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Article history: The aim of this systematic review of systematic reviews was to critically appraise systematic reviews on
Received 26 January 2012 Anterior Cruciate Ligament (ACL) reconstruction rehabilitation to determine which interventions are
Received in revised form supported by the highest quality evidence. Electronic searches were undertaken, of MEDLINE, AMED,
23 April 2012
EMBASE, EBM reviews, PEDro, Scopus, and Web of Science to identify systematic reviews of ACL reha-
Accepted 4 May 2012
bilitation. Two reviewers independently selected the studies, extracted data, and applied quality criteria.
Study quality was assessed using PRISMA and a best evidence synthesis was performed. Five systematic
Keywords:
reviews were included assessing eight rehabilitation components. There was strong evidence (consistent
ACL reconstruction
Physical therapy
evidence from multiple high quality randomised controlled trials (RCTs)) of no added benefit of bracing
Review of systematic reviews (0e6 weeks post-surgery) compared to standard treatment in the short term. Moderate evidence
Interventions (consistent evidence from multiple low quality RCTs and/or one high quality RCT) supported no added
Best evidence synthesis benefit of continuous passive motion to standard treatment for increasing range of motion. There was
moderate evidence of equal effectiveness of closed versus open kinetic chain exercise and home versus
clinic based rehabilitation, on a range of short term outcomes. There was inconsistent or limited evidence
for some interventions. Recommendations for clinical practice are made at specific time points for
specific outcomes.
Ó 2012 Elsevier Ltd. All rights reserved.
1466-853X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2012.05.001
Please cite this article in press as: Lobb, R., et al., A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation,
Physical Therapy in Sport (2012), doi:10.1016/j.ptsp.2012.05.001
2 R. Lobb et al. / Physical Therapy in Sport xxx (2012) 1e9
Systematic reviews on the topic of effective treatments for ACL Database search Results
reconstruction rehabilitation programmes have been published 1. Anterior cruciate ligament 24,203
however the methodological rigour of these systematic reviews has 2. Surgery 2,102,823
not been evaluated using internationally recommended validated 3. Reconstructive surgical procedures/ 76,092
4. 2 OR 3 2,118,580
guidance. The purpose of this systematic review of systematic
5. Physiotherapy 72,601
reviews is to critically appraise systematic reviews on ACL recon- 6. Physical therapy/ 45,528
struction rehabilitation programmes using internationally recom- 7. Rehabilitation 295,863
mended assessment procedures. The aim is to determine which 8. Exercise therapy 32,119
rehabilitation components are supported by high quality system- 9. Electrothers 7278
10. 5 OR 6 OR 7 OR 8 OR 9 383,487
atic reviews to be included in a post -operative ACL reconstruction 11. Systematic review 89,845
rehabilitation program for a variety of outcomes including strength, 12. 1 AND 4 AND 10 AND 11 45
ROM, pain, laxity, activity levels, and RTS. 13. Remove duplicates 38
14. Limit 13 to English language 36
15. Limit 14 to full systematic reviews 32
2. Methods 16. Limit 15 to humans 32
Please cite this article in press as: Lobb, R., et al., A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation,
Physical Therapy in Sport (2012), doi:10.1016/j.ptsp.2012.05.001
R. Lobb et al. / Physical Therapy in Sport xxx (2012) 1e9 3
The level of evidence for each intervention outcome was The strength of evidence ranged from strong evidence of
therefore dependent on the number of RCTs and the quality of no difference between interventions to limited evidence of
the RCTs for each intervention. This best evidence synthesis was effectiveness of an intervention. No evidence was found to strongly
performed to determine if the conclusions made by or moderately support a particular treatment. From reviewing the
review authors were based on the quality of the evidence i.e. evidence the following levels of evidence can be supported:
the conclusions made were consistent with the evidence There was strong evidence of no significant difference for:
reviewed.
