Evaluation of open and closed kinetic chain exercises in rehabilitation following anterior cruciate ligament reconstruction

Effect of open vs. closed kinetic chain exercises in ACL rehabilitation on knee joint pain, laxity, extensor muscles strength, and function: a systematic review with meta-analysis

Anterior cruciate ligament (ACL) injuries are common among physically active individuals, often requiring ACL reconstruction (ACLR) for recovery. Rehabilitating these injuries involves determining the appropriate timing for initiating open kinetic chain (OKC) exercises. Although OKC exercises are effective post-ACLR, their use in rehabilitation remains a subject of debate. Therefore, this study aims to conduct a systematic review to determine whether OKC or closed kinetic chain (CKC) exercises result in differences in laxity, strength of the knee extensor muscle group, function, and functional performance in ACL rehabilitation. Five electronic databases were searched for randomized controlled between-group trials (RCTs). Two reviewers independently evaluated the risk of bias using the PEDro scale. We performed a meta-analysis using a random-effects model or calculated mean differences (fixed-effect) where appropriate. Certainty of evidence was judged using the GRADE approach. The systematic literature search yielded 480 articles, of which 9 met the inclusion criteria. The evidence for all outcomes ranged from very low to low certainty. Across all comparisons, inconsistent results were found in outcome measures related to knee function between OKC and CKC exercises post-ACLR. A significant increase in quadriceps isokinetic strength was found in post-ACLR and ACL-deficient knees in favor of OKC exercises at 3 (p = 0.03) and 4 (p = 0.008) months, respectively. A significant decrease in knee laxity was observed in ACL-deficient knees in favor of OKC at 10 weeks (p = 0.01), although inconsistency was noted at 4 months. Finally, a significant decrease in pain was found in favor of early OKC compared to late OKC (p < 0.003). Additionally, in ACL-deficient knees, low load resistance training (LLRT) OKC showed no significant laxity difference compared to controls (p > 0.05). In contrast, high load resistance training (HLRT) OKC had less laxity than controls at 6 weeks (p = 0.02) but not at 12 weeks (p > 0.05). OKC exercises appear to be superior to CKC for improving quadriceps strength 3-4 months post-injury, whether as a part of conservative or post-surgery rehabilitation. On the other hand, OKC exercises seem to be either superior or equally effective to CKC for improving knee laxity, thus presenting their importance in being included in a rehabilitation protocol from the initial phase.

Systematic Review Registration

PROSPERO [CRD42023475230].

Nurse-Assisted Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction

Despite significant advancements in surgical instruments and operation skills, short- and long-term outcomes following anterior cruciate ligament reconstruction (ACLR) remain unsatisfactory, as many patients fail to return to their pre-injury level of sports. Inadequate ACL rehabilitation is the primary cause of poor outcomes. Nurses have become a crucial element in the rehabilitation process. Although there is no consensus regarding the optimal post-operative rehabilitation protocols, restoring muscle strength and neuromuscular control are consistently the primary goals. This literature review presents nurse-assisted rehabilitation protocols aiming at improving muscle strength and neuromuscular control. The review discusses postoperative rehabilitation, including home-based and supervised rehabilitation, open and closed kinetic chain exercises, eccentric and concentric training, blood flow restriction training, and plyometric training. Each training protocol has its benefits and drawbacks, and should be used cautiously in specific stages of rehabilitation. Neuromuscular training, such as neuromuscular electrical stimulation, neuromuscular control exercises, and vibration therapy, is considered crucial in rehabilitation.

Isokinetic Testing: Why it is More Important Today than Ever

Isokinetics is a proven method to train and objectively assess the capability of muscle groups, particularly at the knee. The current re-injury rates and less than optimal return to sport percentages seen following anterior cruciate ligament surgery highlights the need for greater focus on what tests and methods are used to make these critical decisions. Isokinetics remains the best single method to objectively determine dynamic muscle strength, power, rate of force development and endurance. These factors make it well-suited to play a crucial role in influencing the appropriate patient progression through a rehabilitation program and assisting in determining return to play readiness following injury or surgery. In this article we will discuss why we believe isokinetics is a useful and necessary testing method, and elucidate testing parameters and goals used during knee extension/flexion assessment.

