Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction

Roula Kotsifaki; Vasileios Korakakis; Enda King; Olivia Barbosa; Dustin Maree; Michail Pantouveris; Andreas Bjerregaard; Julius Luomajoki; Jan Wilhelmsen; Rodney Whiteley

doi:10.1136/bjsports-2022-106158

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Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction

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Response to “Expression of concern over the Aspetar consensus for rehabilitation after ACL reconstruction: Premature position on the efficacy of cross-education”
Roula Kotsifaki, Vasileios Korakakis, Enda King, Olivia Barbosa, Dustin Maree, Michail Pantouveris, Andreas Bjerregaard, Julius Luomajoki, Jan Wilhelmsen and Rod Whiteley
Published on: 14 June 2023
Expression of concern over the Aspetar consensus for rehabilitation after ACL reconstruction: Premature position on the efficacy of cross-education
Justin W Andrushko, Joshua C Carr, Jonathan P Farthing, Lindsey K Lepley, Stuart Goodall, Ashlee M Hendy, Glyn Howatson, Jason DeFreitas, Dustin R Grooms, Tjerk Zult, Tibor Hortobágyi, Gulcan Harput, Maria G Papandreou, Kazunori Nosaka, Richard G Carson, Andrea Manca, Franca Dariu, David G Behm, Dawson J Kidgell and Lara A Boyd
Published on: 5 June 2023

Published on: 14 June 2023
Response to “Expression of concern over the Aspetar consensus for rehabilitation after ACL reconstruction: Premature position on the efficacy of cross-education”
- Roula Kotsifaki, Physiotherapist Aspetar Orthopaedic and Sports Medicine Hospital
- Other Contributors:
  Vasileios Korakakis, Physiotherapist
  
  Enda King, Physiotherapist
  
  Olivia Barbosa, Physiotherapist
  
  Dustin Maree, Physiotherapist
  
  Michail Pantouveris, Physiotherapist
  
  Andreas Bjerregaard, Physiotherapist
  
  Julius Luomajoki, Physiotherapist
  
  Jan Wilhelmsen, Physiotherapist
  
  Rod Whiteley, Physiotherapist
Dear Editor,
We thank these researchers for their concern regarding our recent clinical practice guideline1 and the accompanying interactive infographic. 2 We appreciate the opportunity to clarify and reply to these concerns.

The authors appear under the misapprehension that this was a consensus statement. The current work is a clinical practice guideline. According to the GRADE Handbook3: “users of guidelines may be frustrated with the lack of guidance when the guideline panel fails to make a recommendation” and: “clinicians themselves will rarely explore the evidence as thoroughly as a guideline panel, nor will they devote as much thought to the trade-offs, or the possible underlying values and preferences in the population”. Accordingly, GRADE encourages panels to deal with their discomfort and to make recommendations even when confidence in effect estimate is low and/or desirable and undesirable consequences are closely balanced.

The authors argue that there is currently insufficient evidence to reach a consensus recommendation regarding the exclusion of cross-education for post-ACLR rehabilitation. They propose re-evaluating the specific "Not Recommended" position and instead suggest that a "No Recommendation" stance would be more appropriate due to the lack of data. As noted, this is a clinical practice guideline (not a consensus statement) where we prioritise actionable information over agreement.

It is worth noting t...
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Dear Editor,
We thank these researchers for their concern regarding our recent clinical practice guideline1 and the accompanying interactive infographic. 2 We appreciate the opportunity to clarify and reply to these concerns.

The authors appear under the misapprehension that this was a consensus statement. The current work is a clinical practice guideline. According to the GRADE Handbook3: “users of guidelines may be frustrated with the lack of guidance when the guideline panel fails to make a recommendation” and: “clinicians themselves will rarely explore the evidence as thoroughly as a guideline panel, nor will they devote as much thought to the trade-offs, or the possible underlying values and preferences in the population”. Accordingly, GRADE encourages panels to deal with their discomfort and to make recommendations even when confidence in effect estimate is low and/or desirable and undesirable consequences are closely balanced.

