Use of electromyographic biofeedback in rehabilitation following anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

BACKGROUND: Rehabilitation following anterior cruciate ligament (ACL) reconstruction surgery is essential to regain functionality and return to previous activity level. Electromyographic biofeedback may be an effective intervention for rehabilitation of patients following ACL surgery. OBJECTIVE: To synthesize the available evidence on the effect of electromyographic biofeedback in the treatment of quadriceps strength following ACL surgery. DESIGN: Systematic review with meta-analysis. DATA SOURCES: PubMed, EMBASE, CENTRAL and Epistemonikos were searched. ELIGIBILITY CRITERIA: Randomized clinical trials with patients undergoing ACL reconstruction surgery comparing biofeedback with a standard rehabilitation control group. DATA EXTRACTION AND DATA SYNTHESIS: Two authors selected articles and performed data extraction. The analysed outcomes were strength, function, pain, knee extension and balance. The risk of bias of individual studies was assessed using the Cochrane Risk of Bias Tool. Results were combined through random-effects meta-analysis, reporting mean differences. RESULTS: Eight articles were included in the qualitative analysis, and four articles were included in the quantitative analysis. The interventions lasted between 4 and 12 weeks. Three studies evaluated the effect of biofeedback on quadriceps strength; of these, two studies showed a significant difference in favour of the biofeedback group. In addition, biofeedback was found to improve knee extension [standardized mean difference - 1.3, 95% confidence interval (CI) - 1.74 to -0.86] and balance (one study). There was no significant difference in Lysholm score (mean difference -6.21, 95% CI -17.51 to 5.08; I2 =59%) or pain between the biofeedback group and the control group. CONCLUSION: Electromyographic biofeedback in knee rehabilitation could be useful following ACL reconstruction surgery. KEY MESSAGES: SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42020193768).

[Effect of dietary supplements and whey protein on muscle mass and strength of the operated limb after anterior cruciate ligament reconstruction: a systematic review].

Muscle weakness and atrophy of the quadriceps muscle after anterior cruciate ligament reconstruction may persist for up to 6 months after surgery and cause re-injury to the ipsilateral or contralateral limbs. Many authors state that adequate nutritional status during the rehabilitation period can contribute to faster postoperative recovery of muscle mass and strength of the lower limb, be an adjunct to exercise, or serve an alternative treatment strategy. The purpose of the research was to conduct a systematic review of the literature and evaluate the degree of influence of dietary supplements on muscle mass and strength of the operated limb after reconstruction of the anterior cruciate ligament (ACL). Material and methods. The search for articles was carried out in international databases PubMed, Google Scholar, Cochrane Library. The time frame of the search was 22 years. To be included in the review, studies had to meet the PICOS criteria: participants were men and women over 18 years of age after ACL reconstruction; intervention - supplementation after and/or before and after ACL reconstruction; comparison - placebo group or no supplementary interventions; results - assessment of the dynamics of changes in muscle mass (cross-sectional area, muscle thickness or size of skeletal muscle fibers) and / or maximum strength (dynamic or isometric) of the operated limb; research design - randomized controlled trials (RCT). The quality of selected RCTs was assessed using the Cochrane Collaboration Risk of Bias (RoB 2) tool. Results. A total of 1397 articles were found after searching in the databases. This systematic review included 6 RCTs with a total number of patients 186. The following dietary supplements were used: leucine - 1 article, glucosam ine - 1 article, creatine - 1 article, vitamins E and C - 2 articles. One study evaluated the effect of whey protein supplementation in combination with neuromuscular electrical stimulation on isometric strength of the operated limb. When comparing the data of 3 groups in the pre- and postoperative periods, there were no statistically significant differences between the groups. When considering the protocols for taking dietary supplements based on creatine, glucosamine, vitamins E and C, none of the studies demonstrated statistically significant improvements in the parameters of maximum strength or muscle hypertrophy of the operated limb in the main groups compared with the control groups. Also, no results have been obtained indicating that these dietary supplements can slow down muscl e atrophy after surgery. In another study that evaluated the effect of leucine supplementation, by the end of the rehabilitation program, the muscle strength of the operated limb tended to increase more in the leucine group than in the placebo group, but without a statistically significant difference. At 10 cm from the patella, the femoral circumference of the operated limb in the leucine group increased more than in the placebo group, and the differences were statistically significant (р=0.009). Two studies were rated as high risk of bias, three as moderate risk, and one as low risk. Conclusion. None of the supplements used had a statistically significant effect on the muscle strength of the operated limb after ACL reconstru ction. In terms of thigh muscle hypertrophy, the only significant improvement was associated with leucine supplementation and an increase in thigh circumference at a distance of 10 cm from the patella.