Leaf spring exercise: A safe quadriceps strengthening exercise after anterior cruciate ligament reconstruction

BACKGROUND

Leg extensions should be avoided in the early stages after anterior cruciate ligament reconstruction because the force exerted by the quadriceps muscle leads to anterior tibial displacement. To allow for safe quadriceps training in the knee extension range during this period, we devised the leaf spring exercise, which involves placing subjects in the prone position with their knee slightly flexed and instructing them to perform maximum isometric quadriceps contractions while supporting the proximal region of the lower leg's anterior surface and immobilizing the femur's posterior surface to prevent lifting. The current study aimed to examine the safety of Leaf spring exercise by determining the femur-tibia relationship using ultrasound imaging.

METHODS

This controlled laboratory study included patients with unilateral anterior cruciate ligament-deficient knees (8 men and 8 women; age, 24.2 ± 8.3 years) who were instructed to perform Leaf spring exercise of both lower limbs. We measured the femur-tibia-step-off, which indicates the distance between the last point of the medial and lateral condyles of the femur and posterior margin of the tibial plateau, as a parameter to evaluate anterior tibial displacement via ultrasound diagnostic device. Further, peak torque of the quadriceps muscle was calculated using force measurement device.

FINDINGS

No difference in anterior tibial displacement and peak torque was observed between the uninjured and injured sides during Leaf spring exercise.

INTERPRETATION

Leaf spring exercise may add some strain on the reconstructed anterior cruciate ligament; hence, it can be considered a safe quadriceps exercise in the knee extension range.

The effects of the functional garment on the biomechanics during the single leg drop landing

INTRODUCTION

A functional biomechanics garment (FBG) may help to prevent injury by improved kinematics during motion such as single leg drop landing (SLDL). The purpose of this study was to investigate the effects of the FBG on the biomechanics of SLDL.

METHOD

Seventeen female university basketball players participated. Characteristics of the FBG were designed based on biomechanics during weight-loaded performance of human movement. The average values of lower limb kinematics and kinetics in the sagittal and frontal planes from 3 SLDL with and without FBG were measured and compared.

RESULTS

The maximum varus angle of the knee showed a significant difference between the use of FBG (15.3 ± 15.1°) and without the use of FBG (5.9 ± 15.4°), the flexion angular displacement of the hip (with FBG, 21.5 ± 8.1°; without FBG, 24.0 ± 6.7°) between with and without FBG. The moment of the hip with FGB (1.1 ± 0.6 Nm) was significantly smaller than without FGB (1.4 ± 0.8 Nm).

DISCUSSION

Regarding function of the FBG, the rigid part of the hip could counter the excessive adduction and flexion of the hip, and the elastic part of the thigh could support the varus moment when the elastic part stretched. Therefore, the subjects with FBG could control the frontal motion of the knee, which has a risk of knee injury, such as the dynamic valgus of the knee during the SLDL.

CONCLUSION

Use of the FBG decreases dynamic knee valgus, which reduces risk of knee injury.

Retrograde Training: Effects on Lower Body Strength and Power

Backward walking and running on positive grades (retrograde training) represents a closed kinetic chain exercise used by rehabilitation specialists for patellofemoral-related injuries. To date, no longitudinal studies exist to support it use. This investigation examined the effects of retrograde training on lower body strength and power in recreational athletes aged 18-50 years over 6 weeks. Thirty-seven subjects were divided into two groups. Group 1 performed retrograde training 3 days∙wk^-1 using treadmill speeds, grades and bout durations ranging from 1.6-4.9 m∙sec^-1, 2.5-27.5% and 10-30 seconds, respectively (RG, n=19). Group 2 was a control group who continued their normal training (CON, n=18). Pre- and posttests assessed a variety of unilateral and bilateral measures including vertical and linear jumps, one repetition maximum leg press strength, and positive and negative power during weighted squat jumping on a horizontal leg press with a force plate. RG improved significantly in all tests (P<0.05). Mean effect size (ES) of the relative improvement in a majority of tests revealed a moderate to very large ES of RG training (ES range: 0.77-2.71). We conclude retrograde training effective for improving lower body strength and power in recreational athletes.

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.

Anterior Cruciate Ligament Reconstruction Recovery and Rehabilitation: A Systematic Review

BACKGROUND

The success of anterior cruciate ligament (ACL) reconstruction is influenced by effective rehabilitation. Previously published, comprehensive systematic reviews evaluating rehabilitation after ACL reconstruction have studied Level-I and II evidence published through 2012. Interval studies continue to evaluate the efficacy of various rehabilitative modalities.