The authors argue that there is currently insufficient evidence to reach a consensus recommendation regarding the exclusion of cross-education for post-ACLR rehabilitation. They propose re-evaluating the specific "Not Recommended" position and instead suggest that a "No Recommendation" stance would be more appropriate due to the lack of data. As noted, this is a clinical practice guideline (not a consensus statement) where we prioritise actionable information over agreement.

It is worth noting the statement from the US Preventative Services Task Force:
"Decision makers do not have the luxury of waiting for certain evidence. Even though evidence is insufficient, the clinician must still provide advice, patients must make choices, and policy makers must establish policies".4

So, what was this recommendation based on?

The recommendations are primarily based on the critical outcomes, specifically for the cross-education: knee extensor strength and subjective knee function (supplementary file). The summary for these two outcomes was “There is conflicting evidence for an effect of cross-training on quadriceps strength at the early and intermediate phase. There is no effect at the advanced phase of rehabilitation [D]” and “Cross-training might have a positive effect in the early phase of rehabilitation for the subjective knee function, but no difference in the following phases [D]”.

Regarding the significance of eccentric quadriceps strength, the authors suggest that “robust cross-education effects occur after eccentric training when the effects are tested in the trained contraction type.” In the context of our guideline, out of the 17 different strength reports/results analysed (encompassing various timings, testing modes, testing speeds, etc.) only one study5 reported results on eccentric peak torque strength. The standardized mean difference (SMD) for this study was -0.08, which was not significantly different from the control group (supplementary files).

With this low level ([D]) of conflicting evidence, it is then the job of the guideline to recommend clinical practice. Why would we choose to recommend against this practice?

When our goal is to norrmalise strength, gait, and movement patterns, we find it counterproductive to place excessive emphasis on the healthy leg. This approach makes clinical progression more challenging, as the injured leg is constantly trying to catch up to the improving healthy leg, which sets a moving target.

While training both legs is crucial in postoperative rehabilitation after ACLR, incorporating exaggerated cross-education interventions might increase the time, effort, and training load required to complete the program as planned. Furthermore, these interventions may introduce additional barriers to adhering to the already lengthy rehabilitation process, without a guarantee of significant benefits.

The authors call for “for more high-quality randomised clinical trials investigating the efficacy of cross-education for ACLR rehabilitation before a meaningful evidenced-based recommendation can be made.” We agree regarding the call for more research, but we stand by our recommendation based on the existing data.

References
1. Kotsifaki R, Korakakis V, King E, et al. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. Br J Sports Med 2023;57(9):500-14.
2. Kotsifaki R, Korakakis V, King E, et al. Infographic. Aspetar clinical practice guideline on rehabilitation after ACL reconstruction: an interactive figure. Br J Sports Med 2023;57(9):551-52.
3. Schünemann Holger BJ, Guyatt Gordon, Oxman Andrew. GRADE Handbook 2013. Available from: https://gdt.gradepro.org/app/handbook/handbook.html
4. Petitti DB, Teutsch SM, Barton MB, et al. Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med 2009;150(3):199-205.
5. Zult T, Gokeler A, van Raay J, et al. Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial. Knee Surg Sports Traumatol Arthrosc 2019;27(2):478-90.
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Conflict of Interest:
None declared.
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Published on: 5 June 2023
Expression of concern over the Aspetar consensus for rehabilitation after ACL reconstruction: Premature position on the efficacy of cross-education
- Justin W Andrushko, Postdoctoral Fellow Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Other Contributors:
  Joshua C Carr, Assistant Professor
  
