Functional outcomes of accelerated rehabilitation protocol for anterior cruciate ligament reconstruction in amateur athletes: a randomized clinical trial
DOI:
https://doi.org/10.2340/jrm.v56.12296Keywords:
Rehabilitation protocol, Knee pain, Functional outcomes, anterior cruciate ligament reconstructionAbstract
Background: Anterior cruciate ligament (ACL) rupture is the most common knee injury among athletes, and can result in long-term complications and career-ending conditions for sportspeople. There is no consensus in the literature on the effectiveness of rehabilitation after ACL reconstruction, or the best protocol to follow for functional outcome improvement.
Objective: To determine the impact of an accelerated rehabilitation protocol on knee functional outcomes in amateur athletes with anterior cruciate ligament reconstruction (ACLR).
Design: Two-arm, parallel-group randomized comparative design.
Patients: A total of 100 amateur male athletes (mean age 22.01 ± 1.79 years) with ACLR were randomly divided into experimental and control groups (n = 50/group).
Methods: An accelerated rehabilitation protocol and a conventional rehabilitation protocol were used for the experimental group. In contrast, only the conventional rehabilitation protocol was used for the control group. The rehabilitation was delivered in 5 weekly sessions for 22 weeks. The primary outcome measure, knee pain, was measured using a visual analogue scale (VAS). Extensive test batteries, for hop tests, Knee Injury and Osteoarthritis Outcome Score (KOOS), and knee effusion, were measured, aiming to add more objective criteria to determine functional performance.
Results: Both groups (n = 50/group) were well-matched (p = 0.816), with insignificant differences in their demographic characteristics (p > 0.05). A multivariate analysis of variance (MANOVA) test showed no significant difference between the 2 groups (p = 0.781) at baseline. A 2-way MANOVA (2 × 2 MANOVA) of within- and between-group variations indicated overall significant treatment, time, and treatment × time interaction effects (p < 0.001) in favour of the accelerated rehabilitation group.
Conclusion: The accelerated rehabilitation protocol was more effective in improving functional outcomes than a conventional rehabilitation protocol in amateur athletes with ACLR.
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References
Moses B, Orchard J, Orchard J. Systematic review: annual incidence of acl injury and sur-gery in various populations. Res Sports Med 2012; 20: 157–179.
https://doi.org/10.1080/15438627.2012.680633 DOI: https://doi.org/10.1080/15438627.2012.680633
Waldén M, Hägglund M, Magnusson H, Ekstrand J. ACL injuries in men's professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med 2016; 50: 744–750.
https://doi.org/10.1136/bjsports-2015-095952 DOI: https://doi.org/10.1136/bjsports-2015-095952
Machan T, Krupps K. The neuroplastic adaptation trident model: a suggested novel frame-work for ACL rehabilitation. Int J Sports Phys Ther 2021; 16: 896.
https://doi.org/10.26603/001c.23679 DOI: https://doi.org/10.26603/001c.23679
Montalvo AM, Schneider DK, Silva PL, Yut L, Webster KE, Riley MA, et al. "What's my risk of sustaining an ACL injury while playing football (soccer)?" A systematic review with meta-analysis. Br J Sports Med 2019; 53: 1333–1340.
https://doi.org/10.1136/bjsports-2016-097261 DOI: https://doi.org/10.1136/bjsports-2016-097261
Buller LT, Best MJ, Baraga MG, Kaplan LD. Trends in anterior cruciate ligament reconstruc-tion in the United States. Orthop J Sports Med 2015; 3: 232596711456366.
https://doi.org/10.1177/2325967114563664 DOI: https://doi.org/10.1177/2325967114563664
Mather RC, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, et al. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am 2013; 95: 1751–1759.
https://doi.org/10.2106/JBJS.L.01705 DOI: https://doi.org/10.2106/JBJS.L.01705
van Melick N, van Cingel REH, Brooijmans F, Neeter C, van Tienen T, Hullegie W, et al. Evi-dence-based clinical practice update: practice guidelines for anterior cruciate ligament reha-bilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med 2016; 50: 1506–1515.
