Early rehabilitation of acute anterior cruciate ligament injury--a randomized clinical trial

Treatment of Arthrogenic-Muscle-Inhibition in patients after knee-surgery with Motion-Activated-Neuromuscular stimulation - a case-series

Arthrogenic muscle inhibition (AMI) presents a persistent challenge in postoperative knee rehabilitation and is often resistant to standard care. This case series examines the efficacy of Motion-Activated Neuromuscular Electrical Stimulation (mNMES) in addressing AMI refractory to rehabilitation after ACL (revision) surgery, patellar dislocation, trochleoplasty, or conservative treatment of the patellofemoral pain syndrome. Eight patients who had undergone extensive unsuccessful rehabilitation received six weeks of a novel mNMES treatment regimen. Outcome assessments included patient-reported outcome measures (PROMs) and AMI classification. Results revealed significant improvements in pain reduction, knee function, and AMI reduction. Despite study limitations, mNMES demonstrated promising outcomes and could be used as an adjunct to standard rehabilitation, offering potential for enhancing postoperative outcomes in patients refractory to conventional therapy. Further research is required to validate these findings and optimise treatment protocols.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

OBJECTIVE

Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Seven databases were searched in December 2021.

ELIGIBILITY CRITERIA

Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury.

RESULTS

We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I² 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26).

CONCLUSIONS

Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls.

PROSPERO REGISTRATION NUMBER

CRD42021205998.

Persistent knee extension deficits are common after anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials

PURPOSE

Knee extension deficits complicate recovery from ACL injury and reconstruction; however, the incidence of knee extension loss is not well defined. The aim of this review was to identify the incidence of loss of extension (LOE) following ACL rupture and reconstruction, explore the definitions of knee extension deficits reported and identify prognostic factors affecting LOE incidence.

METHODS

A systematic search was conducted in Medline, Cochrane Library and PEDro for studies in publication up to November 2021, with no restrictions on publication year. References were screened and assessed for inclusion using predetermined eligibility criteria. Randomised controlled trials (RCTs) that quantified knee angle, loss of extension or incidence of extension deficit were included for quality assessment and data extraction. Statistical summaries were generated and meta-analyses performed in two parts to examine: (i) the probability of a datapoint being zero incidence compared to a nonzero incidence and (ii) the relationship between the predictors and nonzero LOE incidence.

RESULTS

A sample of 15,494 studies were retrieved using the search criteria, with 53 studies meeting eligibility criteria. The pooled results from 4991 participants were included for analysis, with 4891 participants who had undergone ACLR. The proportion of included studies judged at an overall low risk of bias was small (7.8%). The observed group and study were the most important predictors for whether a datapoint reported an incidence of extension deficit. Time to follow-up (P < 0.001) and graft type (P = 0.02) were found to have a significant influence on nonzero LOE incidence (%). Covariate adjusted estimates of average LOE indicated 1 in 3 patients presenting with LOE at 12 month follow-up, reducing to 1 in 4 at 2 years.

CONCLUSIONS

This review examined the definitions for the measurement and interpretation of postoperative knee extension and established the trajectory of knee extension deficit after ACL injury and reconstruction. While factors associated with loss of extension were identified, the exact trajectory of knee extension deficits was difficult to infer due to discrepancies in measurement techniques and patient variation. On average, 1 in 3 patients may present with loss of extension of at least 3 degrees at 12-month follow-up, decreasing to 1 in 4 at 2 years. These results may be used by clinicians as an upper threshold for acceptable complication rates following ACLR. Future work should focus on LOE as a clinically relevant complication of ACL injury and treatment with appropriate attention to standardisation of definitions, measurements and better understanding of natural history.

PROSPERO REGISTRATION NUMBER

CRD42018092295.

LEVEL OF EVIDENCE

Level I.

Associations between altered movement patterns during single-leg squat and muscle activity at weight-transfer initiation in individuals with anterior cruciate ligament injury

Background

Little is known about factors contributing to the altered movement patterns observed in many individuals with anterior cruciate ligament (ACL) injury. We addressed whether altered muscular activity is such a factor.

Methods

16 participants with unilateral, non-reconstructed ACL rupture were scored for altered movement patterns according to Test for Substitution Patterns (TSP), which includes the single-leg squat (SLS). Surface electromyography (SEMG), was recorded in the lower extremities at initiation of weight-transfer from double-leg to single-leg stance (eyes closed), simulating the initiation of an SLS. Normalised SEMG amplitudes 200–300 ms after weight-transfer initiation were compared between injured and non-injured sides, and correlated to the TSP scores for the SLS. Peak absolute SEMG amplitudes during 5 TSP test movements were also compared between sides.

Results

At weight-transfer initiation, muscle activity was lower in the tibialis anterior, gastrocnemius and peroneus longus muscles on the injured side. Low muscle activity correlated moderately to worse TSP scores for the SLS for the gluteus medius (r_s=−0.56, p=0.03), and gastrocnemius muscles (r_s=−0.56, p=0.02). Median peak absolute amplitude during TSP movements was lower in the quadriceps, gastrocnemius and peroneus longus muscles on the injured side.