Bracing as an adjunct to standard treatment for ROM, strength,
3. Results knee joint laxity, pain, and function (at six weeks to five years
follow-up) (Andersson et al., 2009; Smith & Davies, 2008). RCTs
3.1. Study selection employed accelerated rehabilitation approaches for both brace
and standard treatment groups, however many RCTs lacked
Fig. 1 summarizes the study selection process. Thirty-two detail on the use of different treatments at different time points
reviews were excluded because they did not meet the inclusion (Smith & Davies, 2008)
criteria. Five reviews were eligible for inclusion (Andersson,
Samuelsson, & Karlsson, 2009; Kim, Croy, Hertel, & Saliba, 2010; There was moderate evidence of no significant difference
Smith & Davies, 2007, 2008; Trees, Howe, Dixon, & White, 2005). between:
The outcomes and methodological quality of the five reviews are
reported in Table 2. A total of eight specific interventions were CPM and standard treatment and non-CPM and standard
reported on within these five reviews: bracing, Continuous treatment on ROM and knee joint laxity (at one week to six
passive motion (CPM), neuromuscular electrical stimulation months and six months to a year, respectively) (Smith & Davies,
(NMES), open kinetic chain (OKC) versus closed kinetic chain 2007). None of the RCTs detailed the standard treatment
(CKC) exercise, progressive eccentric exercise, home versus programs, these programs appeared to differ according to the
supervised rehabilitation, accelerated rehabilitation and water weight bearing status, use of knee bracing, and progression
based rehabilitation. (Smith & Davies, 2007).
OKC and CKC strengthening exercises (for leg extensor
muscles) on knee laxity, pain, and function (at 6e14 week-
s)(Andersson et al., 2009). Typically OKC exercises involved leg
extensor resistance training using ankle weights or machines
where the foot was not planted, whereas CKC involved leg
extensor training using a leg press (Andersson et al., 2009).
Participants were typically permitted to do other forms of
exercise such step ups, bicycle ergometry, stretches, and
proprioception exercises.
Home based and clinic based exercise on knee laxity, ROM,
strength, and function (Andersson et al., 2009) (at 6 months to
1 year). Two RCTs specified that home based exercisers had 6
physiotherapy consults and clinic based exercisers had
between 24 and 40 consults; two RCTs did not specify the
amount of physiotherapy input.
Bracing and standard treatment and non-bracing and standard
treatment on pain and post-operative complications at any
time point (Smith & Davies, 2008)
Please cite this article in press as: Lobb, R., et al., A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation,
Physical Therapy in Sport (2012), doi:10.1016/j.ptsp.2012.05.001
Table 2
4
Physical Therapy in Sport (2012), doi:10.1016/j.ptsp.2012.05.001
Please cite this article in press as: Lobb, R., et al., A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation,
Summary of reviews.
Review Quality/27 No of Scope of the review/Interventions Outcomes Authors conclusions Level of Evidence
(PRISMA) studies
Andersson 14 34 Rehabilitation techniques : ‘clinical tests’ including: 1) A post-operative knee brace does not affect Level I (High quality RCT) and Level II (Low Quality
et al., 2009 1) Bracing versus no ROM, strength, clinical outcome and does not reduce the RCT) for the review, no individual technique gradings
brace (7 articles) laxity, Lysholm knee risk of subsequent intra-articular injury given. Authors graded overall review as Level II.
2) Early versus Delayed score, Tegner activity after ACL reconstruction. Only one study 1) Strong evidence no differences between brace
Rehabilitation (6 Articles) level, 1-leg hop test, used the HT graft. and no brace on ROM, strength, laxity, function,
3) Accelerated versus IKDC score, pain and RTS. 2) Early versus Delayed Rehabilitation: a and pain at 4 month to 5 years follow up.
