Literature reviewA review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation
Introduction
Anterior cruciate ligament (ACL) injuries are common, with a reported incidence of 30 cases per 100,000 (Bacchs & Boonos, 2001). Arthroscopically assisted ACL reconstruction using a hamstring or patella-bone- tendon-bone auto-graft is the standard surgical treatment particularly for those who are unable to perform jumping and cutting manoeuvres in sports because of resulting knee instability (Gianotti, Marshall, Humeb, & Bunt, 2009). Systematic review evidence of randomised trials (RCTs) comparing hamstring and patella tendon auto-grafts reports that there is no significant difference between the grafts on a variety of post-operative outcomes, such as return to sport (RTS), pain, muscle strength, knee stability, and range of motion (ROM) (Herrington, Wrapson, Matthews, & Matthews, 2005; Magnussen, Carey, & Spindler, 2011)
There is a general consensus for the effectiveness of a post-operative ACL reconstruction rehabilitation program, however there is little consensus regarding the optimal components of a program (Risberg, Lewek, & Snyder-Mackler, 2004). The speed with which an individual returns to their pre-injury level of sport and activity is mostly dependent on the type of rehabilitation protocol they receive (van Grinsven, van Cingel, Holla, & van Loon, 2010). Conservative approaches of six week cast immobilisation, followed by open kinetic chain (OKC) knee extensor resistive exercises, and a slow return to activity have been superseded by more aggressive approaches which emphasise earlier strength and range of motion (ROM) retraining and time to return to activity (Grodski & Marks, 2004). From a biomechanical perspective, theconservative approach conflicts with evidence of detrimental effects of suboptimal muscle “use” on joints (such as the knee) as well as immobilisation complications (Grodski & Marks, 2004). While the more aggressive approaches focussing on optimal muscle function may stress the graft and compromise joint stability the very objective of the reconstructive surgery (Heijne & Werner, 2007). Findings from a large international survey of orthopaedic surgeons' opinions on ACL reconstruction rehabilitation protocols reflect this variation of thought with large differences in the length or immobilisation, the use of bracing, amount of physical therapy prescribed, and time to return to physical activity being reported (Cook et al., 2008). It is therefore essential to know the effective components of ACL reconstruction rehabilitation programs to inform both clinicians and policy makers.
Clinical practice guidelines usually incorporate the results from systematic reviews as this is considered to be ‘best evidence’. Systematic reviews on the topic of effective treatments for ACL reconstruction rehabilitation programmes have been published however the methodological rigour of these systematic reviews has not been evaluated using internationally recommended validated guidance. The purpose of this systematic review of systematic reviews is to critically appraise systematic reviews on ACL reconstruction rehabilitation programmes using internationally recommended assessment procedures. The aim is to determine which rehabilitation components are supported by high quality systematic reviews to be included in a post -operative ACL reconstruction rehabilitation program for a variety of outcomes including strength, ROM, pain, laxity, activity levels, and RTS.
Section snippets
Eligibility criteria
To be included the review had to meet all of the following criteria:
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Population: male or female adult participants (i.e.16 years and older) who had a post-traumatic ACL reconstruction either by a hamstring or patella tendon auto-graft.
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Intervention: any physiotherapy intervention from the day of surgery.
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Comparison: the interventions were compared to standard treatment.
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Outcomes: pain, ROM, strength, function, Return to work (RTW), and RTS.
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Level of Evidence: systematic reviews needed to state the
Study selection
Fig. 1 summarizes the study selection process. Thirty-two reviews were excluded because they did not meet the inclusion criteria. Five reviews were eligible for inclusion (Andersson, Samuelsson, & Karlsson, 2009; Kim, Croy, Hertel, & Saliba, 2010; Smith & Davies, 2007, 2008; Trees, Howe, Dixon, & White, 2005). The outcomes and methodological quality of the five reviews are reported in Table 2. A total of eight specific interventions were reported on within these five reviews: bracing,
Discussion
The aim of this review was critically appraise systematic reviews on ACL reconstruction rehabilitation programmes using internationally recommended assessment procedures. A best evidence synthesis of the literature was also performed to see if review authors conclusions were consistent with the evidence reviewed. The highest levels of evidence are discussed as follows.
A strong level of evidence was reported in this review for no additional benefit of bracing compared to standard treatment for
Conclusion
This review reports strong evidence of no added benefit of bracing after ACL reconstruction (0–6 weeks post-surgery) as an adjunct to standard treatment in the short term, its use is therefore not recommended. Moderate evidence was found of no added benefit of CPM to standard treatment for routine use after ACL reconstruction with the aim of increasing knee range of motion. Moderate evidence indicates that CKC and OKC are as effective as each other for knee laxity, pain and function, at least
Conflict of interest
I affirm that I have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript.
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Current perspectives of New Zealand physiotherapists on rehabilitation and return to sport following anterior cruciate ligament reconstruction: A survey
2022, Physical Therapy in SportCitation Excerpt :The goals of post-ACLR rehabilitation are to restore neuromuscular function and modify any pre-injury risk factors that may increase the risk of subsequent ACL injury (Adams, Logerstedt, Hunter-Giordano, Axe, & Snyder-Mackler, 2012). While the effectiveness of rehabilitation following ACLR is well accepted (Lobb, Tumilty, & Claydon, 2012), there remains little consensus as to the optimal components of the rehabilitation program (Meredith et al., 2020). While clinical practice guidelines for post-ACL rehabilitation do exist, their usefulness in clinical practice may be limited due to low external validity (Andrade, Pereira, van Cingel, Staal, & Espregueira-Mendes, 2019).
The role of anterolateral augmentation in primary ACL reconstruction
2020, Journal of Clinical Orthopaedics and TraumaCitation Excerpt :Despite such apparent successes, failure rates remain considerable – amongst a multicentre consortium with >2 years follow-up autograft and allograft reconstruction failure rates were found to be 3.5% and 8.9% respectively,5 with clinical failure rates at over 10 years follow-up estimated to be 11.9%.6 Given the degree of failures coupled with inherent heterogeneity in reconstruction methodology, there remain long-standing uncertainties and subsequent controversies on a number of key factors relating to optimal reconstruction including: graft choice7–9 single bundle or double bundle graft,10–12 the role of biological support in graft maturation,13,14suspensory or interference screw fixation15 and the necessity for bracing during post-operative rehabilitation as selected examples.16–18 In these areas of uncertainty there have been randomised trials, meta-analyses and Cochrane reviews concluding no advantage of either method.7–9,12–15
FUNCTIONAL OUTCOMES OF ACCELERATED REHABILITATION PROTOCOL FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN AMATEUR ATHLETES: A RANDOMIZED CLINICAL TRIAL
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