https://doi.org/10.1136/bjsports-2015-095898 DOI: https://doi.org/10.1136/bjsports-2015-095898
Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J Orthop Sports Phys Ther 2012; 42: 153–171.
https://doi.org/10.2519/jospt.2012.3741 DOI: https://doi.org/10.2519/jospt.2012.3741
Elabd OM, Elabd AM. Functional outcomes of a criterion-based rehabilitation protocol for ante-rior cruciate ligament reconstruction in amateur athletes: a randomised clinical trial. J Bodyw Mov Ther 2023; 35: 7–13.
https://doi.org/10.1016/j.jbmt.2023.04.037 DOI: https://doi.org/10.1016/j.jbmt.2023.04.037
Martimbianco ALC, Gomes da Silva BN, de Carvalho APV, Silva V, Torloni MR, Peccin MS. Effectiveness and safety of cryotherapy after arthroscopic anterior cruciate ligament recon-struction. A systematic review of the literature. Phys Ther Sport 2014; 15: 261–268.
https://doi.org/10.1016/j.ptsp.2014.02.008 DOI: https://doi.org/10.1016/j.ptsp.2014.02.008
Imoto AM, Peccin S, Almeida GJM, Saconato H, Atallah ÁN. Effectiveness of electrical stimu-lation on rehabilitation after ligament and meniscal injuries: a systematic review. Sao Paulo Med J 2011; 129: 414–423.
https://doi.org/10.1590/S1516-31802011000600008 DOI: https://doi.org/10.1590/S1516-31802011000600008
Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, et al. Accelerated Versus Nonaccelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2011; 39: 2536–2548.
https://doi.org/10.1177/0363546511422349 DOI: https://doi.org/10.1177/0363546511422349
Christensen JC, Goldfine LR, West HS. The effects of early aggressive rehabilitation on out-comes after anterior cruciate ligament reconstruction using autologous hamstring tendon: a randomized clinical trial. J Sport Rehabil 2013; 22: 191–201.
https://doi.org/10.1123/jsr.22.3.191 DOI: https://doi.org/10.1123/jsr.22.3.191
Lobb R, Tumilty S, Claydon LS. A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation. Phys Ther Sport 2012; 13: 270–278.
https://doi.org/10.1016/j.ptsp.2012.05.001 DOI: https://doi.org/10.1016/j.ptsp.2012.05.001
Sepúlveda F, Sánchez L, Amy E, Micheo W. Anterior cruciate ligament injury. current sports medicine reports 2017; 16: 172–178.
https://doi.org/10.1249/JSR.0000000000000356 DOI: https://doi.org/10.1249/JSR.0000000000000356
Cheecharern S. Return to sport and knee functional scores after anterior cruciate ligament reconstruction: 2 to 10 years' follow-up. Asia Pac J Sports Med Arthrosc Rehabil Technol 2018; 12: 22–29.
https://doi.org/10.1016/j.asmart.2018.01.003 DOI: https://doi.org/10.1016/j.asmart.2018.01.003
Gans I, Retzky JS, Jones LC, Tanaka MJ. Epidemiology of recurrent anterior cruciate liga-ment injuries in national collegiate athletic association sports: the injury surveillance program, 2004–2014. Orthopaed J Sports Med 2018; 6: 232596711877782.
https://doi.org/10.1177/2325967118777823 DOI: https://doi.org/10.1177/2325967118777823
Barber-Westin SD, Noyes FR. Objective criteria for return to athletics after anterior cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. Phys Sportsmed 2011; 39: 100–110.
https://doi.org/10.3810/psm.2011.09.1926 DOI: https://doi.org/10.3810/psm.2011.09.1926
Harris JD, Abrams GD, Bach BR, Williams D, Heidloff D, Bush-Joseph CA, et al. Return to sport after ACL reconstruction. Orthopedics 2014; 37: 103–108.
