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British Journal of Sports Medicine Dec 2016The Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of Dutch anterior cruciate ligament (ACL) experts to develop an evidence... (Review)
Review
AIM
The Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of Dutch anterior cruciate ligament (ACL) experts to develop an evidence statement for rehabilitation after ACL reconstruction.
DESIGN
Clinical practice guideline underpinned by systematic review and expert consensus.
DATA SOURCES
A multidisciplinary working group and steering group systematically reviewed the literature and wrote the guideline. MEDLINE and the Cochrane Library were searched for meta-analyses, systematic reviews, randomised controlled trials and prospective cohort studies published between January 1990 and June 2015.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Included literature must have addressed 1 of 9 predetermined clinical topics: (1) preoperative predictors for postoperative outcome, (2) effectiveness of physical therapy, (3) open and closed kinetic chain quadriceps exercises, (4) strength and neuromuscular training, (5) electrostimulation and electromyographic feedback, (6) cryotherapy, (7) measurements of functional performance, (8) return to play and (9) risk for reinjury.
SUMMARY
Ninety studies were included as the basis for the evidence statement. Rehabilitation after ACL injury should include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2) sport-specific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9-12 months. To assess readiness to return to play and the risk for reinjury, a test battery, including strength tests, hop tests and measurement of movement quality, should be used.
Topics: Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Consensus; Evidence-Based Medicine; Exercise Therapy; Humans; Physical Therapy Modalities; Postoperative Care; Practice Guidelines as Topic; Recovery of Function; Return to Sport
PubMed: 27539507
DOI: 10.1136/bjsports-2015-095898 -
British Journal of Sports Medicine May 2023This guideline was developed to inform clinical practice on rehabilitation after anterior cruciate ligament reconstruction (ACLR) and was performed in accordance with...
This guideline was developed to inform clinical practice on rehabilitation after anterior cruciate ligament reconstruction (ACLR) and was performed in accordance with the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A Guideline Development Group systematically searched and reviewed evidence using randomised clinical trials and systematic reviews to evaluate the effectiveness of rehabilitation interventions and guide clinicians and patients on the content of the optimal rehabilitation protocol after ACLR.The guideline targets patients during rehabilitation after ACLR and investigates the effectiveness of the available interventions to the physiotherapist, alone or in combination (eg, exercise, modalities, objective progression criteria). Exercise interventions should be considered the mainstay of ACLR rehabilitation. However, there is little evidence on the dose-response relationship between volume and/or intensity of exercise and outcomes. Physical therapy modalities can be helpful as an adjunct in the early phase of rehabilitation when pain, swelling and limitations in range of motion are present. Adding modalities in the early phase may allow earlier pain-free commencement of exercise rehabilitation. Return to running and return to training/activity are key milestones for rehabilitation after ACLR. However, there is no evidence on which progression or discharge criteria should be used.While there is a very low level of certainty for most components of rehabilitation, most of the recommendations provided in this guideline were agreed to by expert clinicians. This guideline also highlights several new elements of ACLR management not reported previously.
Topics: Humans; Anterior Cruciate Ligament Injuries; Exercise Therapy; Physical Therapy Modalities; Exercise; Anterior Cruciate Ligament Reconstruction
PubMed: 36731908
DOI: 10.1136/bjsports-2022-106158 -
International Journal of Environmental... Apr 2021Anterior cruciate ligament (ACL) injuries are the most common ligament injury of the knee, accounting for between 100,000 and 200,000 injuries among athletes per year.... (Review)
Review
Anterior cruciate ligament (ACL) injuries are the most common ligament injury of the knee, accounting for between 100,000 and 200,000 injuries among athletes per year. ACL injuries occur via contact and non-contact mechanisms, with the former being more common in males and the later being more common in females. These injuries typically require surgical repair and have relatively high re-rupture rates, resulting in a significant psychological burden for these individuals and long rehabilitation times. Numerous studies have attempted to determine risk factors for ACL rupture, including hormonal, biomechanical, and sport- and gender-specific factors. However, the incidence of ACL injuries continues to rise. Therefore, we performed a systematic review analyzing both ACL injury video analysis studies and studies on athletes who were pre-screened with eventual ACL injury. We investigated biomechanical mechanisms contributing to ACL injury and considered male and female differences. Factors such as hip angle and strength, knee movement, trunk stability, and ankle motion were considered to give a comprehensive, joint by joint analysis of injury risk and possible roles of prevention. Our review demonstrated that poor core stability, landing with heel strike, weak hip abduction strength, and increased knee valgus may contribute to increased ACL injury risk in young athletes.