METHODS

A total of 824 articles from 2012 to 2020 were identified using multiple search engines. Fifty Level-I or II studies met inclusion criteria and were evaluated using the Consolidated Standards of Reporting Trials (CONSORT) criteria and National Institutes of Health (NIH) Study Quality Assessment Tools.

RESULTS

Accelerated rehabilitation can be effective for patients with semitendinosus-gracilis grafts. Blood flow restriction (BFR) training with high-intensity exercise is not effective for ACL reconstruction recovery. Postoperative bracing does not offer any advantages or improve limb asymmetry. Cryotherapy is an effective analgesic when used perioperatively. The early introduction of open kinetic chain exercises may improve ACL reconstruction outcomes, and high-intensity plyometric exercise is not effective. Estimated pre-injury capacity (EPIC) levels may be more accurate than the Limb Symmetry Index (LSI) when using functional test results to predict reinjury rates, and hip external rotation strength may be the most accurate predictor of the hop test performance. Nerve blocks can provide postoperative analgesia with minimal complication risk. Neuromuscular electrical stimulation is effective when used independently and in combination with rehabilitative exercises. Psychological readiness should be evaluated both objectively and subjectively before allowing patients to safely return to sport. Electromyography biofeedback may help to regain muscular function, and whole-body vibration therapy can improve postural control. Supervised rehabilitation is more effective than unsupervised rehabilitation.

CONCLUSIONS

Various rehabilitative modalities following ACL reconstruction are effective in improving surgical outcomes and return-to-sport rates. Further evidence and improved study design are needed to further validate modalities including accelerated rehabilitation, BFR training, functional testing, and return-to-sport criteria.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Six-Week Remodeled Bike Pedal Training Improves Dynamic Control of Lateral Shuffling in Athletes With Functional Ankle Instability

BACKGROUND

Remodeled bicycle pedal training with multidirectional challenges through muscle strengthening and neuromuscular facilitation may increase dynamic postural control and performance during lateral shuffling for athletes with functional ankle instability (FAI).

HYPOTHESIS

The 6-week remodeled bicycle pedal training is effective on the ankle joint control and muscle activation, and especially that of the ankle evertor muscle co-contraction to improve dynamic postural control during lateral shuffling for athletes with FAI.

STUDY DESIGN

Laboratory randomized controlled trial.

LEVEL OF EVIDENCE

Level 2.

METHODS

Fourteen healthy athletes (healthy group) and 26 athletes with FAI aged 18 to 30 years were included in the study. The athletes with FAI were randomly assigned to either the training group (FAI-T group) or the nontraining group (FAI-NT group). The athletes in the FAI-T group underwent 6 weeks of remodeled bicycle pedal training, whereas those in the FAI-NT group did not undergo any intervention. Muscle co-contraction index and muscle activation in the initial contact (IC) and propulsion phases, and ankle joint angle in the IC and propulsion phases were measured during lateral shuffling before and after 6 weeks of training.

RESULTS

After remodeled bicycle pedal training, the FAI-T group demonstrated greater muscle activation in the hamstring (P = 0.01), greater muscle coactivation of the tibialis anterior (TA) and the peroneus longus (P = 0.01), and greater ankle eversion angle in the IC phase. Significantly greater muscle activation of the TA (P = 0.01), greater coactivation of quadriceps and hamstring (P = 0.03), and a smaller ankle inversion angle (P = 0.04) in the propulsion phase were observed in the FAI-T group after training compared with those in the FAI-NT group.

CONCLUSION

Remodeled bicycle pedal training facilitates the TA and peroneus longus activation and the coactivation of the quadriceps and hamstring muscles during lateral shuffling and resulted in enhanced ankle and knee joint stability. In addition, a better ankle movement strategy during a dynamic task can be achieved via a 6-week remodeled pedal training program.

CLINICAL RELEVANCE

This remodeled bicycle pedal training can be effective for rehabilitating athletes with FAI to recover lateral dynamic movement capability.