https://doi.org/10.3928/01477447-20140124-10 DOI: https://doi.org/10.3928/01477447-20140124-10
Røtterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Årøen A. Effect of meniscal and focal cartilage lesions on patient-reported outcome after anterior cruciate ligament reconstruc-tion: a nationwide cohort study from Norway and Sweden of 8476 patients with 2-year follow-up. Am J Sports Med 2013; 41: 535–543.
https://doi.org/10.1177/0363546512473571 DOI: https://doi.org/10.1177/0363546512473571
Akpinar B, Thorhauer E, Irrgang JJ, Tashman S, Fu FH, Anderst WJ. Alteration of knee kine-matics after anatomic anterior cruciate ligament reconstruction is dependent on associated meniscal injury. Am J Sports Med 2018; 46: 1158–1165 https://doi.org/10.1177/0363546517753386 DOI: https://doi.org/10.1177/0363546517753386
Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 bps), and measure of intermittent and constant oste-oarthritis pain (ICOAP). Arthritis Care Res (Hoboken) 2011; 63: S240–S252.
https://doi.org/10.1002/acr.20543 DOI: https://doi.org/10.1002/acr.20543
Olaogun MOB, Adedoyin RA, Anifaloba RO. Reliability and concurrent validity of visual ana-logue scale and modified verbal rating scale of pain assessment in adult patients with knee osteoathritis in Nigeria. South African J Physio Ther 2003; 59: 12.
https://doi.org/10.4102/sajp.v59i2.238 DOI: https://doi.org/10.4102/sajp.v59i2.238
Davies WT, Myer GD, Read PJ. Is it time we better understood the tests we are using for return to sport decision making following ACL reconstruction? A critical review of the hop tests. Sports Med 2020; 50: 485–495.
https://doi.org/10.1007/s40279-019-01221-7 DOI: https://doi.org/10.1007/s40279-019-01221-7
Gustavsson A, Neeter C, Thomeé P, Grävare Silbernagel K, Augustsson J, Thomeé R, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2006; 14: 778–788.
https://doi.org/10.1007/s00167-006-0045-6 DOI: https://doi.org/10.1007/s00167-006-0045-6
Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruc-tion. Phys Ther 2007; 87: 337–349.
https://doi.org/10.2522/ptj.20060143 DOI: https://doi.org/10.2522/ptj.20060143
Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS) - development of a self-administered outcome measure. J Orthop Sports Phys Ther 1998; 28: 88–96.
https://doi.org/10.2519/jospt.1998.28.2.88 DOI: https://doi.org/10.2519/jospt.1998.28.2.88
Collins NJ, Prinsen CAC, Christensen R, Bartels EM, Terwee CB, Roos EM. Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measure-ment properties. Osteoarthr Cartil 2016; 24: 1317–1329.
https://doi.org/10.1016/j.joca.2016.03.010 DOI: https://doi.org/10.1016/j.joca.2016.03.010
Salavati M, Akhbari B, Mohammadi F, Mazaheri M, Khorrami M. Knee injury and Osteoarthritis Outcome Score (KOOS); reliability and validity in competitive athletes after anterior cruciate ligament reconstruction. Osteoarthr Cartil 2011; 19: 406–410.
https://doi.org/10.1016/j.joca.2011.01.010 DOI: https://doi.org/10.1016/j.joca.2011.01.010
Sturgill LP, Snyder-Mackler L, Manal TJ, Axe MJ. Interrater reliability of a clinical scale to as-sess knee joint effusion. J Orthop Sports Phys Ther 2009; 39: 845–849.
https://doi.org/10.2519/jospt.2009.3143 DOI: https://doi.org/10.2519/jospt.2009.3143
Bieler T, Aue Sobol N, Andersen LL, Kiel P, Løfholm P, Aagaard P. The effects of high-intensity versus low-intensity resistance training on leg extensor power and recovery of knee function after ACL-reconstruction. Biomed Res Int 2014; 2014: 1–11.
