Whole-Body Vibration on Performance of Quadriceps After ACL Reconstruction: A Blinded Randomized Controlled Trial

Quadriceps Activation After Anterior Cruciate Ligament Reconstruction: The Early Bird Gets the Worm!

Arthrogenic Muscle Inhibition (AMI) is a phenomenon observed in individuals with joint injury or pathology, characterized by a reflexive inhibition of surrounding musculature, altered neuromuscular control, and compromised functional performance. After anterior cruciate ligament reconstruction (ACLR) one of the most obvious consequences of AMI is the lack of quadriceps activation and strength. Understanding the underlying mechanisms of AMI is crucial for developing effective therapeutic interventions. The surgical procedure needed to reconstruct the ACL has biochemical et physiological consequences such as inflammation, pain, and altered proprioception. These alterations contribute to the development of AMI. Therapeutic interventions aimed at addressing AMI encompass a multidimensional approach targeting pain reduction, inflammation management, proprioceptive training, and quadriceps activation. Early management focusing on pain modulation through modalities like ice, compression, and pharmacological agents help mitigate the inflammatory response and alleviate pain, thereby reducing the reflexive inhibition of quadriceps. Quadriceps activation techniques such as neuromuscular electrical stimulation (NMES) and biofeedback training aid in overcoming muscle inhibition and restoring muscle strength. NMES elicits muscle contractions through electrical stimulation, bypassing the inhibitory mechanisms associated with AMI, thus facilitating muscle activation and strength gains. Comprehensive rehabilitation programs tailored to individual needs and stage of recovery are essential for optimizing outcomes in AMI. The objective of this clinical viewpoint is to delineate the significance of adopting a multimodal approach for the effective management of AMI, emphasizing the integration of pain modulation, proprioceptive training, muscle activation techniques, and manual therapy interventions. Highlighting the critical role of early intervention and targeted rehabilitation programs, this article aims to underscore their importance in restoring optimal function and mitigating long-term complications associated with AMI.

Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction

This guideline was developed to inform clinical practice on rehabilitation after anterior cruciate ligament reconstruction (ACLR) and was performed in accordance with the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A Guideline Development Group systematically searched and reviewed evidence using randomised clinical trials and systematic reviews to evaluate the effectiveness of rehabilitation interventions and guide clinicians and patients on the content of the optimal rehabilitation protocol after ACLR.The guideline targets patients during rehabilitation after ACLR and investigates the effectiveness of the available interventions to the physiotherapist, alone or in combination (eg, exercise, modalities, objective progression criteria). Exercise interventions should be considered the mainstay of ACLR rehabilitation. However, there is little evidence on the dose-response relationship between volume and/or intensity of exercise and outcomes. Physical therapy modalities can be helpful as an adjunct in the early phase of rehabilitation when pain, swelling and limitations in range of motion are present. Adding modalities in the early phase may allow earlier pain-free commencement of exercise rehabilitation. Return to running and return to training/activity are key milestones for rehabilitation after ACLR. However, there is no evidence on which progression or discharge criteria should be used.While there is a very low level of certainty for most components of rehabilitation, most of the recommendations provided in this guideline were agreed to by expert clinicians. This guideline also highlights several new elements of ACLR management not reported previously.

Does the Addition of Whole-Body Vibration Training Improve Postural Stability and Lower Limb Strength During Rehabilitation Following Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis

OBJECTIVES

To investigate whether the addition of whole-body vibration therapy to standard rehabilitation improves postural stability and lower limb strength following anterior cruciate ligament (ACL) reconstruction.

DATA SOURCES

A computer-based literature search of MEDLINE, AMED, SPORTDiscus, Embase, CINAHL, CENTRAL, and Physiotherapy Evidence Database (PEDro) included studies up to October 2019.