  Jonathan P Farthing, Professor
  
  Lindsey K Lepley, Assistant Professor
  
  Stuart Goodall, Associate Professor
  
  Ashlee M Hendy, Lecturer
  
  Glyn Howatson, Professor
  
  Jason DeFreitas, Associate Professor
  
  Dustin R Grooms, Professor
  
  Tjerk Zult, Postdoctoral Research Fellow
  
  Tibor Hortobágyi, Professor
  
  Gulcan Harput, Associate Professor
  
  Maria G Papandreou, Associate Professor
  
  Kazunori Nosaka, Professor
  
  Richard G Carson, Professor
  
  Andrea Manca, Research Associate
  
  Franca Dariu, Professor
  
  David G Behm, Professor
  
  Dawson J Kidgell, Associate Professor
  
  Lara A Boyd, Professor
Dear Editor,

We read with interest the recent consensus statement by Kotsifaki et al. [1] on clinical practice guidelines following anterior cruciate ligament reconstruction (ACLR) and recognize their comprehensive efforts regarding an important area of sports medicine. However, we were surprised and disappointed to see their “Not Recommended” stance on the use of cross-education (i.e., interlimb transfer of strength or motor skill after engaging in unilateral motor training) for the recovery of motor function [1,2]. As a collective group of experts in cross-education and ACLR, we write this response with concern for the danger of drawing a premature conclusion given the limited research on cross-education for post-ACLR recovery [3–9]. Here, we offer a summary of the physiological rationale for the use of cross-education in rehabilitation, extending the views of Kotsifaki et al. [1].

Physical function after ACLR is largely predicated by quadriceps strength and an attenuated quadriceps activation failure [10], and protocols that preserve and restore neuromuscular function post-ACLR are an integral aspect of rehabilitation. Cross-education can attenuate the loss in neuromuscular function during disuse [11–13], serve as an adjunct ACLR rehabilitation protocol for quadriceps strength [3–5,14], and enhance neuroplasticity in pathways known to be attenuated with ACLR [15] when implemented effectively [16,17]. Though our concern is grounded in several aspects of the...
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Dear Editor,

We read with interest the recent consensus statement by Kotsifaki et al. [1] on clinical practice guidelines following anterior cruciate ligament reconstruction (ACLR) and recognize their comprehensive efforts regarding an important area of sports medicine. However, we were surprised and disappointed to see their “Not Recommended” stance on the use of cross-education (i.e., interlimb transfer of strength or motor skill after engaging in unilateral motor training) for the recovery of motor function [1,2]. As a collective group of experts in cross-education and ACLR, we write this response with concern for the danger of drawing a premature conclusion given the limited research on cross-education for post-ACLR recovery [3–9]. Here, we offer a summary of the physiological rationale for the use of cross-education in rehabilitation, extending the views of Kotsifaki et al. [1].

Physical function after ACLR is largely predicated by quadriceps strength and an attenuated quadriceps activation failure [10], and protocols that preserve and restore neuromuscular function post-ACLR are an integral aspect of rehabilitation. Cross-education can attenuate the loss in neuromuscular function during disuse [11–13], serve as an adjunct ACLR rehabilitation protocol for quadriceps strength [3–5,14], and enhance neuroplasticity in pathways known to be attenuated with ACLR [15] when implemented effectively [16,17]. Though our concern is grounded in several aspects of the current work, here we focus on two important themes related to cross-education and ACLR that we believe were not considered by Kotsifaki et al. [1] when making their recommendation.

Training specificity: Cross-education follows the principle of training specificity [18]: the largest effects occur in the contralateral homologous muscle [16,19–22]. Kotsifaki et al. [1] stated that cross-education has no effect on hamstrings strength, single-leg hop performance for distance, balance, or proprioception. Yet, all of the included studies, except Minshull et al. [9], prescribed a knee extensors-focused exercise protocol. We argue that recommendations should rely on the evaluation of specific outcome measures addressed directly by the cross-education intervention rather than non-specific outcomes.

Importance of eccentric quadriceps strength: In summarising the evidence, Kotsifaki et al. [1] prioritised concentric over isometric strength outcomes (with no mention of eccentric), even though four of the seven studies implemented an eccentric strength training protocol [3–5,8]. Not only is eccentric strength important for ACLR recovery [23], but corticospinal excitability is greater during eccentric contractions compared to forceful concentric contractions [24]. Further, robust cross-education effects occur after eccentric training [21,25–27] when the effects are tested in the trained contraction type [25,28]. Given these facets, the a priori criteria applied by Kotsifaki et al. [1] do not appropriately weigh the evidence with respect to how the interventions were designed.

