new and varied surgical methods brings improvements. While some cartilage-repair meth ods have always been amenable to “keyhole” surgical approaches, we have seen the more recent introduction of cartilage-repair methods undertaken through arthroscopic approaches (such as chondrocyte implantation) that in the past were only attainable through a more invasive arthrotomy. Similarly, new single-stage cell-based procedures and “off the shelf’ products are being inves tigated to simplify technology previously only available in 2-stage procedures. With time, it will be interesting to see how the ongoing development of arthroscopic cartilage-repair approaches accessible to all areas of the knee, along with the development of cell-based 1-stage procedures, alters (or reaffirms) the clinical reasoning of employing a particular cartilage-repair method for a certain individual. A persistent issue for patients undergoing cartilagerepair methods is the relatively conservative nature of rehabilitation through the early postoperative phases in order to allow the safe adherence and/or growth of maturing repair tissue. From a clinician perspective, there is a need to implement rehabilitation strategies that are as “aggressive” as possible to maintain, and eventually restore, limb strength and function, without jeopardizing
the repair process. While a “recipe” type approach to rehabilitation after cartilage repair is not possible given the wide array of factors that combine to influence the postoperative environment, further work and better understanding of how varied surgical and patient-specific factors do influence individual patient progression and rehabilitation protocols are still required to better enable an individualized approach. Unfortunately, research in the field of cartilage repair will continue to be limited by what surgical procedures and funding are available to the research group. For example, available cartilage-repair options are based on geographical location and regulatory implications. To date, the need of industry to establish the safety and efficacy of their surgical devices and biologies has largely driven clinical research pertaining to cartilage repair, limiting researchers’ ability to investigate the effect of variations in rehabilitation strategies or timelines. In addi tion, the enrollment of primarily “ideal patients” (young, low body-mass index, neutral alignment, no evidence of osteoarthritis, no patellofemoral defects, no prior failed cartilage procedures, limited concomitant procedures, etc) in many of the clinical trials published to date may limit the generalizability of some results to the actual clinical populations on which cartilage-repair and -res toration procedures are being performed. Therefore, it is imperative that clinical outcomes continue to be examined in real-world settings to further investigate what patient or surgical factors may alter both rehabilitation strategies and overall outcome. Future trials need to be developed with a team approach and should include surgeons, clinicians, and established researchers to investigate the overall best course of patient care presurgically, at the time of surgery, and postsurgery. The papers presented in this special edition, “Current Concepts in Cartilage Management and Rehabilitation,” highlight some of the most current procedures, reha bilitation approaches, and research standards that, with continued refinement, will result in improved outcomes for patients. Jennifers. Howard, PhD, ATC; Jay R. Ebert, PhD; and Karen Hambly, PhD, MCSP Guest Editors
Copyright of Journal of Sport Rehabilitation is the property of Human Kinetics Publishers, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
