Documentation of strength training for research purposes after ACL reconstruction

Multicomponent supervised tele-rehabilitation versus home-based self-rehabilitation management after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial

INTRODUCTION

Our study aims to assess the effectiveness of multicomponent supervised tele-rehabilitation compared to home-based self-rehabilitation management in patients following anterior cruciate ligament reconstruction (ACLR).

METHODS

The current study is designed as a single-center, single-blinded, randomized controlled, two-arm trial. Participants will be randomized and allocated at a 1:1 ratio into either a multicomponent supervised tele-rehabilitation group or a home-based self-rehabilitation group. All participants receive uniform preoperative education through the HJT software. Participants in the intervention group undergo multicomponent supervised tele-rehabilitation, while those in the control group follow a home-based self-rehabilitation program. All the participants were assessed and measured for the included outcomes at the outpatient clinic before the procedure, and in 2, 4, 8, 12, and 24 weeks after ACLR by two assessors. The primary outcome was the percentage of patients who achieve a satisfactory active ROM at the 12 weeks following the ACLR. The satisfactory active ROM was also collected at 2, 4, 8, and 24 weeks after ACLR. The secondary outcomes were active and passive range of motion (ROM), pain, muscle strength, and function results.

REGISTRATION DETAILS

Ethical approval has been obtained from the West China Hospital Ethics Committee (approval number 2023-1929, December 2023). The trial has been registered on ClinicalTrials.gov (registration number NCT06232824, January 2024).

The Nature of Rehabilitation Programs to Improve Musculoskeletal, Biomechanical, Functional, and Patient-Reported Outcomes in Athletes With ACL Reconstruction: A Scoping Review

CONTEXT

After anterior cruciate ligament (ACL) reconstruction (ACLR), athletes commonly undergo prolonged rehabilitation (eg, 9-12 months), but few actually return to preinjury sports activities. The nature (composition, configuration) of an ACL rehabilitation program (ACL-RP) is an important factor in determining rehabilitation outcomes; however, details about the nature of ACL-RPs are reported inconsistently in research studies. To guide future research reporting to support clinical translation and implementation of ACL-RPs, it is necessary to describe the nature, reporting, and outcomes of ACL-RPs in the current literature.

OBJECTIVE

The purpose of this scoping review was to understand the nature and reporting of various ACL-RPs that address musculoskeletal, biomechanical, functional, or patient-reported outcome measures in adult and pediatric athletes with ACLR.

DATA SOURCES

Articles were selected from searches in 5 electronic databases (PubMed, EbscoHost [MEDLINE, SportDiscus, CINAHL Plus], PROQuest, Cochrane, and Embase).

STUDY SELECTION

Studies were included if they evaluated a post-ACL-RP that implemented strength, balance, plyometric, change of direction running, and/or agility running and included self-reported physical function, quality of life, or pain outcomes.

STUDY DESIGN

Scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data were extracted and synthesized to evaluate the reporting of acute program variables (APVs) and exercise descriptors (EDs); 17 studies were included in the final synthesis.

RESULTS

Studies reported between 0% and 67% of the APVs and EDs combined. Only 2 studies were considered to have adequate reporting of both APVs and EDs.

CONCLUSION

Inadequate reporting of APVs and EDs in past studies restricts the translation and implementation of existing research-based ACL-RPs to present-day clinical contexts.

The Effect of Progressive Resistance Exercise on Knee Muscle Strength and Function in Participants with Persistent Hamstring Deficit Following ACL Reconstruction: A Randomized Controlled Trial

