ACL cross bracing protocol - everything you need to know with Geoff Ford

In this episode, Geoff delves into the specifics of the ACL cross bracing protocol utilised in conservative ACL rehabilitation. He discusses the advantages, disadvantages, and relevant literature, along with essential points to address with the patient regarding the potentially demanding experience of wearing a brace.

Geoff Ford is the founder of Be Strong Physio. He is a passionate Physiotherapist and Strength and Conditioning coach (ASCA), Yoga teacher and Strongfirst certified kettlebell instructor. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is Michael Rizk (@thatphysioguy)

Transcript

UNKNOWN: 0:00

So,

SPEAKER_02: 0:05

so on the cross bracing protocol 12 weeks in that brace first four weeks fixed at 90 degrees you're very limited as to what you can do so there's no requirement to be non-weight bearing so you can fully weight bear but just practically speaking you can't do much because your knee doesn't move versus obviously if you're going straight into exercise-based rehab you can really get straight into all of your functional strengthening exercises only really limited by symptoms so

SPEAKER_01: 0:33

As we're learning more and more about conservative approaches to ACL rehab, there might even be a better way to do conservative rehab. Well, today we had Jeff Ford, physio, on to talk to us all things cross-bracing protocol. Now, Jeff's read the research, he's worked pretty closely with Merv Cross, and he's taken a few of his clients through the cross-bracing protocol. So, on today's episode, he discusses the pros and cons, the things that we really have to go through with our clients to understand how this can be a difficult and successful process at the same time. Please enjoy this episode and add another string to your bow with ACL Rehab. My name is Michael Risk and this is Physio Explained. Welcome, Jeff. Thank you for joining us. Thanks for having me, Mick. We're talking cross-bracing protocol, which I was kind of familiar with like, I feel like I heard about it five or 10 years ago, and then it kind of went away. And then I actually saw you were posting a little bit about it. So for the listeners, could you describe what is it firstly?

SPEAKER_02: 1:38

Absolutely. So Cross Bracing Protocol is a 12-week program. which places the knee at 90 degrees. So it's fixed there for the first four weeks. And then every week thereafter, you essentially gradually open it up. So you're getting a little bit more extension until the knee is straight by week 10. And then you've still got another two weeks before the brace is removed and you sort of have your MRI at the end to see how the healing went. Is it just for ACL? It's just for ACL. They've tentatively got some good results with healing of some meniscus and other small injuries, but there's some complications around that too, which I'll go into later.

SPEAKER_01: 2:17

And what's been the results or the purported benefits of this?

SPEAKER_02: 2:23

So, the outcomes from the bracing protocol are so far really, really promising. So, it's probably important to state that the initial research that's out by Filbe and which was 2023, so it was released earlier this year, is a K-series. So there's so far no sort of randomized control trials, but in the K-series, it's a 90% heal rate, which is fantastic. So 72 out of the 80 people that went through that protocol had signs of healing at 12 weeks.

SPEAKER_01: 2:52

That sounds incredibly high. Do we know if they weren't being braced or just normal management, say they're doing physiotherapy for 12 weeks, is there a difference in healing rate or signs of healing?

SPEAKER_02: 3:04

Yeah, absolutely. We do have a bit of research on this. So the CANOON trial, so the primary outcome wasn't around healing for the CANOON trial. It was comparing exercise-based rehab with an option for delayed surgery versus early surgery. But out of the group that weren't allocated to early surgery, there was about a 30% heal rate amongst those people at that 12-week mark. So roughly speaking, you can compare the rate of 30% compared to 90%. And then there seems to be some differences as well in terms of the quality of the heel, because you can have healing, but it might still be a bit of a lax ACL versus you want a nice taut ACL at the end of that process.

SPEAKER_01: 3:43

I'm starting to think already that in that trial where they started exercise early without the brace, there wasn't as much healing, but potentially there would have been some rehab benefits. And... The cross-bracing protocol sounds like a higher healing rate, but you probably can't get as into the rehab. Is that the right assumption, firstly?

SPEAKER_02: 4:04

Correct. So, within that 12-week period... obviously very much limited so on the cross bracing protocol 12 weeks in that brace first four weeks fixed at 90 degrees you're very limited as to what you can do so there's no requirement to be non-weight bearing so you can fully weight bear but just practically speaking you can't do much because your knee doesn't move

SPEAKER_01: 4:25

yeah

SPEAKER_02: 4:25

versus obviously if you're going straight into exercise-based rehab you can really get straight into all of your functional strengthening exercises only really limited by symptoms so early on there'd be a massive time advantage to exercise based rehab without any bracing so you're more likely to get back to potentially playing more quickly the downside might be around the quality of the heel if you do indeed get a heel

SPEAKER_01: 4:51

I'm having so many thoughts Jeff so like if I follow those two groups along and I'd love your opinion on this because we probably don't have the research at this level yet do we know that the healing or the quality of the heel is what would prevent further injury or Any assumptions or research you've read around that?

