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Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction
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  • 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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    Conflict of Interest:
    None declared.
  • 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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    Conflict of Interest:
    None declared.