Non-accelerated (1 article) well-designed RCT with a follow-up of 2) Limited evidence knee brace does not reduce
4) Home based versus at least 1 year is needed. the risk of intra-articular injuries. Limited
supervised (7 articles) 3) Inconclusive whether there is a difference evidence brace at 5 compared to normal brace
5) OKC versus CKC between an accelerated and a prevents loss of extension at 3 months.. Limited
exercises (8 articles) non-accelerated rehabilitation program. evidence no difference between a brace and a
6) Early progressive 4) Home-based and supervised clinic-based neoprene sleeve on function and ROM.
eccentric exercise rehabilitation programs produce equal 3) Inconsistent evidence regarding early versus
versus standard clinical outcomes in short term, however delayed rehab at 1e2 years follow up.
rehabilitation multiple methodological flaws noted in 4) limited evidence no significant difference
7) Protonics device reviewed RCT’s. between accelerated (19 weeks) and non-
and knee brace 5) CKC exercises produce less pain and accelerated (32 weeks) rehabilitation on function
Davies, 2007 Standard Rx þ CPM 3) function 4) radiological post-operatively amongst ACL reconstruction patients 1) joint laxity and 2) ROM. Limited evidence of no
changes, 5) muscle atrophy,, is of any benefit, especially relating to 1) joint laxity, significant difference for 3) function using the IKDC,
6) ecchymoses, 2) ROM, 3) function, IKDC, 4) radiological changes, 4) radiological changes, 5) muscle atrophy after
7) joint position sense, 5) muscle atrophy and ecchymoses 6) outcomes, 6 weeks or 6) ecchymoses at 15 days. Limited
8) pain, 9) swelling, 7) Significantly better joint position sense in evidence of a significantly better 7) joint position
10) blood non-CPM users at day 7. sense in the non-CPM group on day 7. Conflicting
drainage, Studies assessing CPM protocols, efficacy of CPM evidence regarding effects on 8) pain from 24 h
11) post-operative after HT graft, functional outcomes and QOL of CPM to 3 days, 9) swelling at 6 weeks, 10) blood drainage
complications and non-CPM groups recommended. within 24 h, 11) post-operative complications, and
12) length of hospital 12) length of hospital stay.
stay outcomes
Smith & 17 7 RCT’s Post operative bracing vs 1) Knee laxity, No significant difference in bracing compared to no Strong evidence of no significant difference at any
Davies, 2008 no post-operative bracing 2) dynamometry, bracing in terms of 1) joint laxity, 2) isokinetic torque, time point for 1) joint laxity, 2) isokinetic torque,
3) ROM, 4) 3) ROM and 4) function measured using Tegner and 3) ROM, and 4) function including the Tegner scale
function, 5) pain, Lysholm scales at any point in time. and Lysholm scale at any time point.
6) post-operative Not bracing in early stages post operatively appears to Moderate evidence of no significant difference at
complications, provide significantly better 3) ROM and 4) functional any time point for 5) pain or 6) post-operative
7) muscle bulk, outcomes also significantly less swelling and 7) loss complications.
8) patient satisfaction, of muscle bulk. There is limited evidence for: 4) greater leg hop
at 25 weeks but not at one year in the no-brace
Abbreviations: Closed kinetic chain (CKC), Electromyography (EMG), Hamstring tendon (HT), International Knee, Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Open kinetic chain
(OKC), Patella tendon (PT), Randomised Control Trial (RCT) Range of Motion (ROM), Return to Sport (RTS).
