A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation

Abstract

The aim of this systematic review of systematic reviews was to critically appraise systematic reviews on Anterior Cruciate Ligament (ACL) reconstruction rehabilitation to determine which interventions are supported by the highest quality evidence. Electronic searches were undertaken, of MEDLINE, AMED, EMBASE, EBM reviews, PEDro, Scopus, and Web of Science to identify systematic reviews of ACL rehabilitation. Two reviewers independently selected the studies, extracted data, and applied quality criteria. Study quality was assessed using PRISMA and a best evidence synthesis was performed. Five systematic reviews were included assessing eight rehabilitation components. There was strong evidence (consistent evidence from multiple high quality randomised controlled trials (RCTs)) of no added benefit of bracing (0–6 weeks post-surgery) compared to standard treatment in the short term. Moderate evidence (consistent evidence from multiple low quality RCTs and/or one high quality RCT) supported no added benefit of continuous passive motion to standard treatment for increasing range of motion. There was moderate evidence of equal effectiveness of closed versus open kinetic chain exercise and home versus clinic based rehabilitation, on a range of short term outcomes. There was inconsistent or limited evidence for some interventions. Recommendations for clinical practice are made at specific time points for specific outcomes.

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.