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| ====== Symptoms ====== | ====== Symptoms ====== | ||
| - | MS symptoms vary from person to person (Multiple Sclerosis Clinical Presentation, 2016). | + | Symptoms of a severe and acute ACL injury include: |
| - | MS Symptoms include: | + | • Feeling or hearing a "pop" in the knee at the time of injury. |
| - | * Sensory loss | + | • Sudden instability in the knee. This may happen after a jump or change in direction or after a direct blow to the side of the knee. |
| - | * Walking difficulty | + | |
| - | * Spasticity | + | |
| - | * Bladder, bowel, and sexual dysfunction | + | |
| - | * Tremors | + | |
| - | * Optic neuritis | + | |
| - | * Heat intolerance | + | |
| - | * Fatigue | + | |
| - | * Pain | + | |
| - | * Cognitive difficulties | + | |
| - | * Constipation | + | |
| - | <HTML> | + | • Pain on the outside and back of the knee. |
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| - | ====== Diagnosis ====== | + | • Knee swelling within the first few hours of the injury. This may be a sign of bleeding inside the joint. Swelling that occurs suddenly is usually a sign of a serious knee injury. |
| - | <style float-right> | + | • Limited knee movement because of swelling and/or pain. |
| - | {{:ms-mri_t1_535x314-01.jpg|}} | + | |
| - | **Figure 1**: A T1-weighted MRI demonstrating permanent lesions in a MS patient. The dark spots | + | Following an acute injury, the patient will almost always have to stop whatever activity they are doing, however, they may still be able to walk. |
| - | in the scan are the lesions. (Source: Spinms, 2016) | + | If the ACL injury is chronic (long-lasting and recurrent), the knee buckles or gives out, sometimes with pain and swelling. This occurs more frequently over time. It is important to note that not everyone with an ACL injury develops a chronic ACL deficiency. |
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| + | ====== Diagnosis ====== | ||
| - | <style justify> | + | For the clinical examination of a suspected ACL injury, the pivot-shift test, anterior drawer test and Lachman test are used. |
| - | The diagnosis of Multiple Sclerosis (MS) can be detected through MRI, lumbar puncture and electroencephalography. MS is difficult to diagnose due to the multiple symptoms associated with the disease, which can vary from person to person. Magnetic resonance imaging (MRI) can be used to reveal areas of lesions. However, MRI has disadvantages as it lacks specificity and many conditions have similar conditions of MS and as a result many false positives occur. It has been determined that 90% of MS patients will display an abnormal MRI scan and thus MRI should be the first diagnostic tool to be used. However, 5% of individuals show no sign of lesions in the brain while using MRI (Rolak, 2003). | + | |
| + | The Lachman test is known by most authorities as the most reliable and sensitive test, and usually a better alternative to the anterior drawer test. The ACL can also be detected using a magnetic resonance imaging scan (MRI scan). | ||
| - | When there are abnormalities in the cerebrospinal fluid, it can be used to diagnose MS. In the Cerebral spinal fluid (CSF), the white blood cell and spinal fluid proteins are slightly elevated. An elevated Immunoglobin G level in CSF is the most significant in detecting MS. The Immunoglobin G reflects an autoimmune activation and appears as oligoclonal bands on the electrophoresis performed on the CSF. Oligoclonal bands indicate the presence of immunoglobins, which indicate inflammation in the central nervous system. The oligoclonal bands vary from MS patient, but 90% of MS patients present these bands. A limitation to this method is other diseases produce these bands as well and can lead to misdiagnosis. To obtain the CSF it requires undergoing lumbar puncture, which many patients are unsure of doing (Rolak, 2003). | + | Even though clinical examination if done by a professional can be accurate, the diagnosis is usually confirmed by MRI scan, which has significantly narrowed the need for diagnostic arthroscopy and which has a greater accuracy than clinical examination. It may also show a graphic of other structures which may have been involved in the injury, such as a meniscus, or collateral ligament, or posterolateral corner of the knee joint. |
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| - | Another method that could be used is evoked potential, which is used to measure conduction rates in the CNS pathway though the recording of electroencephalographic response to sensory stimulation. Slow conduction rates indicate inflammation and demyelination, presenting an MS lesion (Rolak, 2003). | + | |
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| - | **Prognosis and progression** | + | |
