Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Evidence-based care guideline for return to activity after lower extremity injury in children and young adults ages 5 through 22 years.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for return to activity after lower extremity injury in children and young adults ages 5 through 22 years. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 May 24. 12 p. [37 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Lower extremity injury

Guideline Category
Evaluation
Rehabilitation
Treatment
Clinical Specialty
Family Practice
Pediatrics
Physical Medicine and Rehabilitation
Sports Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Nurses
Patients
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)

To provide recommendations for the return to activity after lower extremity injury in children and young adults ages 5 through 22 years

Target Population

Children and young adults

  • With lower extremity injury/surgery requiring progressive re-entry into activity participation*
  • Ages 5 to 22, skeletally immature and mature
  • Cleared for return to desired activities by physician
  • Who meet the criteria for reintegration into activity participation established in Table 1 in the original guideline document

Note: These guidelines are not intended for use with individuals returning to high-level activities following upper extremity injury/surgery.

*This guideline was developed with a focus on re-entry into activity participation for individuals following knee injury/surgery, but is applicable for individuals following hip or ankle injury/surgery.

Interventions and Practices Considered

Rehabilitation/Treatment

  1. Open communication regarding plan of care
  2. Individualized, criterion-based care
  3. Assessment for and communication of warning signals
  4. Physical therapy functional evaluation including visual analog scale (VAS), girth measures, goniometry, dynamometer assessment, manual muscle test or functional endurance tests, general health instrument, region-specific instrument, single limb (SL) hop test, double limb/single limb squat and jump
  5. Therapeutic activities to optimize strength, muscle performance, and neuromuscular control
  6. Re-integrate to desired activity level
  7. Discharge from therapy and follow-up
Major Outcomes Considered
  • Functional status
  • Successful reintegration into desired activity

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

To select evidence for critical appraisal by the group for the development of this guideline, the Pubmed, OVID (Medline, Cinahl, EmBase and Cochrane databases), and Pedro databases were searched between the dates of January 2008 to June 2008 to generate an unrefined, "combined evidence" database using a search strategy focused on answering clinical questions relevant to return to sport, return to activity, or rehabilitation. The search strategy employed a combination of Boolean searching on human-indexed thesaurus terms (MeSH headings using an OVID Medline interface) and "natural language" searching on searching on human-indexed thesaurus terms (MeSH headings using an OVID Medline interface) and "natural language" searching on words in the title, abstract, and indexing terms. The citations were reduced by: eliminating duplicates and non-English articles. The resulting abstracts were reviewed by team members to eliminate irrelevant citations. During the course of the guideline development, additional clinical questions were generated and subjected to the search process, and some relevant review articles were identified.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The recommendations contained in this guideline were formulated by an interdisciplinary working group which performed systematic and critical literature reviews, using a quality level scale (see "Rating Scheme for the Strength of the Evidence" field), and examined current local clinical practices.

Recommendations have been formulated by a consensus process directed by best evidence, patient and family preference and clinical expertise. During formulation of these recommendations, the team members have remained cognizant of controversies and disagreements over the management of these patients. They have tried to resolve controversial issues by consensus where possible and, when not possible, to offer optional approaches to care in the form of information that includes best supporting evidence of efficacy for alternative choices.

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline has been reviewed and approved by clinical experts not involved in the development process, distributed to senior management, and other parties as appropriate to their intended purposes.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5) are defined at the end of the "Major Recommendations" field.

Overall Considerations

  1. It is recommended that open communication is utilized among the healthcare team, coaches, and the patient and family to ensure effective collaboration with the plan of care (Local Consensus [5]).
  2. It is recommended that progression through this care guideline be individualized based on
    • The nature of the injury
    • Individual/family goals
    • Physical and psychosocial attributes of the individual (Local Consensus [5])
  1. It is recommended that progression through this guideline be criterion-based, and not time-based. Criterion-based progression depends on achievement of clinical milestones with consideration for the activity demands:
    • The amount of cutting, pivoting and contact occurring during the activity
    • The level of activity (recreational versus elite sport participation) (Local Consensus [5])

    Note: All recommended milestones may not be appropriate for every individual; appropriate rehabilitation progression relies on sound clinical judgment (Local Consensus [5]).

  1. It is recommended that the following warning signals prompt communication with the referring physician and medical team:
    • Unexpected or increased irritability
    • Persistent or recurring effusion
    • The occurrence of unexpected symptoms (Local Consensus [5])

Assessment

  1. It is recommended that a Physical Therapy functional evaluation be completed including the components named in Table 2 in the original guideline document to determine an individual’s readiness for entry into the Return to Activity phase (Local Consensus [5]).
  2. It is recommended that the individual's readiness for entry into the Return to Activity phase be based on the criteria in Table 1 in the original guideline document, and that one of the following management strategies be selected:
    • Meets criteria: direct entry into this phase
      • Further evaluation with different assessment tools may be appropriate for some patients based on clinical judgment.
    • Does not meet criteria: continue the advanced phases of rehabilitation with focus on identified impairment(s).