Conclusions

The altered patterns of muscle activity at weight-transfer initiation, correlations between lower activity at movement initiation and altered movement patterns during SLS and the altered peak amplitudes during TSP movements together indicate alterations in sensorimotor control that may contribute to the observed altered movement patterns. Future studies will determine if exercises targeting muscle activity initiation should complement customary ACL injury rehabilitation.

Exploring the effect of space and place on response to exercise therapy for knee and hip pain--a protocol for a double-blind randomised controlled clinical trial: the CONEX trial

INTRODUCTION

Context effects are described as effects of a given treatment, not directly caused by the treatment itself, but rather caused by the context in which treatment is delivered. Exercise is a recommended core treatment in clinical guidelines for musculoskeletal disorders. Although moderately effective overall, variation is seen in size of response to exercise across randomised controlled trial (RCT) studies. Part of this variation may be related to the fact that exercise interventions are performed in different physical environments, which may affect participants differently. The study aims to investigate the effect of exercising in a contextually enhanced physical environment for 8 weeks in people with knee or hip pain.

METHODS AND ANALYSIS

The study is a double-blind RCT. Eligible participants are 35 years or older with persisting knee and/or hip pain for 3 months. Participants are randomised to one of three groups: (1) exercise in a contextually enhanced environment, (2) exercise in a standard environment and (3) waiting list. The contextually enhanced environment is located in a newly built facility, has large windows providing abundant daylight and overlooks a recreational park. The standard environment is in a basement, has artificial lighting and is marked by years of use; that is, resembling many clinical environments. The primary outcome is the participant's global perceived effect rated on a seven-point Likert scale after 8 weeks exercise. Patient-reported and objective secondary outcomes are included.

ETHICS AND DISSEMINATION

The Regional Scientific Ethical Committee for Southern Denmark has approved the study. Study findings will be disseminated in peer-reviewed publications and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02043613.

Knee cartilage assessment with MRI (dGEMRIC) and subjective knee function in ACL injured copers: a cohort study with a 20 year follow-up

OBJECTIVE

To assess knee cartilage quality and subjective knee function, 20 years after injury in anterior cruciate ligament (ACL) injured copers.

METHOD

We examined 32 knees using delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC), 20 years after a complete ACL tear. Only subjects who had coped with the ACL injury without ACL reconstruction (ACLR), and who presented without radiographic signs of osteoarthritis (OA) at an earlier 16-year follow-up, were included in this study. The quality of the central weight-bearing parts of the medial and lateral femoral cartilage was estimated with dGEMRIC (T1Gd). These results were compared with corresponding results in 24 healthy individuals, and with the subjects' self-reported subjective knee function using the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire.

RESULTS

The values of T1Gd in the medial and lateral femoral cartilage of the study group (mean (95% CI)), were 404 (385-423) and 427 (399-455) ms, not statistically different from those of the healthy reference group (P = 0.065 and 0.31). The subjective knee function 20 years after the injury, according to the five domains of the KOOS score, was good, with a mean score of 90 ± 11. Values of T1Gd for the medial femoral cartilage were correlated with the KOOS subgroup QOL (P = 0.021, Pearson correlation).

CONCLUSIONS

Subjects who have managed to cope with their ACL injury for 20 years with sustained good subjective knee function also seem to have knee cartilage of good quality, with T1Gd values not very different from a healthy reference group.

Association between varus alignment and post-traumatic osteoarthritis after anterior cruciate ligament injury

PURPOSE

To investigate the association between varus alignment and post-traumatic osteoarthritis (OA) after an anterior cruciate ligament (ACL) injury.

METHODS

One hundred subjects with an acute complete ACL tear were followed for 15 years. Anterior-posterior radiographs of the tibiofemoral joint were obtained with a knee flexion of 20°, and the patellofemoral joint was examined with skyline view at 50° knee flexion. Joint space narrowing and osteophytes were graded in the tibiofemoral and patellofemoral joints in the injured (ACL) and uninjured knee according to the radiographic atlas of the Osteoarthritis Research Society International. The alignment of the uninjured, contralateral knee was measured at follow-up, using full-limb radiographs of leg with the knee in full extension. Alignment was expressed as the hip-knee-ankle (HKA) angle. Alignment was defined as valgus (HKA ≤178°), neutral (179°-181°) or varus (≥182°).

RESULTS

Data from 68 subjects were included in the analysis. Varus alignment of the uninjured knee at follow-up appeared to be associated with OA of the injured knee 15 years after an ACL injury (odds ratio (95% confidence interval) 3.9 (1.0-15.8, p = 0.052)).

CONCLUSIONS

Varus alignment of the uninjured knee at follow-up may be associated with OA of the injured knee 15 years after an ACL injury.

LEVEL OF EVIDENCE

II.

Effects of neuromuscular training (NEMEX-TJR) on patient-reported outcomes and physical function in severe primary hip or knee osteoarthritis: a controlled before-and-after study

BACKGROUND

The benefits of exercise in mild and moderate knee or hip osteoarthritis (OA) are apparent, but the evidence in severe OA is less clear. We recently reported that neuromuscular training was well tolerated and feasible in patients with severe primary hip or knee OA. The aims of this controlled before-and-after study were to compare baseline status to an age-matched population-based reference group and to examine the effects of neuromuscular training on patient-reported outcomes and physical function in patients with severe primary OA of the hip or knee.