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| - | There are four different patterns of MS, | + | |
| - | + | ||
| - | * Clinically Isolated Syndrome (CIS) | + | |
| - | * Relapsing and remitting (RRMS) | + | |
| - | * Secondary progressive (SPMS) | + | |
| - | * Primary progressive (PPMS) | + | |
| - | + | ||
| - | Clinically Isolated Syndrome refers to a first episode where there is inflammatory demyelination in the CNS. It is not yet considered MS, but could become MS if further activity occurs. In the relapse and remitting stage this indicates good health followed by an immediate change in symptoms. Secondary progressive MS occurs after the relapse and remitting stage. At this point there are more symptoms that are progressively getting worse. Primary progressive MS is the steady development of symptoms that will eventually become worse as the diseases progresses. RRMS, SPMS, and PPMS can be active or not active depending on if there is evidence of relapse or disease activity present (Hedley, 2012). | + | |
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| - | ====== Treatment and Management ====== | + | ====== Treatment ====== |
| - | <style justify> | + | **__Nonsurgical Treatment:__** |
| + | Torn ACL are not able to healed without surgery, however surgery may not always be a viable option for elderly patients or patients with low activity levels. In this situation, non-surgical treatment methods would be more beneficial. These methods are only recommended if the overall stability of the knee is intact. Some of these non-surgical treatment methods can include (UCSF, 2016): | ||
| - | Currently, there is no cure for multiple sclerosis as there are still many unclear aspects to the disease. (Hedley, 2012) There are several treatments available to aid with prolonging the remission period, to manage relapse, and to manage symptoms of the disease. Different treatments are recommended for different patterns of MS. For RRMS, SPMS, disease modifying drugs (DMDs) may be prescribed, whereas with PPMS, symptomatic treatment is the main approach as there has yet to be a proven disease modifying treatment. (Hedley, 2012) There are also complementary therapies available for MS. | + | **Use of Knee Braces:** This can be recommended by your doctor. Knee braces help support and protect the knee and the ACL from further damage. Furthermore, crutches may be implemented to transfer your weight away from your injured knee. This further protects and prevents more damage. |
| - | <HTML> | + | <style float-left> |
| - | <br> | + | {{:brace.jpg|**Figure X:** Illustrates what a typical knee brace looks like and how it is applied to the knee. |
| - | </HTML> | + | (Source: Better Braces, 2016)}} |
| - | **Maintaining Remission** | + | **Figure X**: Illustrates what a typical knee brace looks like and how it is applied to the knee. |
| + | (Source: Better Braces, 2016 ). | ||
| - | There are treatments available to modify the disease course by helping to maintain remission and delay relapse in MS. For RRMS, SPMS, disease modifying drugs (DMDs) may be prescribed. There are many DMDs available for MS. Interferon beta and glatiramer acetate are the current front-line therapies for maintaining remission. These make up the ABC-R therapy of MS, which consists of Avonex (interferon b-1a), Betaseron (interferon b-1b), Copaxone (glatiramer acetate), and Rebif (interferon b-1a). (Hillman, 2014) | + | </style> |
| - | __ Interferon Beta __ | + | **Physical Therapy:** This is usually recommended by doctors when swelling and inflammation of the knee go down. This program involves a series of exercises that will help improve function of the knee joint and strength surrounding muscles. Some of these exercises focus on training the Gluteus Maximus and Gluteus Medius in non-weight scenarios, followed by weight bearing scenarios. This helps to improve the control of the hip movements. In addition, exercises that focus on strengthening the Quadriceps muscles are also implemented. This is because this helps with improved bending of the knee. These exercises are also being implemented in ACL prevention programmes (Physioroom, 2016). |
| - | >Interferon beta is in the family of cytokines, which possess antiviral and immunoregulatory activities. The mechanisms of interferon beta in MS, however, are not clearly understood. (Hedley, 2012) There are two types of interferon beta (interferon beta-1a and interferon beta-1b) that have no difference in effectiveness. They are only different in the way they are manufactured. Interferon beta use in MS patients reduces the number and severity of relapses, and improves MRI measures. (Hillman, 2014) Studies show that MS patients using interferon beta therapy showed 75% fewer brain lesions on a brain MRI compared with a placebo. (Hedley, 2012) The effect of the treatment on long-term progression is not clear. There are some serious side effects of interferon beta. These include flu-like symptoms such as myalgia, fever, chills, asthenia, headache, and nausea, as well as psychological symptoms such as depression. Interferon beta may also lead to the development of neutralizing antibodies that may lead to a decrease in the effectiveness of therapy. (Hillman, 2014) | + | **ACL Reconstructive Surgery:** |