Effects of trunk anterior tilt and knee joint flexion angle changes on muscle activity in the lower limb muscles

[Purpose] We examined the effects of trunk anterior tilt angle (TA) and knee flexion angle (KA) on lower limb muscle activity. [Participants and Methods] Twenty-eight healthy male participants (age, 24.7 ± 4.7 years) performed nine standing tasks with different TA and KA. The participants were instructed to remain still during each task. The nine standing tasks were randomly performed while measurements of muscle activity were obtained for seven muscles: gluteus maximus (GMAX), medial hamstrings (MH), lateral hamstrings (LH), rectus femoris (RF), vastus lateralis (VL), medial gastrocnemius (MG), and soleus (SOL). The activities of these muscles were normalized using isometric grade 3 of the manual muscle testing (isoMMT3). The intra-rater reliability for the mean values of the muscle activities measured with the isoMMT3 (intra-class correlation coefficient with 95% confidence interval) was confirmed using equation ICC (1,3). [Results] GMAX, MH, LH, RF, and MG were affected by both TA and KA, whereas VL was affected by KA, and SOL was affected by TA. [Conclusion] Our findings may facilitate a better understanding of the changes in muscle activity of the lower limb muscles due to differences in TA and KA.

Comparison of knee biomechanical characteristics during exercise between pinnacle and step trainers

BACKGROUND

A novel stair-climber called a pinnacle trainer (PT) provides both sagittal and frontal plane exercise, making it different from a step trainer (ST), which provides only sagittal plane exercise. Exercise with different trajectories may produce different biomechanical responses. There are currently no guidelines for choosing between a PT and a ST for different training or rehabilitation purposes.

RESEARCH QUESTIONS

Are there differences in the electromyographic patterns of lower extremity musculature and biomechanical responses of the knee joint during exercise between using a PT and a ST?

METHODS

This study utilizes a prospective observational study design. Eighteen healthy males participated in the study. A six-axis force and torque transducer embedded in the machine pedal synchronized with a three-dimensional motion capture system were utilized to measure kinematic and kinetic data of the right knee during the stepping movement. The activities of six lower extremity muscles of the same limb were captured with surface electromyography during exercise on the two trainer types.

RESULTS

The co-activation index of the vastus lateralis (VL) and the biceps femoris (BF) recorded during ST exercise was significantly greater than that for the PT exercise. Moreover, exercise using the ST produced a significantly greater knee downward force compared to that for the PT. Exercise with the PT produced a significantly greater internal knee varus moment compared to that for the ST.

SIGNIFICANCE

The ST provided greater co-activation of the BF and VL and a greater knee joint downward force, which may decrease the antero-posterior displacement of the tibia relative to the femur. Exercise with the PT produced a significant internal knee varus moment and a more balanced muscular activation on the vastus medialis and VL compared to that for the ST, which may decrease the maltracking of the patella.

Biomechanical correlation at the knee joint between static lunge and single-leg drop landing - a comparative study among three different toe directions

Background

Toe direction is a critical factor affecting knee biomechanics during various movements including closed kinetic chain (CKC) exercise and landing tasks. Physiotherapists always concentrate on the control of toe direction during CKC exercise as a first step for athletes, as it is believed that correction of toe direction during CKC exercise is important to maintain the appropriate toe position even in high demanding activities such as landing tasks. The purpose of the present study was to investigate knee biomechanics during CKC exercise as well as landing tasks with three different toe directions, and clarify whether biomechanical parameters during CKC exercise would be related to those during landing tasks.

Methods

A total of 23 male recreational level athletes (mean age = 20.0 ± 1.1 yrs) participated. Tegner activity score were 7 for all male subjects. First, the subjects performed weight-bearing static lunge tests (SL) under three different toe directions, including 0 degrees (Toe-neutral: TN), 20 degrees (Toe-In: TI), and - 20 degrees (Toe-out: TO). Thereafter, SLDL was done under three different toe directions. Three-dimensional knee kinematics and kinetics at 60 degrees of knee flexion were calculated. As a statistical analysis, Pearson's correlation coefficient was used to evaluate the relationship between SL and SLDL. The statistical significance level wasset at P=0.05.

Results and Conclusions

Knee abduction angle showed significant correlation between SL and SLDL in all three different directions (TI: r=0.631, p<0.001, TN: r=0.678, p<0.001, TO: r=0.572, p<0.001). In terms of knee internal rotation, strong correlation was also found (TI: r=0.846, p<0.001, TN: r=0.791, p<0.001, TO: r=0.749, p<0.001). In addition, external knee abduction moment presented significant correlation in all three different directions (TI: r=0.574, p<0.001, TN: r=0.499, p<0.01, TO: r=0.469, p<0.01). From the present study, significant correlation between SL and SLDL was found in knee abduction angle, knee internal rotation, and external knee abduction moment under all three different directions including TI, TN, and TO. Physiotherapist should take care of toe direction and reform the movements especially for athletes who present malalignment of the knee joint during SL with TI or TO to prevent ACL injury in landing tasks.