Topics: Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Athletes; Biomechanical Phenomena; Female; Humans; Knee Joint; Male
PubMed: 33917488
DOI: 10.3390/ijerph18073826 -
International Journal of Environmental... Nov 2022Despite the restoration of the mechanical stability of the knee joint after ACL reconstruction (ACLR), patients often experience postoperative limitations. To our... (Review)
Review
Despite the restoration of the mechanical stability of the knee joint after ACL reconstruction (ACLR), patients often experience postoperative limitations. To our knowledge, there are no systematic reviews analyzing additional physiotherapy interventions implementing standard rehabilitation programs in the early postoperative phase after ACLR. The objective of this study was to analyze the additional physiotherapy interventions implemented in standard rehabilitation programs that improve early-stage ACLR rehabilitation. For this systematic review, we followed the PRISMA guidelines. In March 2022 we conducted a literature review using electronic databases. Primary outcomes were pain, edema, muscle strength, ROM, and knee function. The risk of bias and scientific quality of included studies were assessed with the RoB 2, ROBINS-I and PEDro scale. For the review, we included 10 studies that met the inclusion criteria (total = 3271). The included studies evaluated the effectiveness of Kinesio Taping, Whole-body vibration, Local Vibration Training, Trigger Point Dry Needling, High Tone Power Therapy, alternating magnetic field, and App-Based Active Muscle Training Program. Most of the additional physiotherapy interventions improved pain, edema, ROM, knee muscle strength, or knee function in early-stage postoperative ACL rehabilitation. Except for one study, no adverse events occurred in the included studies, which demonstrates the safety of the discussed physiotherapy interventions. Further in-depth research is needed in this area.
Topics: Humans; Anterior Cruciate Ligament Reconstruction; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament; Knee Joint; Pain
PubMed: 36497965
DOI: 10.3390/ijerph192315893 -
British Journal of Sports Medicine Nov 2022Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture.
DESIGN
Living systematic review and meta-analysis.
DATA SOURCES
Six databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed.
ELIGIBILITY CRITERIA
Randomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery.
DATA SYNTHESIS
Bayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence.
RESULTS
Of 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified.
CONCLUSIONS
There is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes.
PROSPERO REGISTRATION NUMBER
CRD42021256537.
Topics: Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Bayes Theorem; Humans; Knee Joint; Osteoarthritis, Knee
PubMed: 36038357
DOI: 10.1136/bjsports-2021-105359 -
PloS One 2020Systematic review.
STUDY DESIGN
Systematic review.
BACKGROUND AND OBJECTIVES
Preoperative neuromuscular function is predictive for knee function and return to sports (RTS) after reconstruction of the anterior cruciate ligament (ACL). The aim of this review was to examine the potential benefits of prehabilitation on pre-/postoperative objective, self-reported and RTS-specific outcomes.
METHODS
A systematic search was conducted within three databases. From the 1.071 studies screened, two randomized control trials (RCTs), two control trials (CTs) and two cohort studies (CS) met the inclusion criteria. Methodological quality rating adopted the PEDro- (RCT, CT) or Newcastle-Ottawa-Scale (CS).
RESULTS AND CONCLUSIONS
Methodological quality of the included studies was moderate (PEDro score: 6.5 ± 1.7; range 4 to 9). Two studies reported higher increases of the maximal quadriceps torque from baseline to pre-reconstruction: one study in the limb symmetry index (LSI), and one in both legs of the prehabilitation group compared to the controls. At 12-weeks post-reconstruction, one study (from two) indicated that the prehabilitation group had a lesser post-operative decline in the single-leg-hop for distance LSI (clinically meaningful). Similar findings were found in terms of quadriceps strength LSI (one study). At both pre-reconstruction (three studies) and two-year post-surgery (two studies), the prehabilitation groups reached significantly higher self-reported knee function (clinically meaningful) than the controls. RTS tended to be faster (one study). At two years post-surgery, RTS rates (one study) were higher in the prehabilitation groups. The results provide evidence for the relevance of prehabilitation prior to ACL-reconstruction to improve neuromuscular and self-reported knee function as well as RTS. More high quality confirmatory RCTs are warranted.
REGISTRATION NUMBER
PROSPERO 2017: CRD42017065491.
Topics: Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Clinical Trials as Topic; Female; Humans; Male; Postoperative Complications; Preoperative Period; Plastic Surgery Procedures; Recovery of Function; Return to Sport
PubMed: 33112865
DOI: 10.1371/journal.pone.0240192 -
Sports Medicine and Arthroscopy Review Jun 2021Recent studies have investigated the various components of postoperative rehabilitation protocols following anterior cruciate ligament reconstruction (ACLR). The...