5
6 R. Lobb et al. / Physical Therapy in Sport xxx (2012) 1e9
weeks post reconstruction participants completed water or NMES and exercise, and exercise on function and self-reported
land based rehabilitation, the exercises were the same (e.g., function (at 6 weeks) and self-reported function (at 12 weeks)
closed chain cycling, gait retraining, side steps, step ups) the (Kim et al., 2010)
only difference was the water or land (Trees et al., 2005) CPM and standard treatment versus non-CPM and standard
treatment for proprioception (at 1 week) (Smith & Davies 07)
There was inconsistent evidence of significant differences Non-bracing and standard treatment and bracing and standard
between: treatment for leg hop (at 6 months but not a year), and swelling
(at 1 week but not at 6 weeks) (Smith & Davies, 2008)
Early and delayed rehabilitation (time points 1e2 years) Bracing and standard treatment and non-bracing and standard
(Andersson et al., 2009). Early rehabilitation consisted of treatment on muscle bulk (at 3 months but not 6 months
protocols such as immediate weight bearing and ROM exer- (Smith & Davies, 2008)
cises (Andersson et al., 2009). Water based and land based exercise on function (at 2 months)
NMES and exercise, and exercise or EMG for strength (at 6e12 (Trees et al., 2005).
weeks) (Kim et al., 2010). NMES parameters were high
frequency (30e75 Hz), long pulse duration (200e400 ms) at an
intensity to the participants maximum tolerance, details about 3.3. PRISMA scores
the exercise and EMG were not provided (Kim et al., 2010).
CPM and standard treatment and non-CPM and standard The quality rating for each item on the PRISMA is detailed in
treatment for pain (at 24 h to 3 days), swelling (at 6 weeks) Table 3. Four out of five of the reviews scored 18 or less (out of
blood drainage (at 24 h), post-operative complications, and a possible 27 marks) on the PRISMA quality checklist (Andersson
length of hospital stay (Smith & Davies, 2007) et al., 2009; Kim et al., 2010; Smith & Davies, 2007, 2008); one
scored 23 (Trees et al., 2005). The lower scores indicate a higher risk
There was limited evidence of a significant difference between: of bias.
Bracing at 5 and a brace at 0 preventing extension loss at 3 1. Identify the report as a systematic review, meta-analysis, or
months (Andersson et al., 2009) both.
CKC exercises resulting in better pain, laxity, subjective 2. Provide a structured summary including, as applicable: back-
outcomes and RTS than OKC at 1 year (Andersson et al., 2009) ground; objectives; data sources; study eligibility criteria,
A combination of CKC and OKC resulting in better strength and participants, and interventions; study appraisal and synthesis
RTS than CKC (Andersson et al., 2009; Trees et al., 2005). methods; results; limitations; conclusions and implications of
Eccentric resistance training resulting in better muscle volume, key findings; systematic review registration number.
strength and function at 1 year compared to standard training 3. Describe the rationale for the review in the context of what is
(Andersson et al., 2009). The eccentric program involved a 12- already known.
week eccentric induced negative work exercise whereas the 4. Provide an explicit statement of questions being addressed
control group received standard training (Andersson et al., with reference to participants, interventions, comparisons,
2009). outcomes, and study design (PICOS).
Table 3
PRISMA items and criteria (Moher et al., 2009). Y ¼ YES N ¼ NO.