The Effect of Open- Versus Closed-Kinetic-Chain Exercises on Anterior Tibial Laxity, Strength, and Function Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background There is controversy surrounding the early use of open-kinetic-chain (OKC) quadriceps-strengthening exercises following anterior cruciate ligament reconstruction (ACLR) due to the belief that increased strain on the graft could cause damage. Objectives To determine whether OKC quadriceps exercises result in differences in anterior tibial laxity, strength, function, quality of life, or adverse events in the ACLR population, when compared to closed-kinetic-chain (CKC) quadriceps exercises. Methods Seven electronic databases (MEDLINE, Embase, AMED, CINAHL, SPORTDiscus, PEDro, and the Cochrane Central Register of Controlled Trials) were searched through April 2017. A systematic review with meta-analysis was conducted on randomized controlled trials comparing OKC versus CKC exercises following ACLR. Outcomes of interest were tibial laxity, strength, and function. A methodological quality assessment of the included studies was completed, and the results were synthesized using meta-analysis and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Ten studies were included in the review. The meta-analysis demonstrated low- to moderate-quality evidence of no between-group differences in anterior tibial laxity, strength, or patient-reported function at any time point. Meta-analysis was unable to be performed for functional outcomes. Conclusion There was limited to moderate-quality evidence of no difference in anterior tibial laxity, strength, patient-reported function, or physical function with early or late introduction of OKC exercises in the ACLR population, when compared to CKC exercises, at all follow-up time points. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(7):552-566. Epub 23 Apr 2018. doi:10.2519/jospt.2018.7656.

Do Knee Bracing and Delayed Weight Bearing Affect Mid-Term Functional Outcome after Anterior Cruciate Ligament Reconstruction?

Purpose  The aim of this study was to assess the effect of knee bracing and timing of full weight bearing after anterior cruciate ligament reconstruction (ACLR) on functional outcomes at mid-term follow-up. Methods  We performed a retrospective study on 41 patients with ACLR. Patients were divided in two groups: ACLR group, who received isolated ACL reconstruction and ACLR-OI group who received ACL reconstruction and adjunctive surgery. Information about age at surgery, bracing, full or progressive weight bearing permission after surgery were collected for the two groups. Subjective IKDC score was obtained at follow-up. Statistical analysis was performed to compare the two groups for IKDC score. Subgroup analysis was performed to assess the effect of postoperative regimen (knee bracing and weight bearing) on functional outcomes. Results  The mean age of patients was 30.8 ± 10.6 years. Mean IKDC score was 87.4 ± 13.9. The mean follow-up was 3.5 ± 1.8 years. Twenty-two (53.7%) patients underwent ACLR only, while 19 (46.3%) also received other interventions, such as meniscal repair and/or collateral ligament suture. Analysis of overall data showed no differences between the groups for IKDC score. Patients in the ACLR group exhibited a significantly better IKDC score when no brace and full weight bearing after 4 weeks from surgery was prescribed in comparison with patients who worn a brace and had delayed full weight bearing. No differences were found with respect to the use of brace and postoperative weight bearing regimen in the ACLR-OI group. Conclusion  Brace and delayed weight bearing after ACLR have a negative influence on long-term functional outcomes. Further research is required to explore possible differences in the patients operated on ACLR and other intervention with respect to the use of a brace and the timing of full weight bearing to identify optimal recovery strategies. Level of Evidence  Level III, retrospective observational study.