https://doi.org/10.1155/2014/278512 DOI: https://doi.org/10.1155/2014/278512
Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction. J Bone Joint Surg 2012; 94: 1737–1748.
https://doi.org/10.2106/JBJS.K.01246 DOI: https://doi.org/10.2106/JBJS.K.01246
Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after ante-rior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. J Orthop Sports Phys Ther 2010; 40: 383–391.
https://doi.org/10.2519/jospt.2010.3184 DOI: https://doi.org/10.2519/jospt.2010.3184
van Grinsven S, van Cingel REH, Holla CJM, van Loon CJM. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010; 18: 1128–1144.
https://doi.org/10.1007/s00167-009-1027-2 DOI: https://doi.org/10.1007/s00167-009-1027-2
McCoy CE. Understanding the intention-to-treat principle in randomized controlled trials. West J Emerg Med 2017; 18: 1075.
https://doi.org/10.5811/westjem.2017.8.35985 DOI: https://doi.org/10.5811/westjem.2017.8.35985
Wright R, Preston E, Fleming B, Amendola A, Andrish J, Bergfeld J, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation - part i: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg 2008; 21: 217–224.
https://doi.org/10.1055/s-0030-1247822 DOI: https://doi.org/10.1055/s-0030-1247822
Dragicevic-Cvjetkovic D, Jandric S, Bijeljac S, Palija S, Manojlovic S, Talic G. The effects of rehabilitation protocol on functional recovery after anterior cruciate ligament reconstruction. Med Arch 2014; 68: 350–352.
https://doi.org/10.5455/medarh.2014.68.350-352 DOI: https://doi.org/10.5455/medarh.2014.68.350-352
Isberg J, Faxén E, Brandsson S, Eriksson BI, Kärrholm J, Karlsson J. Early active extension after anterior cruciate ligament reconstruction does not result in increased laxity of the knee. Knee Surg Sports Traumatol Arthrosc 2006; 14: 1108–1115.
https://doi.org/10.1007/s00167-006-0138-2 DOI: https://doi.org/10.1007/s00167-006-0138-2
Shaw T, Williams MT, Chipchase LS. Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. Aust J Physiother 2005; 51: 9–17.
https://doi.org/10.1016/S0004-9514(05)70048-9 DOI: https://doi.org/10.1016/S0004-9514(05)70048-9
Fukuda TY, Fingerhut D, Moreira VC, Camarini PMF, Scodeller NF, Duarte A, et al. Open ki-netic chain exercises in a restricted range of motion after anterior cruciate ligament recon-struction. Am J Sports Med 2013; 41: 788–794.
https://doi.org/10.1177/0363546513476482 DOI: https://doi.org/10.1177/0363546513476482
Gokeler A, Bisschop M, Benjaminse A, Myer GD, Eppinga P, Otten E. Quadriceps function following ACL reconstruction and rehabilitation: implications for optimisation of current practices. Knee Surg Sports Traumatol Arthrosc 2014; 22: 1163–1174.
https://doi.org/10.1007/s00167-013-2577-x DOI: https://doi.org/10.1007/s00167-013-2577-x
Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol 2019; 33: 33–47.
https://doi.org/10.1016/j.berh.2019.01.018 DOI: https://doi.org/10.1016/j.berh.2019.01.018
Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after an-terior cruciate ligament reconstruction. Am J Sports Med 2013; 41: 216–224.
https://doi.org/10.1177/0363546512459638 DOI: https://doi.org/10.1177/0363546512459638
Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate liga-ment reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 2011; 45: 596–606.
https://doi.org/10.1136/bjsm.2010.076364 DOI: https://doi.org/10.1136/bjsm.2010.076364
Thomeé R, Neeter C, Gustavsson A, Thomeé P, Augustsson J, Eriksson B, et al. Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2012; 20: 1143–1151.
https://doi.org/10.1007/s00167-012-1912-y DOI: https://doi.org/10.1007/s00167-012-1912-y
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