Recent studies have investigated the various components of postoperative rehabilitation protocols following anterior cruciate ligament reconstruction (ACLR). The objective of this article was to access and summarize the latest evidence for postoperative rehabilitation protocols following ACLR to evaluate common timeframes, number of phases, exercises, as well as the length of rehabilitation protocol. Common interventions include vibration training, open-chain and closed-chain exercises, electrical stimulation, postoperative bracing, and aquatic therapy. The eligibility criteria included English-language articles published from 2000 to 2019 pertaining to rehabilitation following ACLR, excluding addresses, commentaries, and editorials. Two blinded reviewers screened, graded, and extracted data from articles. Recommendations on various aspects of rehabilitation were summarized. A total of 3651 articles were retrieved from the database search, and 62 level 1 to 2 studies were available for extraction. On the basis of the evidence, vibration training can be safely incorporated into the postoperative rehabilitation protocol following ACLR. Accelerated rehabilitation may give patients short-term functional benefits. Open kinetic chain exercises may have additional strength and endurance benefits. Postoperative bracing does not confer additional benefits. Long-term use of neuromuscular electrical stimulation seems to be more beneficial than short-term use. Aquatic rehabilitation may be beneficial in the early phases of anterior cruciate ligament rehabilitation.
Topics: Anterior Cruciate Ligament Reconstruction; Athletic Injuries; Combined Modality Therapy; Humans; Postoperative Care; Return to Sport
PubMed: 33972483
DOI: 10.1097/JSA.0000000000000314 -
BMC Musculoskeletal Disorders Oct 2020To explore the effectiveness of preoperative rehabilitation programmes (PreHab) on postoperative physical and psychological outcomes following anterior cruciate ligament...
BACKGROUND
To explore the effectiveness of preoperative rehabilitation programmes (PreHab) on postoperative physical and psychological outcomes following anterior cruciate ligament reconstruction (ACLR).
METHOD
A systematic search was conducted from inception to November 2019. Randomised controlled trials (RCTs) published in English were included. Risk of bias was assessed using Version 2 of the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence.
RESULTS
The search identified 739 potentially eligible studies, three met the inclusion criteria. All included RCTs scored 'high' risk of bias. PreHab in all three RCTs was an exercise programme, each varied in content (strength, control, balance and perturbation training), frequency (10 to 24 sessions) and length (3.1- to 6-weeks). Statistically significant differences (p < 0.05) were reported for quadriceps strength (one RCT) and single leg hop scores (two RCTs) in favour of PreHab three months after ACLR, compared to no PreHab. One RCT reported no statistically significant between-group difference for pain and function. No RCT evaluated post-operative psychological outcomes.
CONCLUSION
Very low quality evidence suggests that PreHab that includes muscular strength, balance and perturbation training offers a small benefit to quadriceps strength and single leg hop scores three months after ACLR compared with no PreHab. There is no consensus on the optimum PreHab programme content, frequency and length. Further research is needed to develop PreHab programmes that consider psychosocial factors and the measurement of relevant post-operative outcomes such as psychological readiness and return to sport.
TRIAL REGISTRATION
PROSPERO trial registration number. CRD42020162754 .
Topics: Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Humans; Preoperative Exercise; Return to Sport
PubMed: 33010802
DOI: 10.1186/s12891-020-03676-6 -
The Journal of Arthroplasty Mar 2015The objective of this study is to compare the clinical, radiographic and surgical outcomes among patients undergoing primary THA performed via the anterior versus... (Comparative Study)
Comparative Study Meta-Analysis Review
The objective of this study is to compare the clinical, radiographic and surgical outcomes among patients undergoing primary THA performed via the anterior versus posterior approach. We searched numerous sources and eventually included 17 studies, totaling 2302 participants. In terms of post-operative pain and function, the anterior approach was significantly favored in 4 studies at short-term follow-up. Pooled estimates showed a significant difference in favor of the anterior approach in terms of length of stay and dislocations. Current evidence comparing outcomes following anterior versus posterior THA does not demonstrate clear superiority of either approach. Until more rigorous, randomized evidence is available, we recommend choice of surgical approach for THA be based on patient characteristics, surgeon experience and surgeon and patient preference.
Topics: Arthroplasty, Replacement, Hip; Humans; Osteoarthritis, Hip
PubMed: 25453632
DOI: 10.1016/j.arth.2014.10.020 -
The American Journal of Sports Medicine Dec 2019Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between... (Meta-Analysis)
Meta-Analysis
Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts.
BACKGROUND
Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and QT is still debatable.
HYPOTHESIS
The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction.
STUDY DESIGN
Meta-analysis; Level of evidence, 2.
METHODS
A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure.
RESULTS
Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference ( = .45), Lachman test ( = .76), pivot-shift test grade 0 ( = .23), pivot-shift test grade 0 or 1 ( = .85), mean Lysholm score ( = .1), mean subjective IKDC score ( = .36), or graft failure ( = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference ( = .75), Lachman test ( = .41), pivot-shift test grade 0 ( = .53), Lysholm score less than 84 ( = .53), mean subjective IKDC score ( = .13), donor-site pain ( = .40), or graft failure ( = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; = .03).
CONCLUSION
QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.
Topics: Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Autografts; Bone-Patellar Tendon-Bone Grafting; Female; Hamstring Tendons; Humans; Knee Joint; Male; Patellar Ligament; Quadriceps Muscle; Tendons
PubMed: 30790526
DOI: 10.1177/0363546518825340