Long Term Changes in Muscles around the Knee Joint after ACL Resection in Rats: Comparisons of ACL-Resected, Contralateral and Normal Limb

The purpose of this study was to investigate the long-term effects of anterior cruciate ligament (ACL) resection on the morphological and contractile characteristics of rectus femoris (RF) and semimembranosus (SM) muscles in both injured and contralateral hindlimbs in rats. Wistar male rats (8-week old) were used. Rats were divided into two groups; ACL-resected and (sham-operated) control groups. Furthermore, right and left limbs of rats in the ACL-resected group were assigned as ACL-resected and contralateral groups, respectively, at 1 day, 1, 4, and 48 weeks after ACL resection. No ACL-resection-associated changes in the mass of both muscles were observed 1 week after ACL resection. On the other hand, ACL-resection-associated reduction on mean fiber cross-sectional area (fiber CSA) in RF muscle lasted 48 weeks after ACL resection. Furthermore, ACL-resection associated increase in fiber composition of type I fiber in RF muscle in contralateral limbs. In addition, long-term effects of ACL resection were observed in both ACL-resected and contralateral limbs. Evidences from this study suggested that ACL resection may cause to change in the morphological (fiber CSA) and contractile (distribution of fiber types) properties of skeletal muscles around the knee joint in not only injured but also contralateral limb. Rehabilitation for quantitative and qualitative muscle changes by ACL resection may be required a special care for a long-term period.

Open versus Closed Kinetic Chain Exercises following an Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

Background

There is no consensus on whether closed kinetic chain (CKC) or open kinetic chain (OKC) exercises should be the intervention of choice following an anterior cruciate ligament (ACL) injury or reconstruction.

Methods

A systematic search identified randomized controlled trials of OKC versus CKC exercise training in people who had undergone ACL reconstructive surgery. All published studies in this systematic review were comparisons between OKC and CKC groups.

Results

Seven studies were included. Lysholm knee scoring scale was not significantly different between OKC and CKC exercise patients: MD: −1.03%; CI: −13.02, 10.95; p value = 0.87 (Chi²  =  0.18, df = 1, and p value  =  0.67). Hughston clinic questionnaire scores were not significantly different between OKC and CKC exercise patients: MD: −1.29% (−12.02, 9.43); p value = 0.81 (Chi²  =  0.01, df = 1, and p value = 0.93).

Conclusions

While OKC and CKC may be beneficial during ACL surgical rehabilitation, there is insufficient evidence to suggest that either one is superior to the other.

Treadmill training with partial body-weight support after anterior cruciate ligament reconstruction: a randomized controlled trial

[Purpose] To compare the effects of treadmill training with partial body weight support (TTPBWS) and conventional physical therapy (PT) on subjects with anterior cruciate ligament reconstructions. [Subjects and Methods] A total of 40 subjects were randomly allocated to either a treatment group or a control group. Subjects received either treadmill training with partial body weight support (treatment group) or conventional physical therapy (control group). The circumferences of the lower extremities, Holden classifications, 10-meter walking times and the International Knee Documentation Committee (IKDC) scores were compared at 12 and 24 weeks post-operation. The knee joint stability was tested at 24 weeks post-operation using a KT-1000. [Results] Significant differences were found between the two groups at the 12 weeks post-operation. For most of the measures, there was no significant difference between the groups at 24 weeks post-operation. Interestingly, for most of the measures, there was no significant difference between their values in the treatment group at 12 weeks and their values in the control group at 24 weeks post-operation. [Conclusion] The function of a subject’s lower extremities can be improved and the improvement was clearly accelerated by the intervention of treadmill training with partial body weight support, without compromising the stability of the knee joints in a given follow-up period.

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.

The effect of hip joint muscle exercise on muscle strength and balance in the knee joint after meniscal injury

[Purpose] This study aimed to evaluate the effect of hip muscle strengthening on muscle strength and balance in the knee joint after a meniscal injury. [Subjects and Methods] This randomized control study enrolled 24 patients who had undergone arthroscopic treatment after a meniscal injury and began a rehabilitative exercise program 8 weeks after surgery. Subjects were divided into 2 groups of 12 subjects each: gluteus medius resistance exercise group and control group. This study investigated muscle strength and balance in the knee joint flexor, extensor, and abductor during an 8-week period. [Results] Measurements of knee extensor muscle strength revealed no significant difference between the control group and the experimental group. Measurements of abductor muscle strength, however, identified a significant difference between the 2 groups. The groups did not differ significantly with regard to balance measurements. [Conclusion] The results of this study suggest that this subject should be approached in light of the correlation between the hip abductor and injury to the lower extremities.

Return to sports after ACL reconstruction: a new functional test protocol

BACKGROUND

In literature, there are lack of studies proposing clear and rationally designed test battery to be performed after an ACL reconstruction.