MAIN RESULTS

Seven randomised controlled trials of moderate-to-high methodological quality involving 244 participants were included. Meta-analysis found statistically significant improvements in medial-lateral stability [standardized mean difference (SMD) = 0.50; 95% confidence interval (CI), 0.12-0.88] and overall stability (SMD = 0.60; 95% CI, 0.14-1.06) favoring whole-body vibration therapy, but effects were not significant for quadriceps strength (SMD = 0.24; 95% CI, -0.65 to 1.13), hamstring strength (SMD = 0.84; 95% CI, -0.05 to 1.72), lower limb strength (SMD = 0.76; 95% CI, -0.16 to 1.67), or anterior-posterior stability (SMD = 0.19; 95% CI, -0.39 to 0.76).

CONCLUSIONS

The addition of whole-body vibration therapy to standard postoperative rehabilitation following ACL reconstruction does not appear to significantly improve lower limb strength and anterior-posterior stability but may improve medial-lateral and overall postural stability. We found small sample sizes in all included trials, statistical heterogeneity, and methodological quality concerns, including publication bias, suggesting that larger high-quality trials are likely to be influential in this field. Registration: PROSPERO 155531.

Local vibration training improves the recovery of quadriceps strength in early rehabilitation after anterior cruciate ligament reconstruction: A feasibility randomised controlled trial

BACKGROUND

After anterior cruciate ligament reconstruction (ACLR), quadriceps strength must be maximised as early as possible.

OBJECTIVES

We tested whether local vibration training (LVT) during the early post-ACLR period (i.e., ∼10 weeks) could improve strength recovery.

METHODS

This was a multicentric, open, parallel-group, randomised controlled trial. Thirty individuals attending ACLR were randomised by use of a dedicated Web application to 2 groups: vibration (standardised rehabilitation plus LVT, n=16) or control (standardised rehabilitation alone, n=14). Experimenters, physiotherapists and participants were not blinded. Both groups received 24 sessions of standardised rehabilitation over ∼10 weeks. In addition, the vibration group received 1 hour of vibration applied to the relaxed quadriceps of the injured leg at the end of each rehabilitation session. The primary outcome - maximal isometric strength of both injured and non-injured legs (i.e., allowing for limb asymmetry measurement) - was evaluated before ACLR (PRE) and after the 10-week rehabilitation (POST).

RESULTS

Seven participants were lost to follow-up, so data for 23 participants were used in the complete-case analysis. For the injured leg, the mean (SD) decrease in maximal strength from PRE to POST was significantly lower for the vibration than control group (n=11, -16% [10] vs. n=12, -30% [11]; P=0.0045, Cohen's d effect size=1.33). Mean PRE-POST change in limb symmetry was lower for the vibration than control group (-19% [11] vs. -29% [13]) but not significantly (P=0.051, Cohen's d effect size=0.85).

CONCLUSION

LVT improved strength recovery after ACLR. This feasibility study suggests that LVT applied to relaxed muscles is a promising modality of vibration therapy that could be implemented early in ACLR.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02929004.

Effects of Whole-Body Vibration Training on Knee Muscle Strength After Anterior Cruciate Ligament Reconstruction: A Critically Appraised Topic

Clinical Scenario: Knee muscle strength weakness after anterior cruciate ligament (ACL) reconstruction is the most commonly seen impairment. Whole-body vibration (WBV) training has been shown to improve muscle strength in both healthy and injured individuals. However, it is not clear yet if WBV training has a beneficial effect in knee muscle strength recovery after ACL reconstruction. Clinical Question: Is adding WBV training to conventional rehabilitation more effective than conventional rehabilitation at improving quadriceps and hamstring muscles strength in individuals who have undergone ACL reconstruction? Summary of Key Findings: After the literature was reviewed, 4 randomized controlled trials met the inclusion criteria and were included in this critically appraised topic. Clinical Bottom Line: There is moderate- to high-quality evidence to support that adding WBV to conventional rehabilitation programs can result in better improvement in knee muscle strength after ACL reconstruction. Strength of Recommendation: Findings from 4 randomized controlled trials indicate that there is level B evidence supporting that WBV is effective for knee muscle strength recovery in patients who had undergone ACL reconstruction.