METHODS

87 patients (60-77 years) with severe primary OA of the hip (n = 38, 55% women) or knee (n = 49, 59% women) awaiting total joint replacement (TJR) had supervised, neuromuscular training (NEMEX-TJR) in groups with individualized level and progression of training. A reference group (n = 43, 53% women) was included for comparison with patients' data. Assessments included self-reported outcomes (HOOS/KOOS) and measures of physical function (chair stands, number of knee bends/30 sec, knee extensor strength, 20-meter walk test) at baseline and at follow-up before TJR. Analysis of covariance (ANCOVA) was used for comparing patients and references and elucidating influence of demographic factors on change. The paired t-test was used for comparisons within groups.

RESULTS

At baseline, patients reported worse scores than the references in all HOOS/KOOS subscales (hip 27-47%, knee 14-52%, of reference scores, respectively) and had functional limitations (hip 72-85%, knee 42-85%, of references scores, respectively). NEMEX-TJR (mean 12 weeks (SD 5.6) of training) improved self-reported outcomes (hip 9-29%, knee 7-20%) and physical function (hip 3-18%, knee 5-19%) (p < 0.005). Between 42% and 62% of hip OA patients, and 39% and 61% of knee OA patients, displayed a clinically meaningful improvement (≥15%) in HOOS/KOOS subscales by training. The improvement in HOOS/KOOS subscale ADL was greater for patients with knee OA than hip OA, while the improvement in subscale Sport/Rec was greater for patients with hip OA than knee OA.

CONCLUSIONS

Both self-reported outcomes and physical function were clearly worse compared with the reference group. Neuromuscular training with an individualized approach and gradual progression showed promise for improving patient-reported outcomes and physical function even in older patients with severe primary OA of the hip or knee.

Guideline on anterior cruciate ligament injury

The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury. The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association. What is the role of physical examination and additional diagnostic tools? Which patient-related outcome measures should be used? What are the relevant parameters that influence the indication for an ACL reconstruction? Which findings or complaints are predictive of a bad result of an ACL injury treatment? What is the optimal timing for surgery for an ACL injury? What is the outcome of different conservative treatment modalities? Which kind of graft gives the best result in an ACL reconstruction? What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy? These 8 questions were answered and recommendations were made, using the "Appraisal of Guidelines for Research and Evaluation" instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.

Principles of brain plasticity in improving sensorimotor function of the knee and leg in patients with anterior cruciate ligament injury: a double-blind randomized exploratory trial

Background

Severe traumatic knee injury, including injury to the anterior cruciate ligament (ACL), leads to impaired sensorimotor function. Although improvements are achieved by training, impairment often persists. Because good sensorimotor function is associated with better patient-reported function and a potential lower risk of future joint problems, more effective treatment is warranted. Temporary cutaneous anesthesia of adjacent body parts was successfully used on the hand and foot to improve sensorimotor function. The aim of this study was to test whether this principle of brain plasticity could be used on the knee. The hypothesis was that temporary anesthesia of the skin area above and below the knee would improve sensorimotor function of the ipsilateral knee and leg in subjects with ACL injury.

Methods

In this double-blind exploratory study, 39 subjects with ACL injury (mean age 24 years, SD 5.2, 49% women, mean 52 weeks after injury or reconstruction) and self-reported functional limitations and lack of trust in the knee were randomized to temporary local cutaneous application of anesthetic (EMLA®) (n = 20) or placebo cream (n = 19). Fifty grams of EMLA®, or placebo, was applied on the leg 10 cm above and 10 cm below the center of patella, leaving the area around the knee without cream. Measures of sensory function (perception of touch, vibration sense, knee kinesthesia) and motor function (knee muscle strength, hop test) were assessed before and after 90 minutes of treatment with EMLA® or placebo. The paired t-test was used for comparisons within groups and analysis of variance between groups, except for ordinal data where the Wilcoxon signed rank test, or Mann–Whitney test, was used. The number of subjects needed was determined by an a priori sample size calculation.

Results

No statistically significant or clinically relevant differences were seen over time (before vs. after) in the measures of sensory or motor functions in the EMLA® group or in the placebo group. There were no differences between the groups due to treatment effect (EMLA® vs. placebo).

Conclusions

Temporary cutaneous anesthesia of adjacent body parts had no effect in improving sensorimotor function of the knee and leg in subjects with severe traumatic knee ligament injury.

Neuromuscular training for rehabilitation of sports injuries: a systematic review

PURPOSE

Although proprioceptive and neuromuscular exercises are considered to be part and parcel of rehabilitation programs after sport injuries, there is an uncertainty regarding the effectiveness of corresponding training interventions. The objective of this review was to evaluate the effectiveness of proprioceptive and neuromuscular training (PT/NT) for the treatment of ankle, knee, and shoulder joint injuries.