METHODS

From 2006 to 2015, 80 football players were subjected, after ACL reconstruction, to a newly conceived test battery analyzing: Isometric and isokinetic force productionThe different phases during the jumpThe correct control of the landing phase after jumpThe control of valgus during landing after jump and cutting movements.

RESULTS

The isokinetic and isometric test do not show any significant relationship with the another test. The laboratory test as well the field test showed them a significant correlation.

CONCLUSIONS

The results showed that a normal force production during the laboratory does not guarantee an equally satisfactory production of force during the field test.

STUDY DESIGN

Case series (Level III).

Effects of neuromuscular training on knee joint stability after anterior cruciate ligament reconstruction

[Purpose] This study examined the effects of neuromuscular training on knee joint stability after anterior cruciate ligament reconstruction. [Subjects and Methods] The subjects were 16 adults who underwent arthroscopic anterior cruciate reconstruction and neuromuscular training. The Lysholm scale was used to assess functional disorders on the affected knee joint. A KT-2000 arthrometer was used to measure anterior displacement of the tibia against the femur. Surface electromyography was used to detect the muscle activation of the vastus medialis oblique, vastus lateralis, biceps femoris, and semitendinosus before and after neuromuscular training. [Results] There was significant relaxation in tibial anterior displacement of the affected and sound sides in the supine position before neuromuscular training. Furthermore, the difference in the tibial anterior displacement of the affected knee joints in the standing position was reduced after neuromuscular training. Moreover, the variation of the muscle activation evoked higher muscle activation of the vastus medialis oblique, vastus lateralis, biceps femoris, and semitendinosus. [Conclusion] Neuromuscular training may improve functional joint stability in patients with orthopedic musculoskeletal injuries in the postoperative period.

Effects of acceleration training 24 weeks after anterior cruciate ligament reconstruction on proprioceptive and dynamic balancing functions

[Purpose] The present study aimed to investigate whether the effects of rehabilitation exercise performed after anterior cruciate ligament reconstruction on proprioceptive sensory and dynamic balancing functions differ between males and females. [Subjects and Methods] Eighteen subjects aged between 20-30 years enrolled in this study. The ages did not significantly differ between the males and females. The rehabilitation exercise program was performed three times per week for 12 weeks (3 months), and was initiated immediately after anterior cruciate ligament reconstruction. Thereafter, the patients visited the hospital once per week to perform rehabilitation exercise during weeks 12-24 (3-6 months), and education on self-exercise and assessments were conducted during the visits. Self-exercise was performed two times per week according to the determined program. [Results] The extension active joint position sense, extension passive joint position sense, and flexion passive joint position sense of the affected and unaffected knees did not show any interaction effects between the measurement periods or between the groups. In the case of the affected knee, the results of two-way repeated-measures analysis of variance showed no significant difference between the measurement periods or between the groups; moreover, no, interaction effects were observed between the measurement periods or between the groups. In the case of the unaffected knee, although no significant difference was observed between the measurement periods, significant differences were observed between the groups. [Conclusion] In conclusion, this study revealed that most knee rehabilitation exercise training programs can be applied to both genders during the recovery period after ACL reconstruction, except for the knee rotational feedback/feedforward function exercise that may exhibit different effects based on the gender.

Visual biofeedback exercises for improving body balance control after anterior cruciate ligament reconstruction

[Purpose] To evaluate the effects of balance training after arthroscopic anterior cruciate ligament reconstruction. [Subjects and Methods] Sixteen patients (mean 33 ± 8 years old) who underwent anterior cruciate ligament reconstruction three months prior to participating in a one-month rehabilitation program. The control group included 15 people aged 34 ± 4 years. Patients' functional level was evaluated according to the Lysholm knee score, and balance quality was ascertained by static and dynamic tests. A balance platform was used to measure the center of foot pressure deflection. Two dynamic balance tests evaluated time of task execution. [Results] Lysholm knee score improved significantly after rehabilitation. Balance in the sagittal plane with eyes closed improved significantly after rehabilitation. The average velocity of center of foot pressure swing in both the frontal and sagittal planes with eyes closed differed significantly from those of controls. Execution time required for the two dynamic tests decreased significantly after rehabilitation and were significantly better than those in the controls. [Conclusion] Maintaining static balance with eyes closed is very challenging after anterior cruciate ligament reconstruction. Maintaining balance in the sagittal plane is particularly difficult. A one-month rehabilitation program partially improves static and dynamic balance.