Does body scanning through visual imagery improve perception and function in patients after anterior cruciate ligament-reconstruction? An exploratory study.

INTRODUCTION: Many people who have undergone Anterior Cruciate Ligament (ACL)-reconstruction do not return to their pre-injury level, with nonphysical factors recognized as barriers to recovery. Fear of movement has been linked to body schema distortions, and interventions directed at the body schema have shown potential to improve function. OBJECTIVE: 1) Describe participants' ability to perform a visual imagery intervention (Body Scan); 2) investigate knee perception differences; 3) investigate if Body Scan led to improvements in perceptual differences; and 4) determine if some individuals improved in functional measures following the intervention. METHODS: A single-arm intervention study was undertaken in people >12-month post ACL-reconstruction (n = 30). Body Scan was delivered using a standardized script developed for this study. Participants were assessed regarding their capacity to perform the Body Scan, perceptual differences between the knees and how perception changed following the intervention. Functional measures (vertical hop, triple hop, mSEBT, quadriceps strength, and hamstring strength) were taken. RESULTS: 96.7% were able to perform a Body Scan, with 93.1% demonstrating a difference in perception between the knees. Of participants with perceptual differences, 92.5% demonstrated improvement in perception following the intervention. Ten participants had a clinically significant improvement in a functional measure following the intervention. CONCLUSION: Most participants could perform Body Scanning. The majority perceived perceptual differences between operated and non-operated knees, and reported more symmetric perception following the intervention. One-third of participants also showed improvements in a functional performance measure. Results suggest this intervention may be a helpful adjunct to rehabilitation post ACL-reconstruction, with further research warranted.

Acupuncture and herbal medicine for postoperative care following anterior cruciate ligament reconstruction: A protocol for systematic review and meta-analysis.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is the primary treatment for patients with anterior cruciate ligament (ACL) injury. Successful postoperative rehabilitation is imperative for their recovery. This protocol details the methods that will be used to systematically analyze the efficacy of acupuncture and herbal medicine for postoperative care following ACLR. METHODS AND ANALYSIS: Randomized controlled trials will be searched in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE/PubMed, Chinese National Knowledge Infrastructure, Japan Medical Abstracts Society, and 7 Korean databases (Oriental Medicine Advanced Searching Integrated System, Korean National Assembly Digital Library, Korean Association of Medical Journal Editors, Korean Studies Information Service System, Korean Traditional Knowledge Portal, National Digital Science Library, and Database Periodical Information Academic). The risk of bias will be assessed using the Cochrane assessment tool of risk of bias. The studies that are selected after checking for eligibility will be quantitatively analyzed as a meta-analysis. The primary outcome will be the scores of pain scales, and the secondary outcomes will be the range of motion of the knee, severity of the swelling, and parameters about the knee joint function. ETHICS AND DISSEMINATION: Ethical approval is not required for this protocol because it does not include patient data. The findings of this review will be disseminated through peer-reviewed publications or conference presentations. REGISTRATION NUMBER: DOI 10.17605/OSF.IO/ZY2W8 (https://osf.io/zy2w8).

Current preoperative physiotherapy management strategies for patients awaiting Anterior Cruciate Ligament Reconstruction (ACLR): A worldwide survey of physiotherapy practice.

BACKGROUND: Anterior cruciate ligament ruptures are the most common ligament injury to the knee with surgical reconstruction considered standard treatment. This study aimed to explore the current physiotherapy management strategies used during the preoperative phase of rehabilitation for patients awaiting anterior cruciate ligament reconstruction (ACLR). METHODS: An anonymous survey was disseminated online via Twitter and the 'interactive Chartered Society of Physiotherapy' message board. Practising physiotherapists who treated at least one patient prior to ACLR in the past year were invited to take part. Responses were collected over a 4-week period in March 2020. Data were analysed using descriptive statistics. RESULTS: In total, 183 respondents replied; 122 completed the full survey. Responses were collected from 20 countries across 3 settings, NHS/public health services, private and sports. Most respondents reported prescribing exercises, advice and education to patients during prehabilitation. Up to 40% also utilised passive treatments including manual therapy, taping/bracing and electrotherapy. The frequency of recommended exercise completion and length of treatment varied. Most respondents (n = 103/84.4%) felt that many patients waiting for ACLR did not receive prehabilitation. Many physiotherapists reported that patients expressed concerns regarding their readiness for surgery (n = 61/50%) and return to preinjury levels of physical activity (n = 112/91.8%). Almost all respondents would discuss non-operative management with patients (n = 112/91.8%) if they had returned to their preinjury level of physical activity before their ACLR. CONCLUSION: Overall, this survey provides some insight as to how physiotherapists manage patients awaiting ACLR. Areas of uncertainty in physiotherapy practice have also been highlighted that require further high-quality research.