METHODS

Two independent reviewers performed a literature search in various databases and reference lists of articles. Data of included trials were then extracted, and methodological quality was assessed by using predetermined forms.

RESULTS

Fifteen trials met the inclusion criteria. PT/NT was effective at increasing functionality as well as at decreasing the incidence of recurrent injuries and "giving way" episodes after ankle sprains and in conservative treatment of anterior cruciate ligament injuries. However, conflicting results or no efficacy of training were reported for static postural control, joint position sense, neuromuscular control, joint laxity, and lower extremity strength. No study that examined PT/NT after shoulder injuries was found.

CONCLUSIONS

From this review, it can be concluded that proprioceptive and neuromuscular interventions after ankle and knee joint injuries can be effective for the prevention of recurrent injuries and the improvement of joint functionality.

WITHDRAWN: Exercise for treating anterior cruciate ligament injuries in combination with collateral ligament and meniscal damage of the knee in adults

BACKGROUND

The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. The ACL may be damaged in isolation but often other ligaments and menisci are implicated. The injury may be managed surgically or conservatively. Injury causes pain, effusion and inflammation leading to alteration in muscle function. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation.

OBJECTIVES

To present the best evidence for effectiveness of exercise used in the treatment of ACL injuries in combination with collateral ligament and meniscal damage to the knee in adults, on return to work and pre-injury levels of activity.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2006), Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1996 to October 2006), EMBASE (1980 to October 2006), other databases and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised trials testing exercise programmes designed to treat adults with ACL injuries in combination with collateral ligament and meniscal damage. Included trials randomised participants to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Five trials (243 participants) evaluated different exercise programmes following ACL reconstruction and one trial (100 participants) compared supervised with self-monitored exercises as part of conservative treatment. No study compared the effect of exercise versus no exercise. Methodological quality scores varied considerably across the trials; participant and assessor blinding were poorly reported. Pooling of data was rarely possible due to the wide variety of comparisons, outcome measures and time points reported, and lack of appropriate data. Insufficient evidence was found to support the efficacy of one exercise intervention over another.

AUTHORS' CONCLUSIONS

This review has demonstrated an absence of evidence to support one form of exercise intervention over another. Further research should be considered in the form of large scale well-designed and well-reported randomised controlled trials with suitable outcome measures and surveillance periods. Suitable outcome measures should include a measure of functional outcome relevant to the individual.

WITHDRAWN: Exercise for treating isolated anterior cruciate ligament injuries in adults

BACKGROUND

The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. Injury causes pain, effusion and inflammation leading to the inability to fully activate the thigh muscles. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation.

OBJECTIVES

To present the best evidence for effectiveness of exercise used in the rehabilitation of isolated ACL injuries in adults, on return to work and pre-injury levels of activity.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (Feb 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2005), MEDLINE (1996 to March 2005), EMBASE (1980 to March 2005), other databases and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials testing exercise programmes designed to rehabilitate adults with isolated ACL injuries. Trials where participants were randomised to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions, were included. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Nine trials involving 391 participants were included. Only two trials, involving 76 participants, reported conservative rehabilitation and seven trials, involving 315 participants, evaluated rehabilitation following ACL reconstruction. Methodological quality scores varied considerably across the trials, with the nature of participant and assessor blinding poorly reported. Trial comparisons fell into six categories. Pooling of data was rarely possible due to lack of appropriate data as well as the wide variety in outcome measures and time points reported. Insufficient evidence was found to support the efficacy of one exercise intervention over another.

AUTHORS' CONCLUSIONS

This review has demonstrated an absence of evidence to support one form of exercise intervention against another and the use of supplementary exercises in the management of isolated ACL injuries. Further research in the form of large scale well designed randomised controlled trials with suitable outcome measures and surveillance periods, using standardised reporting should be considered.

The influence of posterior-inferior tibial slope in ACL injury

PURPOSE

To explore the effect of different posterior-inferior tibial slope (PITS) angles on ACL injury at non-contact sports, knee laxity and the need for ACL reconstruction.

METHODS

One hundred patients with an acute, arthroscopically verified total ACL rupture were followed prospectively with the intention of treating the injury without reconstruction. Knee laxity was assessed with the Lachman and pivot shift tests with the patients under general anesthesia within 10 days of injury. After 15 years, 22 patients of 94 available for follow-up had undergone reconstruction a mean of 4 years after injury. Reconstruction was performed in case of repeated giving-way episodes (n = 16) or meniscus lesions suitable for fixation (n = 6). Knee radiographs were available from 82 patients. Two independent readers determined the PITS angle.

RESULTS

Patients injured in contact sports had a greater mean PITS angle than those injured in non-contact sports (10.5° and 9.3°, respectively, P = 0.03). The mean PITS angle was 10.1 (SD = 2.3) for non-reconstructed knees and 9.1 (SD = 3.0) for reconstructed knees (P = NS). Eight of 17 reconstructed knees showed a PITS angle of less than 7.6° (P = 0.006), and the odds ratio of need for reconstruction was 3.9 (CI 1.26-12.3, P = 0.02). No significant difference in PITS angle was found between patients with low- and high-grade instability.