| + | ACL reconstruction is recommended for those: | ||
| + | * Who are young and active | ||
| + | * Who suffer from persistent knee pain | ||
| + | * Who suffer from pain during routine activities (ex- Walking) | ||
| + | * Who are aspiring athletes | ||
| - | __ Glatiramer Acetate __ | ||
| - | >Glatiramer acetate is thought to alter the immune processes believed to be responsible for the pathogenesis of MS, however its mechanism is not fully known. (Hedley, 2012) Studies have shown that there is delay of progression from CIS to “clinically definite MS” in MS patients for up to three years with use of glatiramer acetate. (Hedley, 2012) This treatment reduces the number and severity of relapses, and the formation of new lesions on a brain MRI, however its effects on long-term progression are not clear. (Hedley, 2012) Adverse effects of glatiramer acetate minor and mainly consist of injection site reactions, seen in 70% of patients. (Hedley, 2012) Other less common side effects include lipoatrophy, flushing, shortness of breath, chest tightness, and palpitations. (Hillman, 2014) | + | **Surgical Treatment:** |
| - | + | The most common method to repair a torn ACL is through ACL reconstructive surgery. This surgery is required to replace the torn anterior cruciate ligament with either another ligament from your body or from a tissue sample from a cadaver. This tissue graft will help with the growth of a new ligament. Ultimately, this surgery helps restore knee function and stability (UCSF, 2016). | |
| - | Deciding on which treatment to use (interferon beta or glatiramer acetate) depends on patient preference in type and frequency of injection. (See Figure 7) | + | |
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| + | {{:surgical_treatment_1.jpg|**Figure X:** Illustrates how the ACL looks before the injury and how the ACL looks after surgery. | ||
| + | (Source: A.D.A.M, 2013)}} | ||
| - | {{:table_01.png|}} | + | **Figure X**: Illustrates how the ACL looks before the injury and how the ACL looks after surgery. |
| - | + | (Source:A.D.A.M, 2013). | |
| - | **Figure 7**: The dosing, frequency, and route of administration for the ACB-R therapies. (Source: Hillman & Khorassani, 2014) | + | |
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| + | Tissue grafts can be retrieved from many sources. Some of these sources can include (Krans, 2016): | ||
| + | * Patellar tendon: Graft can be taken from the tendon that attaches from the bottom of the patella to your tibia. | ||
| + | * Hamstring: The graft can be taken from the tendon that connects the hamstring muscle to back of the knee. | ||
| + | * Quadriceps: A graft from the tendon that connects the quadriceps muscle. | ||
| + | * Cadaver: It is retrieved from a corpse, and is called an allograft. | ||
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| - | There are several other treatments available aside from the front-line ABC-R therapies. | + | **Allografts: Risks and Benefits:** |
| + | An allograft is when a tissue graft is retrieved from a member of the same species but are not genetically identical to the recipient. The increased in the development of new techniques and research are one of the main reasons for the rise in the use of allografts in surgery. Some of the advantages of using allografts are very beneficial in cases requiring multiple ligament reconstruction surgeries and they have a very low rate of donor morbidity. However, this type of tissue graft does have some disadvantages. Primarily, this method is very costly and takes a longer time to treat and prepare for the procedure. Furthermore, the sterilization process involves radiation, which can potentially alter the biomechanical properties of the graft. Most importantly, this type of tissue graft has been associated with elongation and rupturing after surgery. A study was conducted on 120 young active adults that were cadets at the U.S. Military Academy at West Point. This study observed that an allograft ACL surgery was approximately 7 times more likely to fail compared to an autograft ACL reconstruction (Mayo Clinic, 2016). | ||
| - | __Natalizumab__ | + | <style float-left> |
| + | {{:allograft.jpg|**Figure X:** Demonstrates the different types of allografts. | ||
| + | (Source: Mayo Foundation for Medical Education and Research, 2016)}} | ||