Michigan Initiative for Anterior Cruciate Ligament Rehabilitation (MiACLR): A Protocol for a Randomized Clinical Trial.

OBJECTIVE: Restoring quadriceps muscle strength following anterior cruciate ligament reconstruction (ACLR) may prevent the posttraumatic osteoarthritis that affects over 50% of knees with ACLR. However, a fundamental gap exists in our understanding of how to maximize muscle strength through rehabilitation. Neurological deficits and muscle atrophy are 2 of the leading mechanisms of muscle weakness after ACLR. High-intensity neuromuscular electrical stimulation (NMES) and eccentric exercise (ECC) have been shown to independently target these mechanisms. If delivered in succession, NMES and then ECC may be able to significantly improve strength recovery. The objectives of this study were to evaluate the ability of NMES combined with ECC to restore quadriceps strength and biomechanical symmetry and maintain cartilage health at 9 and 18 months after ACLR. METHODS: This study is a randomized, double-blind, placebo-controlled, single-center clinical trial conducted at the University of Michigan. A total of 112 participants between the ages of 14 and 45 years and with an anterior cruciate ligament rupture will be included. Participants will be randomly assigned 1:1 to NMES combined with ECC or NMES placebo combined with ECC placebo. NMES or NMES placebo will be delivered 2 times per week for 8 weeks beginning 10 to 14 days postoperatively and will be directly followed by 8 weeks of ECC or ECC placebo delivered 2 times per week. The co-primary endpoints are change from baseline to 9 months and change from baseline to 18 months after ACLR in isokinetic quadriceps strength symmetry. Secondary outcome measures include isometric quadriceps strength, quadriceps activation, quadriceps muscle morphology (cross-sectional area), knee biomechanics (sagittal plane knee angles and moments), indexes of patient-reported function, and cartilage health (T1ρ and T2 relaxation time mapping on magnetic resonance imaging). IMPACT: The findings from this study might identify an intervention capable of targeting the lingering quadriceps weakness after ACLR and in turn prevent deterioration in cartilage health after ACLR, thereby potentially improving function in this patient population.

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II).

OBJECTIVES: To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction. DESIGN: Systematic review of CPGs (PROSPERO number: CRD42017020407). DATA SOURCES: Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018. ELIGIBILITY CRITERIA: English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction. RESULTS: Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was 'applicability' (can clinicians implement this in practice?) (29%) and the highest 'scope and purpose' (78%) and 'clarity of presentation' (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing. CONCLUSION: The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.

Effectiveness of Accelerated Recovery Performance for Post-ACL Reconstruction Rehabilitation.

Atrophy and protracted recovery of normal function of the ipsilateral quadriceps femoris muscle following anterior cruciate ligament reconstruction surgery is well documented. The Accelerated Recovery Performance trainer is a type of electrical stimulation device that delivers a high-pulse frequency via a direct current, making it unique from many other devices on the market. The purpose of the present study was to investigate the effects of the direct current (via the Accelerated Recovery Performance trainer protocol) on gains in thigh circumference following anterior cruciate ligament reconstruction. Twenty-five patients were enrolled following isolated anterior cruciate ligament reconstruction and randomly assigned to either an isometric rehabilitation protocol augmented with the Accelerated Recovery Performance trainer protocol (experimental group) or the isometric rehabilitation protocol alone (control group). The two groups participated in sixteen sessions of directed rehabilitation over a two-month time period. Patients were followed with serial thigh circumference measurements at 5, 10, 15, and 20 centimeters above the superior patellar pole. Comparison of the overall mean circumferential gains in thigh circumference of the involved leg demonstrated approximately 3:1 gains in the ARP group over the control group, demonstrating it to be superior to isometric rehabilitation alone with regards to gains in thigh girth. The Accelerated Recovery Performance trainer protocol should be considered for post-anterior cruciate ligament reconstruction rehabilitation in order to reverse disuse atrophy of the ipsilateral quadriceps femoris.