CONCLUSION

The main finding of the study was that reconstructed knees were overrepresented in knees with extremely low PITS angles. Additionally, patients injured in contact sports had higher PITS angles than those injured in non-contact sports, and PITS angle did not influence knee laxity.

Feasibility of neuromuscular training in patients with severe hip or knee OA: the individualized goal-based NEMEX-TJR training program

Background

Although improvements are achieved by general exercise, training to improve sensorimotor control may be needed for people with osteoarthritis (OA). The aim was to apply the principles of neuromuscular training, which have been successfully used in younger and middle-aged patients with knee injuries, to older patients with severe hip or knee OA. We hypothesized that the training program was feasible, determined as: 1) at most acceptable self-reported pain following training; 2) decreased or unchanged pain during the training period; 3) few joint specific adverse events related to training, and 4) achieved progression of training level during the training period.

Methods

Seventy-six patients, between 60 and 77 years, with severe hip (n = 38, 55% women) or knee OA (n = 38, 61% women) underwent an individualized, goal-based neuromuscular training program (NEMEX-TJR) in groups for a median of 11 weeks (quartiles 7 to 15) prior to total joint replacement (TJR). Pain was self-reported immediately after each training session on a 0 to 10 cm, no pain to pain as bad as it could be, scale, where 0-2 indicates safe, > 2 to 5 acceptable and > 5 high risk pain. Joint specific adverse events were: not attending or ceasing training because of increased pain/problems in the index joint related to training, and self-reported pain > 5 after training. The level of difficulty of training was registered.

Results

Patients with severe OA of the hip or knee reported safe pain (median 2 cm) after training. Self-reported pain was lower at training sessions 10 and 20 (p = 0.04) and unchanged at training sessions 5 and 15 (p = 0.170, p = 0.161) compared with training session 1. There were no joint specific adverse events in terms of not attending or ceasing training. Few patients (n = 17, 22%) reported adverse events in terms of self-reported pain > 5 after one or more training sessions. Progression of training level was achieved over time (p < 0.001).

Conclusions

The NEMEX-TJR training program is feasible in patients with severe hip or knee OA, in terms of safe self-reported pain following training, decreased or unchanged pain during the training period, few joint specific adverse events, and achieved progression of training level during the training period.

Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials

PURPOSE

The primary aim was to investigate and assess the current evidence of randomized controlled trials (RCTs) on anterior cruciate ligament (ACL) injuries, with special reference to the choice of surgical techniques and aspects of rehabilitation. A secondary aim was to clarify relative strengths and weaknesses of the selected studies, resolve literature conflicts, and finally, evaluate the need for further studies.

METHODS

A PubMed database search using the key words "anterior cruciate ligament" was performed. The search was limited to only RCTs published in English during the period of January 1995 to March 2009. Articles concerning surgical technique and rehabilitation were obtained. After initial screening and subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 70 articles were included in this review.

RESULTS

Initial graft tension and the use of a ligament augmentation device do not affect clinical outcome. Bioabsorbable screws and titanium screws produced equal clinical outcome, regardless of graft type. Radiographic signs of osteoarthritis develop in 50% of ACL-injured patients, regardless of treatment. Meniscectomy further increases the risk. Furthermore, the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. Closed kinetic chain exercises produced less pain and laxity while promoting better subjective outcome than open kinetic chain exercises after patellar tendon reconstruction.

CONCLUSIONS

In terms of quality assessment, several weaknesses pertaining to study design were discovered among the included RCTs, which intelligibly stress the need for further high-quality studies.

LEVEL OF EVIDENCE

Level II, systematic review of RCTs.

Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study

BACKGROUND

The occurrence of osteoarthritis (OA), associated meniscal injuries, meniscectomy, and patient-related measures for patients treated nonoperatively after anterior cruciate ligament (ACL) injuries have not been well described in the literature in terms of natural history.

HYPOTHESIS

Patients with ACL injury can achieve a low occurrence of tibiofemoral OA and good knee function when treated without ACL reconstruction.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

One hundred consecutive patients with an acute, complete ACL injury were observed for 15 years. All patients were primarily treated with activity modification and without ACL reconstruction. To achieve improved functional stability, supervised physical therapy was initiated early after injury. The patients were examined using anteroposterior weightbearing radiography. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to quantify knee-related symptoms and knee function.

RESULTS

Seventy-nine patients consented to radiographic examination and 93 completed the KOOS questionnaire. Thirteen patients (16%), all of whom were among the 35 patients whose knees were meniscectomized, developed radiographic tibiofemoral OA. In contrast, none of the remaining nonmeniscectomized and radiographed knees developed OA (n = 44) (P < .0001). Sixty-three patients (68%) had an asymptomatic knee. Twenty-two patients (23%) had undergone ACL reconstruction with a mean time of 4 years after injury.

CONCLUSION

The study had a favorable long-term outcome regarding incidence of radiographic knee OA, knee function and symptoms, and need for ACL reconstruction. Although risk factors for posttraumatic OA are multifactorial, the primary risk factor that stood out in this study was if a meniscectomy had been performed. Early activity modification and neuromuscular knee rehabilitation might also have been related to the low prevalence of radiographic knee OA. In patients with ACL injury willing to moderate activity level to avoid reinjury, initial treatment without ACL reconstruction should be considered.