SPEAKER_02: 5:09

I don't think we have that sort of data yet. So out of the case series, the cross-bracing protocol, I think there was four people. Hopefully I get the stats right on this. There's four people who had a grade one heel. Yeah. So grade zero is best. And then it goes down. So grade one heel, I think it was four people who had a subsequent injury. And they all occurred during either like high speed, so skiing or contact situations like rugby AFL. So we don't know whether they would have ruptured anyway, because there's similar mechanism of injury or whether there was some sort of structural integrity kind of issue with the ACL. So really, we just don't know yet.

UNKNOWN: 5:51

Yeah.

SPEAKER_00: 5:54

This podcast is sponsored by Cliniko.

SPEAKER_01: 6:28

I guess I'm starting to think there could be three emerging groups, the people that have the ACL surgery, the people that don't have it and do conservative or physiotherapy rehab without the cross bracing, and then the people who do the cross bracing. And the surgical group would have a reconstructed ACL, the conservative group would have maybe a non-healed ACL, and the cross bracing would have a healed ACL. But I wonder what their injury rates would be across all those three. That would be fascinating. And does it matter? Does it come down to the quality of the rehab?

SPEAKER_02: 6:59

This is really tricky, but in the Phil Bay article for the CrossFit Racing Protocol, people who had the higher quality heels had better patient-reported outcomes.

SPEAKER_01: 7:10

Yeah.

SPEAKER_02: 7:11

So possibly subjectively, they feel like they have a better heel. They also had better return to sport rates. However, the big caveat there is people were told about the quality of their heel. Right. So if you're told, hey, you've got a great quality heel... Awesome. I'm good to go. And that's going to obviously influence your outcomes versus maybe the quality of your heel isn't that great. You might move forwards with a little bit of apprehension there. So, it really remains to be seen.

SPEAKER_01: 7:39

So many amazing follow-up studies could be done. Talk to me about the nitty-gritty of it. How are you making these decisions with patients to go surgical, conservative, or cross-bracing? How does that conversation look and sound? It's a

SPEAKER_02: 7:53

really interesting conversation. I guess my approach, like with my approach with everything, I try and be as person-centred as I can be because I think there's no point in us going in and batting for a certain approach. Like you need to do cross-bracing, you need to do surgery. I think it's all about informing that person in their own unique context because there are advantages and disadvantages to each approach. There are actually some tight contraindications Absolute contraindications at the moment are things like bucket handle tears, loose bodies, so osteochondral loose bodies. past or present DVT or family histories of thrombosis or thromboembolisms presenting more than three weeks after ACL injury. So that's a big one, unfortunately, at the moment because people aren't that aware of it. So they often come in and say, oh, I'd love to do the cross-bracing protocol. And then you sort of find out that they're too far down the track potentially because the two ends of the stumps then basically seal over and there's no way that it can still heal. So there's some big contraindications, probably often more relevant from when they come in to have conversation with me are some of those potential sort of contrary or the relative contraindications so they're things like social support whether it's your driving leg or not can be a big issue because your bracing is at 90 degrees you can't drive if it's your right foot so that's a really big thing to discuss and then just mobility and i think the psychosocial impacts of it as well are huge so the people that i've sort of taken through the protocol some of them have really psychologically struggled in particular because of their lack of being able to go out and have that social support and also their outlet with their, you know, participating in sports and going out and mixing with groups. So that's been difficult. They've often isolated at home. So you've got to be really honest and open with people about the true implications of this. But there are lots of little tips and things that you can do to potentially help get through that process.

SPEAKER_01: 9:48

What are some of those conversations and tips that you're giving to your patients? And are they on crutches or the kind of the J scooter where they're rolling along?

SPEAKER_02: 9:57

Either. That's one of the tips is you can get those little scooters. Tom Cross is fantastic with this. So he often shares videos and pictures with people about some of the things. And some people like to send him little challenges of the obscure places they've gotten into with their mobility scooters and stuff. So he tries to make it more enjoyable for people. But yeah, getting scooters, having that support level, I think still exercising, letting people know you're still going to be exercising. You're going to be working really hard. And for some people, that's important because they think, hey, I'm going to be stuck in a brace. I can't do any exercise. But you can still absolutely do everything on your other side or your upper body. And your start's straight away with exercises. So initially be isometrics on your affected side, but over the coming weeks, you're quickly progressing that. And then there is a Facebook group for all the past participants who have gone through this protocol are on that Facebook group. So they all share heaps of really cool little tips and stuff. So yeah, telling people they can have that support and that contact even just virtually is really, really helpful.