Intervention

  1. It is recommended that the patient participate in therapeutic activities that functionally progress and optimize strength and muscle performance (Local Consensus [5]):
    • Focus activities to challenge muscle demand: progress intensity, frequency and duration of activity
    • Focus activities to challenge muscle power generation
    • Focus on activity-, sport-, position-specific activities
    • Activity progressions:
      • Single leg to double leg transitions, and vice versa
      • Alter planes of movement to focus on lateral and rotational activities, and transition activities
      • Add unanticipated perturbations and changes in support surface
      • Add sequential and simultaneous activities
      • Challenge multiple trunk (core) and lower extremity muscle groups simultaneously
  1. It is recommended that the patient participate in therapeutic activities that functionally progress neuromuscular control (see Table 3 in the original guideline document) (Local Consensus [5]):
    • Focus on activity-, sport-, position-specific activities and drills
      • Promote transfer of skills from clinic to field/court
    • Focus on high-level plyometric activities
      • Power generation during take-off
      • Force attenuating strategies during landing
    • Activity progressions:
      • Progress impact loading
      • Progress intensity, frequency, and duration of therapeutic activities
      • Single leg to double leg transitions, and vice versa
      • Alter planes of movement to focus on cutting/pivoting and transition activities
      • Add activity- or sport-specific perturbations
      • Alter support surface
      • Add sequential and simultaneous activities
  1. It is recommended that the Physical Therapist guide the patient through a progressive re-integration into desired activity (Local Consensus [5]):
    • Progressive reintegration that coincides with activities and training in the clinic:
      • Improve cardiovascular/activity endurance
      • Maintain appropriate performance technique
    • Initial return to play: non-contact drills, conditioning activities
      • Modify time of participation
      • Modify speed/demand of participation (50% effort or speed progressing to full effort and full speed)
    • Progress return to play: contact drills, full practice:
      • Modify time of participation
      • Modify speed and demand of participation
    • Progress return to play: scrimmage and game time:
      • Modify time of participation
  1. It is recommended that when the goals in Table 4 in the original guideline document are achieved, the patient
    • Be cleared for unrestricted activity participation
    • Follow up with the physical therapist to ensure successful reintegration and participation in unrestricted activity participation (Local Consensus [5]).

Discharge from Therapy

  1. It is recommended that discharge from therapy be based on clinical judgment, attainment of goals in Table 4 in the original guideline document and successful participation in desired activity (Local Consensus [5]).

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is classified for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

The objective of the Return to Activity phase of rehabilitation is successful transition of the patient with knee injury/surgery or other lower extremity injury from the end stage rehabilitation to safe participation in sports with minimal risk of further injury.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

These recommendations result from review of literature and practices current at the time of their formulations. This guideline does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this guideline is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for return to activity after lower extremity injury in children and young adults ages 5 through 22 years. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 May 24. 12 p. [37 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 May 24
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Division of Occupational Therapy and Physical Therapy Guideline Development Team

Composition of Group That Authored the Guideline

Division of Occupational Therapy and Physical Therapy Guideline Development Team: Laura Schmitt, PT, MPT, PhD, Division of Occupational Therapy and Physical Therapy (Team Leader); Robyn Byrnes, PT, DPT, CSCS, Division of Occupational Therapy and Physical Therapy; Chad Cherny, PT, DPT, CSCS, Division of Occupational Therapy and Physical Therapy; Alyson Filipa, PT, DPT, MS, CSCS, Division of Occupational Therapy and Physical Therapy; Adrick Harrison, PT, MPT, CSCS*, Department of Physical Therapy, College of Mount St. Joseph; Mark Paterno, PT, MS, SCS, ATC, Division of Occupational Therapy and Physical Therapy; Teresa Smith, PT, DPT, CSCS, Division of Occupational Therapy and Physical Therapy

*At the time of development of the guideline, Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center

Senior Clinical Director: Rebecca D. Reder, OTD, OTR/L, Division of Occupational Therapy and Physical Therapy

Division of Health Policy & Clinical Effectiveness Support: Eloise Clark, MPH, MBA, Lead Guidelines Program Administrator

Financial Disclosures/Conflicts of Interest

All Team Members listed (see "Composition of Group That Authored the Guideline" field) have declared whether they have any conflict of interest and none were identified.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Also, the appendices of the original guideline document External Web Site Policy contain assessments for strength, function and technique, including a tuck-jump assessment form.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 10, 2010.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Evidence-based Care Guideline (EBCG) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the EBCG include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The EBCG may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any EBCG, or its companion documents, adopted, adapted, implemented or hyperlinked by the organization is appreciated.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...