Clinically assessed knee joint laxity as a predictor for reconstruction after an anterior cruciate ligament injury: a prospective study of 100 patients treated with activity modification and rehabilitation

BACKGROUND

The association of early knee joint laxity with the need for later reconstruction of the anterior cruciate ligament has not been extensively studied.

HYPOTHESIS

The grade of knee laxity can be used as an early predictor of the need for later reconstruction.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

One hundred consecutive patients with an acute arthroscopically verified total anterior cruciate ligament rupture were followed prospectively for 15 years. Lachman and pivot-shift tests were performed with the patient under general anesthesia before arthroscopy. After 3 months, the tests were repeated in an ordinary clinical setting. All patients underwent rehabilitation as the first choice of treatment. Anterior cruciate ligament reconstruction was performed only in cases of significant reinjuries (n = 16) or reparable meniscal lesions (n = 6) at a mean of 4 years after injury (range, 4 months-11 years). After 15 years, 94 patients were available for follow-up.

RESULTS

Of the later reconstructed patients (n = 18), 82% had a high-grade Lachman test under anesthesia compared with 63% of the nonreconstructed patients (n = 45; P = .048). At 3 months, 44% of the nonreconstructed patients (n = 32) had a high-grade Lachman test compared with 82% of the reconstructed patients (n = 18; P = .007). Twenty-five patients displayed a normal pivot-shift test at 3 months, of whom 1 underwent later reconstruction (P = .009). A high-grade pivot-shift test at 3 months was associated with an 11.4 relative risk for reconstruction.

CONCLUSION

A positive pivot-shift test at 3 months after injury in an awake patient is the strongest predictor for the future need for reconstruction. Furthermore, a normal pivot-shift test at 3 months indicates a low risk for reconstruction and is characteristic for copers.

Normalized motor function but impaired sensory function after unilateral non-reconstructed ACL injury: patients compared with uninjured controls

Improvement in motor function after anterior cruciate ligament (ACL) injury is achieved by appropriate rehabilitation. However, it has been questioned whether training after injury can lead to sensory improvement. We hypothesized that motor function can be restored after unilateral non-reconstructed ACL injury, whereas the sensory function cannot, i.e., there would be no difference in functional performance or knee muscle strength between subjects with ACL injury and uninjured controls, but the subjects with ACL injury would have poorer kinesthesia than the uninjured controls. This is a Cross-Sectional Study, wherein 56 (20 women and 36 men) individuals with unilateral non-reconstructed ACL injury were assessed at a mean of 15 years (SD 1.4 years) after the initial injury. All patients initially underwent rehabilitation and were advised to modify their activity level, in order to cope with the ACL insufficiency. At 15 years, they had good subjective function and acceptable activity level. Twenty-eight (14 women and 14 men) uninjured subjects served as controls. Patients and controls were assessed with the one-leg hop test for distance, isometric and isokinetic knee muscle strength, and kinesthesia (the threshold to detection of passive motion). The individuals with ACL injury had the same or better functional performance, measured by the one-leg hop test for distance, and knee muscle strength compared with the uninjured controls. Kinesthesia was poorer in the patient group than in the control group. The results indicate that motor function can be restored but that the sensory function is persistently disturbed after ACL injury.

15-year follow-up of neuromuscular function in patients with unilateral nonreconstructed anterior cruciate ligament injury initially treated with rehabilitation and activity modification: a longitudinal prospective study

BACKGROUND

It has been suggested that neuromuscular function is of importance in the overall outcome after anterior cruciate ligament (ACL) injury.

HYPOTHESIS

Good neuromuscular function can be achieved and maintained over time in subjects with ACL injury treated with rehabilitation and activity modification but without reconstructive surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

One hundred consecutive patients (42 women and 58 men) with acute ACL injury at a nonprofessional, recreational or competitive activity level were assessed 1, 3, and 15 years after injury. Their mean age at inclusion was 26 years (range, 15-43 years). All patients initially underwent rehabilitation and were advised to modify their activity level, especially by avoiding contact sports. Patients with recurrent giving-way episodes or secondary meniscal injuries that required fixation were subsequently excluded and underwent reconstruction of the ACL. Sixty-seven patients (71% of those available for follow-up) with unilateral nonreconstructed injury remained at the 15-year follow-up. Fifty-six of these 67 patients were examined with the single-legged hop test for distance and knee muscle strength. The limb symmetry index (LSI), calculated by dividing the result for the injured leg by that of the uninjured leg and multiplying by 100, was used for comparisons over time (paired t test).

RESULTS

The LSI for the single-legged hop test was higher at the 3-year follow-up (mean, 98.5%; standard deviation [SD], 7.6%) than at the 15-year follow-up (mean, 94.8%; SD, 10.5%) (mean difference, -3.7%; 95% confidence interval [CI], -6.1% to -1.2%; P = .004). The LSI for isometric extension was higher at the 15-year follow-up (mean, 97.2%; SD, 13.7%) than at the 1-year follow-up (mean, 88.2%; SD, 15.4%) (mean difference, 9.0%; 95% CI, 3.7% to 14.4%; P = .001). At the 15-year follow-up, between 69% and 85% of the patients had an LSI >or= 90%.