OBJECTIVE: To investigate the effect of progressive resistance exercise compared with low-intensity home-based exercises on knee-muscle strength and joint function in people with anterior cruciate ligament (ACL) reconstruction and persistent hamstring strength deficits at 12-24 months after surgery. DESIGN: Randomized controlled superiority trial with parallel groups, balanced randomization (1:1), and blinded outcome assessment. METHODS: People with ACL reconstruction (hamstring autograft) and persistent hamstring muscle strength asymmetry were recruited 1 to 2 years postsurgery and randomized to either 12 weeks of supervised progressive strength training (SNG), or 12 weeks of home-based, low-intensity exercises (CON). The primary outcome was between-group difference in change in maximal isometric knee flexor muscle strength at 12-week follow-up. RESULTS: Fifty-one participants (45% women, 27 ± 6 years) were randomized to SNG (n = 25) or CON (n = 26), with 88% follow-up rate at 12 weeks. People in the SNG group improved their knee flexor muscle strength (0.18 N·m/kg, 95% confidence interval [CI]: 0.07, 0.29; P = .002) more than the CON group, from baseline to 12 weeks. The SNG group also had superior Knee Injury and Osteoarthritis Outcome Scores for Pain (4.6, 95% CI: 0.4, 8.7; P = .031) and daily living function (4.7, 95% CI: 1.2, 8.2; P = .010) compared to the CON group. CONCLUSION: In people with persistent hamstring muscle strength deficits after ACL reconstruction, 12 weeks of supervised progressive strength training was superior to low-intensity home-based exercises for improving maximal knee flexor muscle strength and some patient-reported outcomes. J Orthop Sports Phys Ther 2023;53(1):40-48. Epub: 17 October 2022. doi:10.2519/jospt.2022.11360.

ACL Reconstruction: Which Additional Physiotherapy Interventions Improve Early-Stage Rehabilitation? A Systematic Review

Despite the restoration of the mechanical stability of the knee joint after ACL reconstruction (ACLR), patients often experience postoperative limitations. To our knowledge, there are no systematic reviews analyzing additional physiotherapy interventions implementing standard rehabilitation programs in the early postoperative phase after ACLR. The objective of this study was to analyze the additional physiotherapy interventions implemented in standard rehabilitation programs that improve early-stage ACLR rehabilitation. For this systematic review, we followed the PRISMA guidelines. In March 2022 we conducted a literature review using electronic databases. Primary outcomes were pain, edema, muscle strength, ROM, and knee function. The risk of bias and scientific quality of included studies were assessed with the RoB 2, ROBINS-I and PEDro scale. For the review, we included 10 studies that met the inclusion criteria (total n = 3271). The included studies evaluated the effectiveness of Kinesio Taping, Whole-body vibration, Local Vibration Training, Trigger Point Dry Needling, High Tone Power Therapy, alternating magnetic field, and App-Based Active Muscle Training Program. Most of the additional physiotherapy interventions improved pain, edema, ROM, knee muscle strength, or knee function in early-stage postoperative ACL rehabilitation. Except for one study, no adverse events occurred in the included studies, which demonstrates the safety of the discussed physiotherapy interventions. Further in-depth research is needed in this area.

Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus

OBJECTIVE

Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes.

DESIGN

Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

ELIGIBILITY CRITERIA

Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults.

RESULTS

We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion.

CONCLUSION

The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

Exercise Descriptors That Determine Muscle Strength Gains Are Missing From Reported Anterior Cruciate Ligament Reconstruction Rehabilitation Programs: A Scoping Review of 117 Exercises in 41 Studies

OBJECTIVE

To (1) describe which strength training exercise descriptors are reported in anterior cruciate ligament reconstruction (ACLR) rehabilitation research, and (2) compare the current standards of reporting ACLR strength training exercise descriptors to international best-practice strength training guidelines.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the MEDLINE, PsycINFO, CINAHL, SPORTDiscus, Academic Search, ERIC, Health Source: Nursing, Health Source: Consumer, MasterFILE, and Africa-Wide Information databases.

STUDY SELECTION CRITERIA

We included level I to IV studies of ACLR rehabilitation programs with 1 or more reported strength training exercise descriptors. We used a predefined list of 19 exercise descriptors, based on the American College of Sports Medicine (ACSM) exercise recommendations, the Consensus on Exercise Reporting Template (CERT), and the Toigo and Boutellier exercise descriptor framework.

DATA SYNTHESIS

Completeness and the standard of reporting exercise descriptors in ACLR rehabilitation programs were assessed by means of international best-practice strength training standards.

RESULTS

We extracted data on 117 exercises from 41 studies. A median of 7 of the 19 possible exercise descriptors were reported (range, 3-16). Reporting of specific exercise descriptors varied across studies, from 95% (name of the strength training exercise) to 5% (exercise aim, exercise order). On average, 46%, 35%, and 43% of the exercise descriptors included in the ACSM, CERT, and Toigo and Boutellier guidelines were reported, respectively.