Variability in rehabilitation protocols following pediatric anterior cruciate ligament (ACL) reconstruction.

Objectives: The objective of this study was to assess the variability of publicly available pediatric anterior cruciate ligament (ACL) reconstruction rehabilitation protocols produced by academic orthopedic surgery departments and children's hospitals.Methods: A web-based search was performed to identify rehabilitation protocols. Protocol and literature review guided the development of a comprehensive scoring rubric that was used to assess protocols for the presence and timing of postoperative adjunctive therapy and physical therapy recommendations.Results: A search of 180 academic orthopedic surgery programs and 250 children's hospitals identified 21 rehabilitation protocols. A majority of these protocols (90%) recommended postoperative adjunctive therapies such as bracing (81%), cryotherapy (43%), electrical muscle stimulation (24%), and/or continuous passive motion (14%). Several protocols (57%) recommended a specific weight-bearing status in the immediate postoperative period, but there was minimal consensus on that status. Conversely, there was more agreement amongst protocols that recommended strength exercises (52%); a majority of protocols suggested quad sets (91%), ankle pumps (73%), leg press (64%), and/or double-leg squats (55%). Ten protocols (48%) recommended initiation of stretches in the first week following surgery, and most commonly suggested patella mobilizations start at an average of 1.9 weeks postop (range 0-8 weeks). Twelve protocols (57%) discussed return to play, with an average recommended return to play at 7.5 months (range 3-11 months) postoperatively. However, few protocols recommended that patients get approval from their surgeon (19%) or pass specific tests (24%) prior to return to play.Conclusion: Few academic departments of orthopedic surgery or children's hospitals publish pediatric ACL reconstruction protocols online. Given the substantial variability observed amongst these protocols and recent findings that patients increasingly turn to the internet for medical information, this study suggests that standardization of pediatric ACL reconstruction rehabilitation has the potential to further optimize patient care.

Rehabilitation and nutrition protocols for optimising return to play from traditional ACL reconstruction in elite rugby union players: A case study.

Current nutrition and exercise focus during rehabilitation periods has been on reducing muscle atrophy associated with immobilisation. This case report outlines a best practice anterior cruciate ligament (ACL) rehabilitation programme undertaken by two professional rugby athletes, with the addition of an evidence-based supplementation (gelatine and vitamin C) and exercise protocol focused on collagenous tissue. Both players ruptured their left ACL and were repaired with a traditional hamstring graft. Players undertook a structured rehabilitation programme for 34 weeks before being clinically assessed ready to play. Players saw minimal changes in body composition in the early rehabilitation period (P1 - 0.8 kg; P2 - 0.4 kg). Leg lean mass reduced in both legs of Player 1 (Injured - 0.8 kg, Non-injured - 0.6 kg) at 17 weeks, with Player 2 only experiencing a loss of 0.3 kg of lean tissue in the injured leg. Both players returned to baseline body compositions after 24 weeks. Leg strength returned to a maximum at 24 and 15 weeks, respectively, with knee function returning to baseline by 30 weeks. This case report provides evidence that nutrition and rehabilitation programmes targeted at minimising the effects of disuse in both muscle and connective tissue may assist return to play after ACL injury.

Body Composition and Strength Parameters in Elite Judo Athletes 5 Years after Anterior Cruciate Ligament Reconstruction.

The purpose of this study was to investigate if there are still deficits in muscle mass or strength capabilities in elite judo athletes with a history of anterior cruciate ligament reconstruction (ACLR) after their return to the sport. Therefore, bioimpedance analysis, 3D-laser thigh circumference measurement and isokinetic dynamometry in a closed kinetic chain were used. The side-to-side differences were investigated in a group of judo athletes 5 years after ACLR (n=17) and compared with a group of healthy judo athletes (n=27). Neither thigh circumferences, nor muscle masses of the lower extremities differed in formerly injured judo athletes compared to healthy judo athletes. In contrast, isokinetic strength testing showed a significantly larger side-to-side difference of peak muscle force in formerly injured judo athletes (p=0.021). They provided significantly lower peak forces with the formerly injured leg than with the non-injured leg (p<0.001). The authors conclude that strength capabilities, but not body composition, remains altered in recovered judo athletes in mean 5 years after ACLR and definitely after their return to sports. This indicates that the focus of rehabilitation protocols and return to sports assessments should focus more on maximum strength capabilities.