The effectiveness of vibration therapy for muscle peak torque and postural control in individuals with anterior cruciate ligament reconstruction: a systematic review and meta-analysis of clinical trials

Objective

This study aimed to review and summarize the existing evidence on the effectiveness of vibration therapy (VT) in comparison with conventional rehabilitation in anterior cruciate ligament (ACL)-reconstructed patients considering muscle peak torque and postural control.

Methods

We searched available online databases for relevant studies published up to February 2020. All randomized clinical trials investigating the effect of VT on quadriceps peak torque, hamstring peak torque, and postural control (closed-eye and open-eye) were included. Overall, 13 clinical trials with a total sample size of 407 participants were included for the meta-analysis. We used the pooled mean difference with random effects model for meta-analyses. We assessed the heterogeneity of the studies using the I² and Cochran’s Q test. Meta-regression analysis was used to assess the source of heterogeneity.

Results

We found that VT significantly improved hamstring peak torque [weighted mean difference (WMD) 12.67, 95% CI 4.51–20.83] and quadriceps peak torque (WMD 0.11, 95% CI −0.06 to 0.29). However, subgroup analysis showed a significant increase in mentioned muscles’ peak torque in studies employing interventions including both local muscle vibration (LMV) and vibration frequency higher than 100 Hz (WMD 20.84, 95% CI 11.75–29.93). With regard to postural control, we observed a significant improvement only in open-eye mediolateral postural control (WMD 0.26, 95% CI −1.26 to 1.77).

Conclusion

This study suggests that VT, especially LMV type with vibration frequency higher than 100 Hz, can be effective in rehabilitation of ACL-reconstructed patients. Although improvement in the peak torque of hamstring and quadriceps muscles was seen, there was no significant improvement in postural control, especially closed-eye, in comparison with conventional rehabilitation.

Level of evidence

1.

Highlights

Vibration therapy can increase hamstring peak torque in individuals with ACL reconstruction.

Local muscle vibration type in comparison with whole-body vibration is recommended for ACL-reconstructed patients.

Vibration frequency higher than 100 Hz is preferred in ACL-reconstructed rehabilitation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-021-00589-5.

Effects of Whole-Body Vibration Therapy on Quadriceps Function in Patients With Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

Quadriceps dysfunction is common for patients after anterior cruciate ligament reconstruction (ACLR). Whole-body vibration (WBV) could effectively treat quadriceps dysfunction.

OBJECTIVE

To summarize WBV protocols for patients with ACLR and to evaluate the effects of WBV on quadriceps function.

DATA SOURCES

PubMed, CINAHL, SportDiscus, Web of Science, Medline, and Embase were searched from inception to January 2020.

STUDY SELECTION

Randomized controlled trials recruiting patients with ACLR, using WBV as intervention, and reporting at least 1 of the following outcomes, strength, rate of torque development (RTD), and voluntary activation ratio of quadriceps, were included.

STUDY DESIGN

Systematic review.

EVIDENCE LEVEL

Level 3.

METHODS

This systematic review was reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality of evidence was determined by PEDro criteria and GRADE system. Participant characteristics, interventions, and the relevant results of the included studies were extracted and synthesized in a narrative way.

RESULTS

In total, 8 studies were included. Of these, 2 studies had serious risk of bias. Five of 8 studies implemented a series of WBV program ranging from 2 to 10 weeks in duration, while the other 3 studies implemented a single session of WBV. Eight WBV protocols were reported. The reported outcomes consisted of quadriceps strength, RTD, and central activation ratio. WBV protocols were heterogeneous. Low quality of evidence supported that exclusive conventional rehabilitation was more effective than exclusive WBV therapy in increasing quadriceps strength. Low quality of evidence supported that WBV combined with conventional rehabilitation was more beneficial in increasing quadriceps strength when compared with conventional rehabilitation alone. Very low quality of evidence supported the efficacy of a single session of WBV on quadriceps function.