| - | >Natalizumab is a monoclonal antibody that is currently the best treatment for preventing relapses. (Hedley, 2012) 67% of patients using Natalizumab are relapse free (compared to 41% of patients with a placebo) after two years of treatment. (Hedley, 2012) This treatment is recommended for patients with rapidly evolving severe RRMS. There are however, several side effects including infections, urticaria, and headaches to name a few. (Hedley, 2012) One side effect that could possibly escalate to something serious is an increased risk of progressive multifocal leukoencephalopathy (PML). With PML, there is a progressive inflammation of white matter in the brain. Due to the morality of up to 50% with PML, Natalizumab is not a first-line therapy. (Hedley, 2012) | + | **Figure X**: Demonstrates the different types of allografts. |
| - | + | (Source: Mayo Foundation for Medical Education and Research, 2016). | |
| - | __Mitoxantrone__ | + | |
| - | + | ||
| - | >Mitoxantrone is not used as often since the development of natalizumab. It is a DNA-reactive agent of which the mechanism of action is not yet known, but is approved in the US to treat SPMS and RRMS. (Hedley, 2012) It is cytotoxic, thus has serious side effects such as life threatening reactions and cardiac toxicity. Mitoxantrone has a maximum lifetime dose and thus is not used long-term. (Hedley, 2012) | + | |
| - | + | ||
| - | __Azathioprine__ | + | |
| - | + | ||
| - | >Azathioprine is an immunosuppressant that is used to try to prevent relapse and to slow disease progression. It is not commonly used as side effects include gastrointestinal disturbances, bone marrow suppression, and hepatic toxicity. (Hedley, 2012) | + | |
| - | + | ||
| - | __Fingolimod__ | + | |
| - | + | ||
| - | >Fingolimod is a sphingosine-1-phosphate receptor modulator that retains lymphocytes in lymph nodes. This prevents lymphocytes from reaching the CNS and causing damage. (Hedley, 2012) In RRMS patients where interferon beta is unsuccessful, fingolimod is used. It is administered orally (one capsule daily). (Hedley, 2012) The development of oral agents are exciting as it is a easier method of administration than injections. | + | |
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| - | **Maintaining Relapse** | + | |
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| - | There are also treatments to manage relapse MS. Relapses in MS are caused by inflammation in the CNS, damaging the myelin of nerve fibers. Due to the varying lengths, severity, and nature of relapses, treatment is not always needed. (Hedley, 2012) Treatment is recommended for severe relapses when distress is experienced or when there is increased limitation of activities. Corticosteroids are the treatment of choice when there is demyelination. Methylprednisolone is a synthetic glucocorticoid that is a strong anti-inflammatory. (Hedley, 2012) It is unclear what it does exactly with MS, but it is thought to aid by immunosuppression or to reduce the accumulation of fluid around nerve damage. Studies have shown that steroids are effective in speeding up recovery from relapse, however there are no benefits to the long-term progression of disease. (Hedley, 2012) There are short-term and long-term treatments available, however long-term treatment should be avoided due to the side effects. Side effects of long-term treatment include weight gain, acne, cataracts, osteoporosis, deterioration of the head of the thigh bone, and diabetes. The side effects of short-term treatment are minor. (Hillman, 2014) | + | |
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| - | **Maintaining Symptoms** | + | |
| - | + | ||
| - | Treatment for complications that are associated with MS are also available. Common symptoms of MS are fatigue, bladder and bowel problems, weakness, spasticity, and swallowing difficulties. | + | |
| - | + | ||
| - | __Fatigue__ | + | |
| - | + | ||
| - | >Up to 95% of MS patients experience fatigue, and more than half describe it as one of the most troubling symptoms of MS. (Amato & Portaccio, 2012) The pathophysiology of fatigue in MS is not well understood. There are both pharmacological and non-pharmacological therapeutic approaches to MS. The most studied pharmaceuticals are amantadine, modafinil, and aminopyridines. There are several non-pharmacological interventions. One is neuro-rehabilitation, which improves compensation, adaptation and reconditioning. Another is exercise, which has very promising results such as reduced fatigue, improve in mood and quality of life. (Amato & Portaccio, 2012) Finally there is behavioural therapy, which strives to educate patients and caregivers about how to make small behavioural changes to reduce fatigue. This may include education on planning rest, relaxation techniques, adapting daily living activities, making everyday tasks more energy efficient, and controlling external temperature. (Amato & Portaccio, 2012) | + | |