SPEAKER_01: 10:53

That's really great idea. What are some of the exercises you're prescribing at the start when they're in

SPEAKER_02: 10:59

90s? Pretty boring ones to start with. So you're doing things like wall sits, even split squats, isometric split squats, isometric leg press. And then you go to town on your glutes with a band. So you can do all your sort of bridge variations, clams, abduction, adduction exercises in the gym. That's one of the main ones. Even do like a bend knee calf raise with your knee at 90 degrees there. And then heaps and heaps of single leg on the other side. So really trying to get their other side strong. And I always think it's important to emphasize that to people. You may get some neural crossover effects, but also you want your comparison leg to be really, really strong. Because if it's not, we're going to be looking at your limb symmetry index against kind of a weaker leg. So I really encourage people to get that nice and strong.

SPEAKER_01: 11:43

How are they doing their cardio when they're, say, in the 90 to 110 range?

SPEAKER_02: 11:47

Really early on, you're pretty limited. So you can use the little hand ergos. I mean, I try and get creative. So try and get people to use even more like a strength-based exercise and then play with the rest, the work to rest intervals. So that way you're getting your heart rate up. You can do little things like that as well. And then as soon as they're able to getting them on the bike and the row or things like that.

SPEAKER_01: 12:09

It's even challenging my rehab and yeah, creating circuits. It would be a lot of fun. Maybe not so much fun for the patient. How do you now make the decision between, say, the conservative and the cross-bracing? Was there something that you read that kind of made you feel like this is a way to go?

SPEAKER_02: 12:26

Good question. I think I, and you sort of alluded to this, but I try and outline that there are three major choices. So you've got early ACL reconstruction surgery. You've got exercise-based therapy with an option still for delayed surgery. I think that's really important to emphasise. And then you've got the bracing. Now within bracing, you don't just have cross bracing. I think that's really important to emphasize too. Cross bracing wasn't the first bracing protocol. There have been other attempts that people had it like 20 degrees rather than 90, or they've just limited the range. So there are other options out there that you don't have to just be fixed at 90 degrees. And then there is cross bracing where you are fixed at 90. However, even within that, there is a 12-week, eight-week and six-week version. So there are different options there for people given their circumstances, et cetera. But I think within the cross bracing, so if you're going down the non-early surgery route, If you're a good candidate, that's probably only about 40% or 50% of people. I haven't sort of gone into that. But if you're a good candidate, the rate of heal is just so much higher on the cross-bracing protocol so far. So I really do emphasize that to people. And then in the end, they can decide. But I think it's important to inform people that people with healing do report better patient-based outcomes. Even on the Canoon trial, those that had a heal had better outcomes. patient-reported outcomes than the people who didn't have a heel in the non-surgical group.

SPEAKER_01: 13:55

Yeah. So you're really taking that best evidence trial that we have and matching it with the cross-bracing literature that you've read and making that decision with them?

SPEAKER_02: 14:05

Exactly.

SPEAKER_01: 14:06

Other than the contraindications to cross-bracing, is there any other reason either from your end as the clinician or from the patient's end that they're saying no to cross-bracing and going into conservative therapy?

SPEAKER_02: 14:19

Yes, probably timelines is a big one. So if they know that they've got a big sporting outcome, now they need to return to sport by a set date. There is some uncertainty if you go down the healing route. You don't know whether you're going to be successful. If you're not successful, you may then want to go on and opt for surgery. So you've then just increased your timeline by an extra, say, three months. Yeah. So I find that that's quite a big one. I should emphasize another one I encountered recently was going on anticoagulants. So because you fix at 90 degrees, you have to be on anticoagulants. Yeah. I've had actually two people now say they don't want to go on anticoagulants. So you can either then go on a modified bracing protocol. Otherwise, you're not suitable. It's not safe to have you fixed at 90 degrees.

SPEAKER_01: 15:07

And Jeff, if we're inexperienced in the cross-bracing protocol and we want to know more about it, where would you recommend we start? Even for some people, this is the first they're hearing about it. What would you recommend to start with?

SPEAKER_02: 15:19

Definitely go read the paper. I think that's a fantastic resource. And then have a look at any materials. So Tom Cross has been on a couple of podcasts. He's actually been on the Wild Physio podcast. I would recommend having a listen to him on there. He's been on there a couple of times. Yep. And it's really good listening to Tom going through the history of it. I think that's really important too. There's actually some really good material out there now because it's such a hot topic. There are actually some really good even blog posts. Go out there and have a read of some of those as well.

SPEAKER_01: 15:49

Jeff, thanks so much for your time. There's a lot of info there. I feel upskilled in cross-bracing.

SPEAKER_02: 15:54

Wonderful. Thank Thank you so much for having me. Really appreciate it, mate. Thank you, mate.