Literature reviewA systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type?
Introduction
Appropriate treatment of injury to the anterior cruciate ligament (ACL) remains controversial despite years of intensive basic and clinical research. Surgical reconstruction of a ruptured ACL is common, and effective rehabilitation programs are necessary for people with ACL deficiency as well as for those following ACL reconstruction. Currently, there is little consensus regarding the optimal rehabilitation program following either ACL injury or reconstruction.
Rehabilitation programs are designed to rebuild muscle strength, reestablish joint mobility and neuromuscular control, and to enable patients to return to pre-injury activity levels. These objectives are based on the current knowledge of lower limb functional disabilities in individuals with ACL deficiency (Rudolph et al., 1998, Snyder-Mackler et al., 1995) and patients undergoing ACL reconstruction (Barrett, 1991, DeVita et al., 1998, Holm et al., 2000, Risberg et al., 1999, Wojtys and Huston, 2000). Physical therapy practice, once largely based on clinical experience and theory, has changed considerably over the last 10–15 years to be increasingly based on higher quality clinical research. The best or least biased evidence of physical therapy effectiveness comes from randomized clinical trials (RCTs) and systematic reviews, which have increased dramatically over the past years.
The objective of this paper is to provide an evidence-based review of the effectiveness of various rehabilitation programs, including some specific exercise components, that have been used for surgically or non-surgically treated ACL injuries in adult patients.
Section snippets
Selection criteria for studies
RCTs were included for assessment if they evaluated the effect of a particular rehabilitation program or the specific exercises used within a rehabilitation program following ACL injury or reconstruction. Studies were excluded if they examined passive modalities, such as cryotherapy, continuous passive motion, braces, or electrophysical agents (with the exception of neuromuscular electrical stimulation for the purpose of improving muscle strength). Cardiorespiratory or general fitness responses
ACL strain values related to rehabilitation exercises
Although evidence exists regarding the strain on the ACL during various types of exercises (Beynnon and Fleming, 1998, Beynnon et al., 1995, Beynnon et al., 1997a) this evidence is limited and inconclusive on the magnitude of loading that is detrimental to a graft following ACL reconstruction. Absence of strain is detrimental to healing, as is excessive strain. It is important to design a rehabilitation program for patients after ACL reconstruction that will both optimally load the ACL graft
Rehabilitation protocols
The duration of therapy treatments has been assessed in two separate trials (Ekstrand, 1990, Frosch et al., 2001). The first examined the duration of the entire program and the second evaluated the duration of the individual treatment sessions. In order to evaluate the duration of the entire program, the effect of an extended 8-month rehabilitation program was compared to a 6-month (control group) rehabilitation program following ACL reconstruction (Ekstrand, 1990). No significant differences
Supervised and home-based rehabilitation programs
The effects of home-based, self-monitored rehabilitation programs compared to clinic-based supervised rehabilitation programs has been studied in subjects with ACL reconstruction (Beard and Dodd, 1998, Schenck et al., 1997) as well as subjects with an ACL rupture (Ageberg et al., 2001, Fischer et al., 1998, Zatterstrom et al., 1998, Zatterstrom et al., 2000). All rehabilitation programs described were led by physical therapists, while the home-based programs included physical therapy visits for
Summary
All of the above studies focused on physical therapy-led programs with various amount of supervision by a physical therapist. None of the studies evaluated the effect of a physical therapy-led program versus a truly unsupervised program. Collectively, these studies suggest that patients undergoing ACL reconstruction may not require rehabilitation to be continuously monitored by a physical therapist, but some assessments, education, instructions, and adjustments for progression are needed. In
Strength training
Although all lower extremity muscles must be included in rehabilitation following ACL injury or reconstruction, particular attention is paid to strengthening the quadriceps, the most affected muscle in these situations. Quadriceps muscle weakness remains one of the major challenges for patients and their therapists and some studies have demonstrated that quadriceps weakness can persist for 2 years after surgery (Risberg et al., 1999). In addition, quadriceps strength is a significant outcome
Neuromuscular training
The biomechanics of the knee are altered after ACL injury. Simply restoring mechanical restraints has been shown to be insufficient for a satisfactory outcome (Seto et al., 1988, Snyder-Mackler et al., 1997), but neuromuscular training may induce compensatory alterations in muscle activity patterns to enhance the control of abnormal joint translations during functional activities (Wojtys et al., 2000). Neuromuscular training has therefore become integrated into ACL rehabilitation protocols (
Specific exercises
Very few specific exercises have been evaluated for effectiveness in eliminating lower limb dysfunction. In fact, only three RCTs were identified that provided evidence for prescribing specific exercises (Blanpied et al., 2000, Hehl et al., 1995, Meyers et al., 2002). Specific exercises have also been examined for biomechanical and muscle activity purposes.
Hehl et al. (1995) examined the effect of adding isokinetic strength training from the 7th to the 9th week after ACL reconstruction or
Conclusions
Evidence for effective ACL rehabilitation has been assessed based on RCTs from six different areas: rehabilitation protocols, home versus supervised rehabilitation, CKC versus OKC exercises, NMES for quadriceps muscle strengthening, neuromuscular training, and specific exercises used within rehabilitation programs. Several of the RCTs in this systematic review have significant flaws, and limited evidence could be derived from them. Adequate statistical power calculations are missing in nearly
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