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| + | **Autografts: Risks and Benefits:** | ||
| + | An autograft is when a tissue graft is retrieved from one part of the recipient’s body and placed in another part. Some common autograft sites can include patellar, hamstring and quadriceps tendons. Some of the associated advantages with this type of graft are minimal contamination, disease transmission and less structural alteration due to not irradiating the graft. The disadvantage associated with this type of graft is there is an increased post-surgery pain and recent research has indicated that if the hamstring tendon is used as a graft and the diameter is less than 8 millimetres, then there is increased risk of failure of the graft (Mayo Clinic, 2016). | ||
| <style float-right> | <style float-right> | ||
| + | {{:autograft.jpg|**Figure X:** Demonstrates the extraction and retrieval of an autograft sample. | ||
| + | (Source: Mayo Foundation for Medical Education and Research, 2016)}} | ||
| - | {{:treadmill_training.jpg|}} | + | **Figure X**: Demonstrates the extraction and retrieval of an autograft sample. |
| - | + | (Source: Mayo Foundation for Medical Education and Research, 2016). | |
| - | **Figure 8**: Body weight assisted treadmill training. There is physical assistance for each | + | |
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| - | leg due to impaired walking ability. (Source: http://agelessphysio.com) | + | |
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| + | **How to Prepare for ACL reconstruction:** | ||
| + | Throughout this whole process, you will always be meeting with various health practitioners to help prepare you for this procedure. Before the surgery, the doctor and surgeon will discuss treatment options as well advising on medical and personal decisions required. Also, using medical imaging techniques several knee examinations occur before and after the surgery. During the day of the surgery, it is recommended you fast for 12 hours and refrain from aspirin and other blood thinning medications, as this may cause complications during the surgery. It is also recommended to have someone else with you so they can support you and help with post-surgery instructions to follow. The most important advice would be to ask questions and for advice from your health practitioner, as this may reduce some of the burden associated with the procedure (Krans, 2016). | ||
| - | <style justify> | + | **How ACL Reconstruction is Performed:** |
| + | This procedure involves the use of intravenous (IV) lines, which are used to administer and inject medication as well as sedatives. Next, the allograft or autograft is prepared to be implanted into the knee. The tendon is prepared with bone plugs, which can anchor the tendon to the knee. Next, an incision is made into the front of the knee to allow for a thin tube that can allow for a fiber optic camera and surgical tools to pass through. Furthermore, the surgeon will remove the torn ACL and remove debris from the area. The surgeon will then drill small holes into your tibia and femur so the bone plugs can be attached with posts, screws, staples, or washers. After, the attachment of the new ligament, the surgeon will assess the knee’s motion and will ensure that the graft is secure. In addition, after the knee is assessed, the surgeons will suture the wound up. They will then place a brace on your knee to stabilize it. This procedure length can vary as there are many various techniques and versions of this procedure. It all depends on the various factors involved (Krans, 2016). | ||
| - | __Bladder__ | + | **Risks of ACL Reconstruction:** |
| - | > Another symptom of MS is an overactive bladder. To manage an overactive bladder, MS patients can reduce fluid intake and caffeine to reduce symptoms of urgency and frequency. However, a daily intake of 1-2 litres of water is recommended. (Fowler et al., 2009) Pharmacological interventions such as antimuscarinic medication is also available to reduce incontinence, frequency, and urgency in MS. (Fowler et al., 2009) Some physical interventions would include pelvic floor exercises to strengthen the pelvic floor and treat stress incontinence. This is effective in patients whose neural pathways to their pelvic floor muscles are intact. (Fowler et al., 2009) In MS patients with neurogenic bladder dysfunction, clean intermittent self-catheterization is used. (Fowler et al., 2009) | + | There are some risks associated with ACL reconstruction surgery. These can include: |
| + | - Excessive Bleeding and blood clotting | ||
| + | - Persistent Knee Pain | ||
| + | - Possible Infections | ||
| + | - Loss of Knee motion | ||
| + | - Rejection of tissue graft, causing inflammation | ||