CONCLUSION

Key exercise descriptors for muscle strength gains are not reported in studies on ACLR rehabilitation. Only the exercise name, number of exercises, frequency, and experimental period were reported in most of the studies. J Orthop Sports Phys Ther 2022;52(2):100-112. Epub 16 Nov 2021. doi:10.2519/jospt.2022.10651.

The effectiveness of preoperative exercise programmes on quadriceps strength prior to and following anterior cruciate ligament (ACL) reconstruction: A systematic review

OBJECTIVES

to evaluate the effectiveness of preoperative exercise programmes on quadriceps strength prior to and following anterior cruciate ligament (ACL) reconstruction.

DESIGN

Systematic review.

METHODS

a systematic review was undertaken, included studies were evaluated using the Modified Downs and Black checklist which is appropriate for determining the quality of randomised and non-randomised studies. Scientific databases searched included PubMED, EBSCO Health, CINAHL, Medline, and Cochrane Library databases from inception to March 2021.

RESULTS

Ten studies met the inclusion criteria. There were six randomised studies and four prospective studies. The level of evidence is categorised as 'limited' due to heterogenicity and only six studies reported quadriceps strength increases. Five studies demonstrated preoperative exercise of 4-16 weeks duration can significantly increase preoperative quadriceps strength. One study demonstrated preoperative OKC exercise produced significantly stronger preoperative quadriceps compared to CKC exercise. One study showed no between group (intervention vs control) quadriceps strength difference pre or 12 weeks postoperatively.

CONCLUSIONS

4-16 weeks of preoperative exercise could increase quadriceps strength preoperatively but any persistent postoperative strength benefit from undertaking a standardised preoperative intervention is unclear. There is considerable variation and methodological limitations across the included studies and the composition of optimal preoperative ACLR exercise is currently unknown.

Ability of Isokinetic Dynamometer to Predict Isotonic Knee Extension 1-Repetition Maximum

CONTEXT

Resistance training exercise prescription is often based on exercises performed at a percentage of a 1-repetition maximum (1RM). Following knee injury, there is no consensus when a patient can safely perform 1RM testing. Resistance training programs require the use of higher loads, and loads used in knee injury rehabilitation may be too low to elicit gains in strength and power. A maximum isometric contraction can safely be performed during early stages of knee rehabilitation and has potential to predict an isotonic knee extension 1RM.

OBJECTIVE

To determine whether a 1RM on an isotonic knee extension machine can be predicted from isometric peak torque measurements.

DESIGN

Descriptive laboratory study.

SETTING

University research laboratory.

PARTICIPANTS

A total of 20 (12 males and 8 females) healthy, physically active adults.

MAIN OUTCOME MEASURES

An isokinetic dynamometer was used to determine isometric peak torque (in N·m). 1RM testing was performed on a knee extension machine. Linear regression was used to develop a prediction equation, and Bland-Altman plots with limits of agreement calculations were used to validate the equation.

RESULTS

There was a significant correlation (P < .001, r = .926) between peak torque (283.0 [22.6] N·m) and the knee extension 1RM (69.1 [22.6] kg). The prediction equation overestimated the loads (2.3 [9.1] kg; 95% confidence interval, -15.6 to 20.1 kg).

CONCLUSIONS

The results show that isometric peak torque values obtained on an isokinetic dynamometer can be used to estimate 1RM values for isotonic knee extension. Although the prediction equation tends to overestimate loads, the relatively wide confidence intervals indicate that results should be viewed with caution.

Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial

PURPOSE

The aim of this study was to investigate the effects of concentric and eccentric cross-education (CE) on quadriceps strength and knee function recoveries after anterior cruciate ligament (ACL) reconstruction.