CONCLUSIONS

Good functional performance and knee muscle strength can be achieved and maintained over time in the majority of patients with ACL injury treated with rehabilitation and early activity modification but without reconstructive surgery.

WITHDRAWN: Physiotherapist-led programmes and interventions for rehabilitation of anterior cruciate ligament, medial collateral ligament and meniscal injuries of the knee in adults

BACKGROUND

Soft-tissue injuries of the knee, mainly involving the anterior cruciate ligament (ACL), the medial collateral ligament (MCL) and menisci, are common and their rehabilitation after non-surgical or surgical treatment often involves intensive and prolonged physiotherapy.

OBJECTIVES

To examine the evidence for effectiveness of various physiotherapist-led (or 'directed') rehabilitation programmes, and of various interventions used within these programmes, for rehabilitation of acute or chronic ACL, MCL or meniscal injuries of the knee in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group's specialised register (to June 2001), MEDLINE (from 1966 to August 1999), EMBASE (from 1980 to February 1997), CINAHL (1982 to April 1999), CURRENT CONTENTS (up to March 1999) and reference lists of relevant articles, and consulted colleagues. Date of the most recent search: June 2001.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials evaluating physiotherapist-led rehabilitation programmes, or components of rehabilitation programmes, for the treatment or post-surgical rehabilitation of ACL, MCL or knee meniscal injuries. Excluded were trials investigating electrical stimulation, or various interventions such as cryotherapy, immobilisation braces and continuous passive motion when used in initial or early treatment. Laboratory based trials reporting intermediate outcomes were also excluded.

DATA COLLECTION AND ANALYSIS

All trials, judged as fitting the selection criteria by two reviewers, were independently assessed by two reviewers for methodological quality by use of an 11 item checklist. Data were independently extracted by two reviewers. Any disagreement was resolved by discussion. Although quantitative data from most trials are presented, using relative risks or mean differences together with 95 per cent confidence intervals, trial heterogeneity and lack of outcome data prevented meaningful pooling of results from comparable trials.

MAIN RESULTS

Thirty-one trials, involving 1545 mainly young and male patients, met the inclusion criteria of the review. Methodological quality was highly variable: allocation concealment and / or assessor blinding were rare, and assessment of outcome was often incomplete and short-term. ACL injury and /or deficiency was the main focus of 18 trials, MCL injury of two trials, meniscal injury of nine trials and a mixture of soft-tissue injuries in the other two trials. The trial comparisons fell into five main categories: rehabilitation programme versus control (6 trials); one rehabilitation programme versus another (6 trials); different timing of rehabilitation (4 trials); one component of a programme versus another (6 trials); supplementary interventions to a programme versus none (9 trials). No trial provided sufficient evidence to establish the relative effectiveness of the intervention(s) under investigation.

AUTHORS' CONCLUSIONS

The available evidence for physiotherapist-led rehabilitation of ACL, MCL and meniscal injuries is wide ranging in terms of scope but insufficient to establish the relative effectiveness of the various approaches and methods in current use. There is a need for further research involving good quality, large scale randomised trials with sufficiently long follow-up to fully assess knee function and recovery.

Exercise for treating anterior cruciate ligament injuries in combination with collateral ligament and meniscal damage of the knee in adults

BACKGROUND

The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. The ACL may be damaged in isolation but often other ligaments and menisci are implicated. The injury may be managed surgically or conservatively. Injury causes pain, effusion and inflammation leading to alteration in muscle function. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation.

OBJECTIVES

To present the best evidence for effectiveness of exercise used in the treatment of ACL injuries in combination with collateral ligament and meniscal damage to the knee in adults, on return to work and pre-injury levels of activity.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2006), Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1996 to October 2006), EMBASE (1980 to October 2006), other databases and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised trials testing exercise programmes designed to treat adults with ACL injuries in combination with collateral ligament and meniscal damage. Included trials randomised participants to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Five trials (243 participants) evaluated different exercise programmes following ACL reconstruction and one trial (100 participants) compared supervised with self-monitored exercises as part of conservative treatment. No study compared the effect of exercise versus no exercise. Methodological quality scores varied considerably across the trials; participant and assessor blinding were poorly reported. Pooling of data was rarely possible due to the wide variety of comparisons, outcome measures and time points reported, and lack of appropriate data. Insufficient evidence was found to support the efficacy of one exercise intervention over another.

AUTHORS' CONCLUSIONS

This review has demonstrated an absence of evidence to support one form of exercise intervention over another. Further research should be considered in the form of large scale well-designed and well-reported randomised controlled trials with suitable outcome measures and surveillance periods. Suitable outcome measures should include a measure of functional outcome relevant to the individual.