Our recommendation
Many features of effective cross-education interventions [17] have not been adequately explored with respect to ACLR (e.g., motor skill). There was also considerable variability in how the cross-education training was implemented across studies with differences in exercise intensity, contraction type, muscle group, and training volume [3–9]. This leads us to conclude there is insufficient evidence for a consensus recommendation for the exclusion of cross-education for post-ACLR rehabilitation. We suggest reconsidering the specific “Not Recommended” position regarding cross-education, and instead, contend that “No Recommendation” is more appropriate based on insufficient data. Despite the currently limited literature, cross-education paradigms present a promising and low-risk approach to enhance systems-level rehabilitation. Cross-education has successfully preserved or enhanced the neuromuscular system in many experimental paradigms and during complex rehabilitation. Therefore, we put out a call for action for more high-quality randomised clinical trials investigating the efficacy of cross-education for ACLR rehabilitation before a meaningful evidenced-based recommendation can be made.

References
1 Kotsifaki R, Korakakis V, King E, et al. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. Br J Sports Med 2023;57:500–14. doi:10.1136/BJSPORTS-2022-106158
2 Kotsifaki R, Korakakis V, King E, et al. Infographic. Aspetar clinical practice guideline on rehabilitation after ACL reconstruction: an interactive figure. Br J Sports Med 2023;57:551–2. doi:10.1136/BJSPORTS-2022-106679
3 Papandreou MG, Papaioannou N, Antonogiannakis E, et al. The effect of cross exercise on quadriceps strength in different knee angles after the anterior cruciate ligament reconstruction. Brazilian J Biomotricity 2007;1:123–38.
4 Papandreou M, Billis E, Papathanasiou G, et al. Cross-exercise on quadriceps deficit after ACL reconstruction. J Knee Surg 2013;26:051–8. doi:10.1055/s-0032-1313744
5 Papandreou MG, Billis E V., Antonogiannakis EM, et al. Effect of cross exercise on quadriceps acceleration reaction time and subjective scores (Lysholm questionnaire) following anterior cruciate ligament reconstruction. J Orthop Surg Res 2009;4:1–9. doi:10.1186/1749-799X-4-2/FIGURES/2
6 Zult T, Gokeler A, van Raay JJAM, et al. Cross-education does not accelerate the rehabilitation of neuromuscular functions after ACL reconstruction: a randomized controlled clinical trial. Eur J Appl Physiol 2018;118:1609–23. doi:10.1007/S00421-018-3892-1/TABLES/6
7 Zult T, Gokeler A, van Raay JJAM, et al. Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial. Knee Surgery, Sport Traumatol Arthrosc 2019;27:478–90. doi:10.1007/S00167-018-5116-Y/TABLES/5
8 Harput G, Ulusoy B, Yildiz TI, et al. Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial. Knee Surgery, Sport Traumatol Arthrosc 2019;27:68–75. doi:10.1007/S00167-018-5040-1/TABLES/4
9 Minshull C, Gallacher P, Roberts S, et al. Contralateral strength training attenuates muscle performance loss following anterior cruciate ligament (ACL) reconstruction: a randomised-controlled trial. Eur J Appl Physiol 2021;121:3551–9. doi:10.1007/S00421-021-04812-3/TABLES/3
10 Lepley LK, Palmieri-Smith RM. Quadriceps strength, muscle activation failure, and patient-reported function at the time of return to activity in patients following anterior cruciate ligament reconstruction: A cross-sectional study. J Orthop Sports Phys Ther 2015;45:1017–25. doi:10.2519/JOSPT.2015.5753
11 Andrushko JW, Gould LA, Farthing JP. Contralateral effects of unilateral training: sparing of muscle strength and size after immobilization. Appl Physiol Nutr Metab 2018;43:1131–9. doi:10.1139/apnm-2018-0073
