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How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)
  1. Renato Andrade1,2,3,
  2. Rogério Pereira1,2,3,4,
  3. Robert van Cingel5,6,
  4. J Bart Staal6,7,
  5. João Espregueira-Mendes1,2,8,9
  1. 1Clínica do Dragão, Espregueira-Mendes Sports Centre, FIFA Medical Centre of Excellence, Porto, Portugal
  2. 2Dom Henrique Research Centre, Porto, Portugal
  3. 3Faculty of Sports, University of Porto, Porto, Portugal
  4. 4Superior School of Health, University Fernando Pessoa, Porto, Portugal
  5. 5Sport Medisch Centrum Papendal, Arnhem, The Netherlands
  6. 6Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
  7. 7Research Group Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, The Netherlands
  8. 8School of Medicine, University of Minho, Braga, Portugal
  9. 9ICVS/3B’s–PT Government Associate Laboratory, Braga/Guimarães, Portugal
  1. Correspondence to Renato Andrade, Clínica do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Porto 4350-415, Portugal; randrade{at}


Objectives To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction.

Design Systematic review of CPGs (PROSPERO number: CRD42017020407).

Data sources Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018.

Eligibility criteria English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations.

Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction.

Results Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was ‘applicability’ (can clinicians implement this in practice?) (29%) and the highest ‘scope and purpose’ (78%) and ‘clarity of presentation’ (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing.

Conclusion The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.

  • anterior cruciate ligament
  • ACL
  • rehabilitation
  • physiotherapy
  • postoperative
  • evidence-based
  • clinical practice guidelines
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  • Contributors RA and RP performed the database searches, data analysis and initial interpretation of results. RA was responsible for initial drafting of the article, assisted by RP and reviewed by all authors. RvC and JBS provided advice throughout the interpretation of data and manuscript drafting. All authors were involved in the conception, design and interpretation of data. All authors read and reviewed the manuscript critically for important intellectual content and approved the final version to be submitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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