Activity level and subjective knee function 15 years after anterior cruciate ligament injury: a prospective, longitudinal study of nonreconstructed patients

BACKGROUND

The activity level and subjective knee function after an anterior cruciate ligament (ACL) injury treated without reconstruction have not been well elucidated.

HYPOTHESIS

Patients with ACL injury can achieve good knee function and satisfactory long-term activity level when treated by early activity modification combined with rehabilitation.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

MATERIALS AND METHODS

One hundred patients with an acute total ACL injury were observed for 15 years. All patients initially underwent arthroscopic surgery and a rehabilitation program. They were advised to modify their activity level, especially by avoiding contact sports. Patients with recurrent giving-way episodes and/or secondary meniscal injuries that required fixation (n = 6) were subsequently excluded and underwent reconstruction (n = 22). Sixty-seven patients with unilateral nonreconstructed ACL injury remained at the 15-year follow-up. The Lysholm knee score, Tegner activity level, and a visual analog score for global knee function were recorded at regular intervals. At the final follow-up, patients were further evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective knee evaluation form.

RESULTS

Forty patients resumed their preinjury activity level or higher within 3 years. The median activity level 15 years after injury had decreased from 7 to 4 according to Tegner activity scale (P < .001). The mean Lysholm knee score was 96 and 95, 1 and 3 years after injury, respectively, but declined to 86 after 15 years (P < .001). Forty-nine patients had good/excellent results, and 14 had fair (n = 6) or poor function (n = 8) at 15 years. Patients injured in contact sports scored lower in the quality of life sub-scale of KOOS than those injured in noncontact sports (P < .05). Thirteen of the 67 patients (19%) were reoperated with an arthroscopic procedure because of knee symptoms.

CONCLUSION

Early activity modification and neuromuscular rehabilitation resulted in a good knee function and an acceptable activity level in the majority of the nonreconstructed patients. The decline in activity level of patients engaged in contact sports at the time of injury affected their subjective quality of life more than patients involved in noncontact sports.

Exercise for treating isolated anterior cruciate ligament injuries in adults

BACKGROUND

The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. Injury causes pain, effusion and inflammation leading to the inability to fully activate the thigh muscles. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation.

OBJECTIVES

To present the best evidence for effectiveness of exercise used in the rehabilitation of isolated ACL injuries in adults, on return to work and pre-injury levels of activity.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PEDro - The Physiotherapy Evidence Database, CINAHL, AMED, and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials testing exercise programmes designed to rehabilitate adults with isolated ACL injuries. Trials where participants were randomised to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year.

DATA COLLECTION AND ANALYSIS

All trials judged to have met the inclusion criteria were independently assessed for methodological quality by use of a 15 point checklist. Pairs of authors independently extracted data. For each study, relative risk and 95% confidence intervals were calculated for dichotomous outcomes and mean differences and 95% confidence intervals calculated for continuous outcomes.

MAIN RESULTS

Nine trials, involving 391 participants met the inclusion criteria of the review. Only two trials, involving 76 participants, reported conservative rehabilitation and seven trials, involving 315 participants, evaluated rehabilitation following ACL reconstruction. Methodological quality scores varied considerably across the trials, with the nature of participant and assessor blinding poorly reported. Trial comparisons fell into six categories. Pooling of data was rarely possible due to lack of appropriate data as well as the wide variety in outcome measures and time points reported. Insufficient evidence was found to support the efficacy of one exercise intervention over another.

AUTHORS' CONCLUSIONS

This review has demonstrated an absence of evidence to support one form of exercise intervention against another and the use of supplementary exercises in the management of isolated ACL injuries. Further research in the form of large scale well designed randomised controlled trials with suitable outcome measures and surveillance periods, using standardised reporting should be considered.

Consequences of a ligament injury on neuromuscular function and relevance to rehabilitation - using the anterior cruciate ligament-injured knee as model

The purpose of this article is to survey current knowledge concerning the consequences of a ligament injury on neuromuscular function and its relevance to rehabilitation, in relation to clinical practice. Although it deals with the ACL-injured knee, these views may also apply to other joints. The effects of a ligament injury on neuromuscular function are first considered - i.e., proprioception, postural control, muscle strength, functional performance, movement and activation pattern, central mechanisms, motor control and learning. The treatment and effects of rehabilitation on neuromuscular function are then discussed. The survey is concluded by discussing the clinical significance.

Dynamic knee stability: current theory and implications for clinicians and scientists

We will discuss the mechanisms by which dynamic knee stability may be achieved and relate this to issues that interest clinicians and scientists concerned with dynamic knee stability. Emphasis is placed on the neurophysiologic evidence and theory related to neuromuscular control. Specific topics discussed include the ensemble firing of peripheral mechanoreceptors, the potential for muscle stiffness modulation via force and length feedback, postural control synergies, motor programs, and the neural control of gait. Factors related to answering the difficult question of whether or not knee ligament injuries can be prevented during athletic activities are discussed. Prevention programs that train athletes to perform their sport skills in a safe fashion are put forth as the most promising prospect for injury prevention. Methods of assessing neuromuscular function are reviewed critically and the need for future research in this area is emphasized. We conclude with a brief review of the literature regarding neuromuscular training programs.