METHODS

Forty-eight patients (age: 29.5 ± 6.8 years, body mass index: 26.1 ± 3.2 kg/m²) who had undergone ACL reconstruction with hamstring tendon autograft were included in the study. The patients were randomly divided into three groups when they reached four weeks post surgery: (1) concentric CE (n = 16); (2) eccentric CE (n = 16); and (3) control (n = 16). All groups followed the same post-surgical rehabilitation program for their reconstructed limb. Additionally, the two experimental groups followed eight weeks of isokinetic training for the uninjured knee at 60°/s for 3 days per week. Quadriceps maximum voluntary isometric strength (MVIC) was measured during the 4th week (pre-training), 12th week (post training), and 24th week post surgery. The single-leg hop distance and International Knee Documentary Committee (IKDC) scores were also evaluated during the 24th week post surgery. Analysis of variance was used for statistical analysis.

RESULTS

Group-by-time interaction was significant for quadriceps MVICs for reconstructed and healthy limbs (p = 0.02). Quadriceps strength of both knees was greater in concentric and eccentric CE groups compared to control group during the 12th- and 24th weeks post surgery (p < 0.05). Strength gain was 28% and 31% in concentric and eccentric CE groups, respectively, when compared with the control group. Concentric and eccentric CE had similar effects on quadriceps strength recovery (n.s.). IKDC score, and single-leg hop distances were not significantly different among groups (n.s.).

CONCLUSIONS

Concentric and eccentric quadricep strengthening of healthy limbs in early phases of ACL rehabilitation improved post-surgical quadriceps strength recovery of the reconstructed limb. CE should be integrated into ACL reconstruction rehabilitation, especially in the early rehabilitative phases to restore quadriceps strength.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Reporting of acute programme variables and exercise descriptors in rehabilitation strength training for tibiofemoral joint soft tissue injury: A systematic review

OBJECTIVE

Strength training acute programme variables (APVs) can impact tibiofemoral joint injury outcomes. Exercise descriptors (EDs; e.g. patient-position) specify configurations within which APVs are applied. Evidence-based practice depends on adequate reporting of APVs and EDs to replicate strength training interventions in clinical practice. This systematic review assessed APV and ED reporting for adults with tibiofemoral joint injury (anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL)/medial collateral ligament (MCL)/lateral collateral ligament (LCL)/meniscus/hyaline cartilage (HC)).

METHODS

PRISMA guidelines were followed. Specific key-term combinations were employed and database searches performed. Descriptive/observational/experimental studies were included (2006-2018). Studies needed to report pre-defined APVs or EDs for ≥51% of all exercises to be included. Frequency counts were made of studies adequately reporting APVs and EDs.

RESULTS

Sixteen articles were included (ACL = 13; meniscus = 3). No PCL/MCL/LCL/HC articles were identified. Of nine APVs, five and four were consistently reported by the majority of ACL (≥7) and meniscal (≥2) studies, respectively. Of eight EDs, four were consistently reported by the majority of both ACL (≥8) and meniscal (≥2) studies.

CONCLUSION

Many APVs and EDs were not adequately reported. Future studies should better document APVs and EDs for higher standards of intervention reporting and enhanced translation of research to clinical practice.

The effect of targeted exercise on knee-muscle function in patients with persistent hamstring deficiency following ACL reconstruction - study protocol for a randomized controlled trial

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction, using hamstring auto-graft is a common surgical procedure, which often leads to persistent hamstring muscle-strength deficiency and reduced function. The purpose of this randomized controlled trial (RCT) is to investigate the effect of a combined, progressive, strength and neuromuscular exercise intervention on knee muscle strength, functional capacity and hamstring muscle-tendon morphology in ACL-reconstructed patients with persistent hamstring muscle-strength deficiency compared with controls.

METHODS/DESIGN

The study is designed as a multicenter, parallel-group RCT with balanced randomization (1:1) and blinded outcome assessments (level of evidence: II) and will be reported in accordance with the CONSORT Statement. Fifty ACL-reconstructed patients (hamstring auto-graft) with persistent limb-to-limb knee-flexor muscle-strength asymmetry at 12-24 months' post surgery, will be recruited through outpatient clinics and advertisements. Patients will be randomized to a 12-week progressive, strength and neuromuscular exercise group (SNG) with supervised training twice weekly or a control intervention (CON) consisting of a home-based, low-intensity exercise program. Outcome measures include between-group change in maximal isometric knee-flexor strength (primary outcome) and knee-extensor muscle strength, hamstring-to-quadriceps strength ratios of the leg that has been operated on and Knee injury and Osteoarthritis Outcome Score (KOOS) (secondary outcomes). In addition, several explorative outcomes will be investigated: The International Knee Documentation Committee Subjective Knee Form (IKDC), the Tegner Activity Score, rate of force development (RFD) for the knee flexors and extensors, tendon regeneration and potential muscle hypertrophy at graft harvest site evaluated by magnetic resonance imaging (MRI), postural control, kinetic/kinematic gait characteristics and knee-related functional capacity.