12 Hendy AM, Spittle M, Kidgell DJ. Cross education and immobilisation: Mechanisms and implications for injury rehabilitation. J Sci Med Sport 2012;15:94–101. doi:10.1016/j.jsams.2011.07.007
13 Valdes O, Ramirez C, Perez F, et al. Contralateral effects of eccentric resistance training on immobilized arm. Scand J Med Sci Sports 2021;31:76–90. doi:10.1111/sms.13821
14 Cuyul-Vásquez I, Álvarez E, Riquelme A, et al. Effectiveness of unilateral training of the uninjured limb on muscle strength and knee function of patients with anterior cruciate ligament reconstruction: A systematic review and meta-analysis of cross-education. J Sport Rehabil 2022;31:605–16. doi:10.1123/JSR.2021-0204
15 Lepley LK, Grooms DR, Burland JP, et al. Eccentric cross-exercise after anterior cruciate ligament reconstruction: Novel case series to enhance neuroplasticity. Phys Ther Sport 2018;34:55–65. doi:10.1016/J.PTSP.2018.08.010
16 Manca A, Hortobágyi T, Carroll TJ, et al. Contralateral effects of unilateral strength and skill training: Modified delphi consensus to establish key aspects of cross-education. Sport Med 2021;51:11–20. doi:10.1007/s40279-020-01377-7
17 Voskuil C, Andrushko JW, Huddleston B, et al. Exercise prescription and strategies to promote the cross-education of strength: a scoping review. Appl Physiol Nutr Metab Published Online First: 8 May 2023. doi:10.1139/APNM-2023-0041
18 Barnett ML, Ross D, Schmidt RA, et al. Motor skills learning and the specificity of training principle. Res Quarterly Am Assoc Heal Phys Educ Recreat 2013;44:440–7. doi:10.1080/10671188.1973.10615224
19 Andrushko JW, Lanovaz JL, Björkman KM, et al. Unilateral strength training leads to muscle-specific sparing effects during opposite homologous limb immobilization. J Appl Physiol 2018;124:866–76. doi:10.1152/japplphysiol.00971.2017
20 Green LA, Gabriel DA. The effect of unilateral training on contralateral limb strength in young, older, and patient populations: a meta-analysis of cross education. Phys Ther Rev 2018;23. doi:10.1080/10833196.2018.1499272
21 Manca A, Dragone D, Dvir Z, et al. Cross-education of muscular strength following unilateral resistance training: a meta-analysis. Eur J Appl Physiol 2017;117:2335–54. doi:10.1007/s00421-017-3720-z
22 Munn J, Herbert RD, Gandevia SC. Contralateral effects of unilateral resistance training: A meta-analysis. J Appl Physiol 2004;96:1861–6. doi:10.1152/JAPPLPHYSIOL.00541.2003/ASSET/IMAGES/LARGE/ZDG0050430490002.JPEG
23 Lepley LK, Wojtys EM, Palmieri-Smith RM. Combination of eccentric exercise and neuromuscular electrical stimulation to improve quadriceps function post-ACL reconstruction. Knee 2015;22:270–7. doi:10.1016/j.knee.2014.11.013
24 Howatson G, Taylor MB, Rider P, et al. Ipsilateral motor cortical responses to TMS during lengthening and shortening of the contralateral wrist flexors. Eur J Neurosci 2011;33:978–90. doi:10.1111/j.1460-9568.2010.07567.x
25 Hortobágyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sports Exerc 1997;29:107–12. doi:10.1097/00005768-199701000-00015
26 Farthing JP, Chilibeck PD. The effect of eccentric training at different velocities on cross-education. Eur J Appl Physiol 2003;89:570–7. doi:10.1007/s00421-003-0841-3
27 Chen TC, Wu S-H, Chen H-L, et al. Effects of unilateral eccentric versus concentric training of non-immobilized arm during immobilization. Med Sci Sport Exerc Published Online First: 20 February 2023. doi:10.1249/MSS.0000000000003140
28 Lepley LK, Palmieri-Smith RM. Cross-education strength and activation after eccentric exercise. J Athl Train 2014;49:582–9. doi:10.4085/1062-6050-49.3.24
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Conflict of Interest:
None declared.
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