PRISMA item Andersson Kim et al., Smith & Davies, Smith & Davies, Trees et al.,
et al., 2009 2010 2007 2008 2005
1. Title Y Y Y Y N
2. Abstract: structured summary Y Y Y Y Y
3. Introduction: Rationale Y Y Y Y Y
4. Introduction: Objectives Y Y Y Y Y
5. Methods: protocol and registration N N N N Y
6. Methods: eligibility criteria N Y Y Y Y
7. Information sources Y Y Y Y Y
8. Methods: search Y N Y N Y
9. Methods: study selection N N Y Y Y
10. Methods: data collection process N Y N Y Y
11. Methods: data items Y Y Y Y Y
12. Methods: risk of bias in individual studies Y Y Y Y N
13. Methods: summary measures N Y N N Y
14. Methods: synthesis of results N Y N N Y
15. Methods: risk of bias across studies N N N N N
16. Methods: additional analyses N N N N Y
17. Results: study selection N Y Y Y Y
18. Results: study characteristics Y Y Y Y Y
19. Results: risk of bias within studies Y Y Y Y Y
20. Results: results of individual studies N Y N N Y
21. Results: Synthesis of results N Y N N Y
22. Results: risk of bias across studies N N N N N
23. Results: additional analyses N N N N Y
24. Discussion: summary of evidence Y Y Y Y Y
25. Discussion: limitations Y N Y Y Y
26. Discussion: conclusions Y Y Y Y Y
27. Funding Y N N Y Y
Please cite this article in press as: Lobb, R., et al., A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation,
Physical Therapy in Sport (2012), doi:10.1016/j.ptsp.2012.05.001
R. Lobb et al. / Physical Therapy in Sport xxx (2012) 1e9 7
Please cite this article in press as: Lobb, R., et al., A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation,
Physical Therapy in Sport (2012), doi:10.1016/j.ptsp.2012.05.001
8 R. Lobb et al. / Physical Therapy in Sport xxx (2012) 1e9
function in the short term (6e14 weeks) (Hooper, Morrissey, acknowledged that a language restriction was imposed on this
Drechsler, Morrissey, & King, 2001; Morrissey et al., 2000, 2002; review to RCTs in English, which may have introduced a language
Perry, Morrissey, King, Morrissey, & Earnshaw, 2005. Another bias (Egger et al., 1997).
review on this topic (Trees et al., 2005) provides limited evidence
(one RCT) of no significant difference on function. The reason for
these conflicting evidence levels between reviews (moderate 5. Conclusion
versus limited) is the primary outcomes of Trees et al., 2005 were
function and RTS, limiting the RCTs included in the review. The one This review reports strong evidence of no added benefit of
RCT (Bynum et al., 1995) which provided limited evidence at one bracing after ACL reconstruction (0e6 weeks post-surgery) as an
year of the effect of these exercises on knee laxity reports decreased adjunct to standard treatment in the short term, its use is therefore
KT-1000 side to side difference in favour of CKC whereas Lachman’s not recommended. Moderate evidence was found of no added
showed no difference between groups. The evidence reported in benefit of CPM to standard treatment for routine use after ACL
this review therefore supports the use of either CKC (e.g. leg press) reconstruction with the aim of increasing knee range of motion.
or OKC (e.g. use of ankle weights) leg extensor exercises in the short Moderate evidence indicates that CKC and OKC are as effective as
term, with further longer term RCTs (one year) being required. each other for knee laxity, pain and function, at least in the short
Home based versus supervised based rehabilitation explores term (6e14 weeks) after ACL reconstruction. Moderate evidence
whether the quality of physiotherapy based supervised exercise is shows home based and clinic based rehabilitation are equally
attainable in cost saving home based exercise protocols, given to effective; however the degree of physiotherapy input remains
patients on discharge after surgery. Moderate evidence reported in unclear. There is consistence and limiting evidence for a lot of other
this review supports the finding that both modes of physiotherapy interventions including: the use of NMES and exercise, accelerated
are equally effective as there is no difference between groups for and non-accelerated rehabilitation, early and delayed rehabilita-
knee laxity, ROM, strength, and function, (time points six months tion, and eccentric resistance programmes after ACL reconstruc-
to one year) (Andersson et al., 2009). Again, conflict appears tion. These specific interventions require further investigation.
between two reviews on the levels of evidence for some outcomes
due to the primary outcomes of one review (Trees et al., 2005) Conflict of interest
being function and RTS, limiting the number of RCTS in that I affirm that I have no financial affiliation (including research
review. It is unclear; however, what home based rehabilitation funding) or involvement with any commercial organization that
consists of. Several of the RCTs (Fischer, Tewes, Boyd, & Smith, has a direct financial interest in any matter included in this
1998; Schenck, Blaschak, Lance, Turturro, & Holmes, 1997) indi- manuscript.
cated that home based rehabilitation groups received six physio-
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Please cite this article in press as: Lobb, R., et al., A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation,
Physical Therapy in Sport (2012), doi:10.1016/j.ptsp.2012.05.001