DISCUSSION

This RCT is designed to investigate the effect of combined, progressive-resistance and neuromuscular exercises on knee-flexor/extensor strength, in the late rehabilitation phase following ACL reconstruction. Reduced hamstring strength represents a potential risk factor for secondary ACL rupture and accelerated progression of osteoarthritis. If deemed effective, the intervention paradigm introduced in this study may help to improve current treatment strategies in ACL-reconstructed patients.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02939677 (recruiting). Registered on 20 October 2016.

Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus

AIM

The Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of Dutch anterior cruciate ligament (ACL) experts to develop an evidence statement for rehabilitation after ACL reconstruction.

DESIGN

Clinical practice guideline underpinned by systematic review and expert consensus.

DATA SOURCES

A multidisciplinary working group and steering group systematically reviewed the literature and wrote the guideline. MEDLINE and the Cochrane Library were searched for meta-analyses, systematic reviews, randomised controlled trials and prospective cohort studies published between January 1990 and June 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included literature must have addressed 1 of 9 predetermined clinical topics: (1) preoperative predictors for postoperative outcome, (2) effectiveness of physical therapy, (3) open and closed kinetic chain quadriceps exercises, (4) strength and neuromuscular training, (5) electrostimulation and electromyographic feedback, (6) cryotherapy, (7) measurements of functional performance, (8) return to play and (9) risk for reinjury.

SUMMARY

Ninety studies were included as the basis for the evidence statement. Rehabilitation after ACL injury should include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2) sport-specific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9-12 months. To assess readiness to return to play and the risk for reinjury, a test battery, including strength tests, hop tests and measurement of movement quality, should be used.

A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament

BACKGROUND

There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL).

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.

Efeitos do método pilates no torque isocinético dos extensores e flexores do joelho: estudo piloto

INTRODUÇÃO: apesar da popularização do método Pilates como forma de exercício físico, os estudos com a técnica ainda não têm explorado os seus efeitos sobre o torque isocinético dos músculos extensores e flexores do joelho.OBJETIVO: verificar os efeitos do método Pilates no torque isocinético dos extensores e flexores do joelho em mulheres jovens.MÉTODOS: 10 voluntárias foram submetidas à avaliação isocinética (60°/s e 300°/s) dos extensores e flexores do joelho, do membro inferior dominante, pré e pós-intervenção com o método Pilates, considerando-se o pico de torque (PT) e o trabalho total (TT). Oito intervenções foram realizadas ao longo de quatro semanas, constando de 28 exercícios de alongamento e fortalecimento para os principais grupos musculares. A análise estatística, utilizando os testes tde Student ou Wilcoxonpara amostras dependentes, foi utilizada (p<0,05).RESULTADOS: os resultados mostraram melhora significativa para a maioria das variáveis observadas, tanto na extensão do joelho (TT 60°/s - 8,98%, p = 0,0166; PT 300°/s - 11,80%, p = 0,0077; TT 300°/s - 19,68%, p = 0,0051), quanto na flexão (PT 60°/s - 11,44%, p = 0,0171; TT 60°/s - 11,55%, p = 0,0395; TT 300°/s - 12,86%, p = 0,0145), com exceção para duas variáveis, uma referente ao movimento de extensão do joelho (PT 60°/s - 3,04%, p = 0,4413) e outra ao movimento de flexão (PT 300°/s - 2,30%, p = 0,3873).CONCLUSÃO: foi possível verificar que oito sessões de Pilates, realizadas ao longo de quatro semanas, proporcionaram melhora significativa do torque isocinético dos músculos extensores e flexores do joelho em mulheres jovens, em relação ao PT e TT (60°/s e 300°/s) para a maioria das variáveis analisadas.