| + | There are other risks that are also associated with this procedure. If someone is a young growing child, they can have potential growth plate injuries, preventing the growth of their bones in affected areas. One way to prevent this is that doctors advise children to wait until they are older to have this procedure. Although there are risks associated with this procedure, this procedure has been labelled a gold standard solution to persistent knee injuries. This procedure has approximately 82 to 90% success rate (Krans, 2016). | ||
| - | __Walking Ability__ | + | **Post ACL Reconstruction:** |
| - | > A common symptom of MS is impaired walking ability. Dalfampridine (Fampyra or Ampyra) can be used to improve walking ability. Dalfampridine is a potassium channel blocker that enhances conduction along demyelinated nerve fibres. (Hillman, 2014) In phase 3 clinical trials, walking speed was increased by about 25% within weeks in MS patients. (Hedley, 2012) There are, however, side effects such as a greater risk of seizures, anxiety, insomnia, dizziness, and tremor. (Hedley, 2012) In terms of physical therapy, exercise through treadmill training has been shown to improve walking endurance and velocity. (Amato & Portaccio, 2012) (See Figure 8) | + | The road to recovery from surgery involves rehabilitation. Also, to deal with some of the other symptoms such as excessive pain, pain suppression medications are prescribed. Furthermore, to prevent infections to the wound, it is suggested that you clean the wound and keep it clean. In addition, to alleviate pain and reduce inflammation to the knee, it is recommended that you ice this area, as advised by the doctor. After a few weeks, the patient should be able to regain range of motion in the knee. Athletes typically return to full fitness within 6 to 12 months. Finally, this is all followed by physical therapy and rehabilitation, which is very vital to the success of recovering (Krans, 2016). |
| - | __Depression__ | + | <style float-left> |
| - | > Depression can be a psychological symptom of MS or from interferon beta therapy. For MS patients with severe depression, interferon is avoided. (Hillman, 2014) | + | {{:post_surgery.jpg|**Figure X:** Illustrates how the ACL is reconstructed and where the new graft is placed. |
| + | (Source: Tower Orthopaedics, 2016)}} | ||
| - | **Complementary Therapies** | + | **Figure X**: Illustrates how the ACL is reconstructed and where the new graft is placed. |
| - | + | (Source: Tower Orthopaedics, 2016). | |
| - | Finally, there are therapies available that can be used alongside MS treatment that may help with the general sense of wellbeing in MS patients and help them to feel and cope better with the disease and the treatment. Some complementary therapies include reflexology, massage, tai chi, magnetic field therapy, neural therapy, and fish oils. (Hedley, 2012) Also linoleic acid, found in sunflower, corn, soya, and safflower oils, may reduce the progression of MS. (Hedley, 2012) | + | |
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| - | **Current Research** | + | |
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| - | The majority of research being done on MS primarily involves targeting new medications which better combat relapsing-remitting MS, as well as improving symptomatic treatments. However there is current research being done which aims to promote myelin repair, thus acting as a protective agent against MS. A study done by de la Fuente et al. in 2015, looked at vitamin D as an agent to promote remyelination, which is the process which drives specialized cells to fix damaged myelin found in the CNS nerve fibres. This process happen naturally in a healthy individual, however those afflicted with MS experience a decrease in the function over time due to the continuous damage being done to their myelin (de la Fuente et al. 2015). Cells termed oligodendrocyte progenitor cells (OPC) are responsible for creating oligodendrocytes which manufacture the myelin sheath (de la Fuente et al. 2015). Vitamin D is important because it binds to a specific protein, retinoid X receptor-y (RXR-y), which aids in swiftly maturing OPC into oligodendrocytes. Thus increasing the rate at which the myelin repairing oligodendrocytes, this would be greatly beneficial in battling MS. The study looked at a MS like disease in rats, more specifically focusing on the vitamin D receptors. They found that the RXR-y protein interacts with the vitamin D receptor, which stays active during the remyelination stage. This led to improved remyelination. Furthermore when the vitamin D receptors were prevented from binding and functioning correctly, the OPCs did not develop properly into oligodendrocytes, therefore leading to malfunctioning remyelination in the rats. This type of study investigating the remyelination enhancement possibility from vitamin D is the trend in current research. | + | |
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