CONCLUSIONS

There is no standardized WBV protocol for patients with ACLR, and the effectiveness of WBV in rehabilitation on quadriceps function remains inconclusive.

Whole-Body Vibration for Individuals with Reconstructed Anterior Cruciate Ligament: A Systematic Review

Background

ACL ruptures are a prevalent condition, affecting daily living activities, associated with high financial burden.

Objective

To assess the effect of whole-body vibration (WBV) in the rehabilitation of patients with reconstructed anterior cruciate ligament. Methodology. An electronic search in Pubmed, Scopus, Web of Science, and PEDro databases was conducted and randomized controlled trials (RCTs) in humans that analysed the effects of WBV in patients with ACL injury subjected to reconstruction surgery, published in English, Portuguese, Spanish, Italian, or French were included. Records were identified through database search and reference screening by two reviewers, which independently examined titles and abstracts and irrelevant studies were excluded based in eligibility criteria. Relevant full texts were analysed for eligibility, and all relevant studies were included in the systematic review.

Results

Ten studies were included in the systematic review with a mean methodological quality score of 6. Results demonstrate positive effects of WBV in relevant outcomes such as knee function, electromyographic activity, balance, and muscle strength.

Conclusions

WBV demonstrated a positive effect in strength, balance, electromyographic activity, and knee function.

Correlation of force sense error test measured by a pressure biofeedback unit and EMG activity of quadriceps femoris in healthy individuals

BACKGROUND

Our study developed a force sense error test (FSET) method for use on the quadriceps muscle, which could be employed in clinical practice to correlate the results of quadriceps muscle activity levels determined by surface electromyography (sEMG).

METHODS

Twenty-four healthy individuals were included in the study. A pressure biofeedback unit (PBU) placed under the knee joint, was used for force sense error test (FSET) evaluation. First, a maximum contraction value was determined with the PBU. Next, 50% and 65% of the maximum contraction value were used for the analysis. Concurrently, norm values for the quadriceps muscle activity levels were determined by sEMG. Simultaneously, quadriceps muscle activity levels were recorded while testing the FSET using the PBU. Each measurement was repeated in triplicate, and the average constant errors observed by the PBU were recorded in mmHg.

RESULTS

The FSET for both 50% and 65% of the normal mmHg value determined using the PBU positively correlated with activity change levels in the quadriceps muscle determined by sEMG (p < 0.05).

CONCLUSIONS

The relationship between the FSET measured using PBU and changes in the level of activity in the quadriceps muscle showed that a PBU can be used in clinical practice for proprioceptive evaluation of the knee region.

Effects of Whole-Body Vibration on Lumbar-Abdominal Muscles Activation in Healthy Young Adults: A Pilot Study

BACKGROUND This study investigated how whole-body vibration (WBV), exercise, and their interactions influence core muscle activity in healthy young adults. MATERIAL AND METHODS Twenty-three healthy young adults (8 males and 15 females; age: 21.87±2.33 years) participated in the study. The activities of muscle multifidi (MM), rectus abdominis muscle (RM), erector spinae (ES), abdominis obliquus externus (AOE), and abdominis obliquus internus (AOI) were measured through surface electromyography (sEMG) while participants were performing 4 different exercise forms under 3 WBV conditions (condition 1: 5 Hz, 2 mm; condition 2: 10 Hz, 2 mm; and condition 3: 15 Hz, 2 mm) and a no-WBV condition in single experimental sessions. RESULTS The WBV frequency of 15 Hz is the best vibration stimulation for core muscles in all of the exercises (P<0.05). Single bridge is a better exercise for RM and AOE (P<0.05) compared with other exercises, and crunches is the best exercise for MM, AOI, and ES (P<0.05). Significant interaction effect was observed in different frequencies and exercises (P>0.05) except for AOI (F=0.990, P=0.378). CONCLUSIONS High vibration frequencies can lead to enhanced exercise benefits within an appropriate frequency range, and different exercises have diverse effects on various muscles. Single bridge and crunches are appropriate exercise forms for lumbar-abdominal muscles.