Reducing Fear of Reinjury and Pain Perception in Athletes With First-Time Anterior Cruciate Ligament Reconstructions by Implementing Imagery Training.

Clinical Scenario: The anterior cruciate ligament is one of the major stabilizing ligaments of the knee joint by preventing anterior translation of the femur in the closed kinetic chain. A ruptured anterior cruciate ligament may require reconstructive surgery for patients who wish to return to physical activity. For the most part, surgeries are successful at repairing the ruptured ligament and restoring ligamentous function; the percentage of athletes that return to a competitive level of physical activity is only 44%, and 24% of patients report a main factor of preventing their return is fear of reinjury and pain. Most physiotherapy and rehabilitation research has focused on the physical treatment and is limited on the psychological aspects of recovery. Imagery has been suggested to be effective at reducing anxiety, tension, and pain, while promoting and encouraging healing after an injury. Imagery is defined as a process of performing a skill in one's mind using the senses (touch, feel, smell, vision, etc) without any overt actions. Clinical Question: In athletes who are first-time anterior cruciate ligament reconstruction patients, does imagery training in combination with standard physical therapy reduce the fear of reinjury and pain perception? Summary of Key Findings: Previous research has primarily looked at the physical treatment aspect, and few studies have focused on the psychological factors affecting recovery. Researchers concluded that fear of reinjury was the unique predictor of return to sport even in a sample of participants that reported very little or almost no pain at all. Imagery as a therapy is an effective intervention in reducing fear of reinjury and confidence building. Furthermore, mental imagery is suggested to assist with a reduction in anxiety, pain, and tension, while promoting healing. Clinical Bottom Line: Based on the strength of recommendation taxonomy, there is a combination of level A and B evidence proposing that imagery, in combination with traditional physical therapy, can be effective at reducing psychological distress such as fear of reinjury and pain perception in first-time anterior cruciate ligament reconstruction patients.

Adding high-frequency transcutaneous electrical nerve stimulation to the first phase of post anterior cruciate ligament reconstruction rehabilitation does not improve pain and function in young male athletes more than exercise alone: a randomized single-blind clinical trial.

PURPOSE: Knee ligamentous trauma and the following pain is one of the most prevalent athletic injuries. Transcutaneous electrical nerve stimulation is one of the conservative approaches in controlling pain which is low cost, noninvasive, and safe with low complications. Our purpose was to study whether transcutaneous electrical nerve stimulation (TENS) could help athletes perform better during the first phase of rehabilitation (0-4 weeks) after anterior cruciate ligament (ACL) reconstruction surgery and until the follow-up. METHODS: This randomized single blind (exercise instructor and assessor) clinical trial was performed on 70 male athletes, undergone ACL surgery. After the surgery, patients were randomly divided into two groups: the first group received semi-supervised exercise plus high-frequency TENSTENS for 35 min a day and the second group only performed exercises. Treatment duration continued for 20 sessions, 4 weeks. The visual analog scale (VAS) score (100 mm), International Knee Documentation Committee (IKDC) questionnaire and knee flexion Range of motion (ROM) were evaluated for all patients after the surgery (before commencing the rehabilitation program), after 4 weeks and 14 weeks from the surgery. RESULTS: Mixed ANOVA was used to explore the interaction effects of time and group on outcome measures and post hoc additional tests were performed on the data. The VAS, IKDC questionnaire score and knee flexion ROM increased in both groups over time, but the amount of improvement did not differ between the two groups, implying no additional improvement in the group receiving TENS along with exercises. CONCLUSION: The findings of the present trial shows that adding TENS to a specific protocol of semi-supervised exercise in the first phase of rehabilitation after ACL reconstruction is not efficient on improving knee function and pain more than exercise alone. Implications for Rehabilitation Injury to the anterior cruciate ligament of the knee is a common injury specifically in athletes. Incorporating effective pain relieving strategies during the post anterior cruciate ligament reconstruction surgery rehabilitation could lead to improvement in regaining the range of motion and function of the knee which is of crucial importance after the surgery. Applying transcutaneous electrical nerve stimulation alongside a specific protocol of semi-supervised exercise in the first phase of rehabilitation after anterior cruciate ligament reconstruction did not have any additional effect to exercise alone.

Do psychosocial interventions improve rehabilitation outcomes after anterior cruciate ligament reconstruction? A systematic review.

OBJECTIVE: To examine the role of psychosocial interventions in improving patient-reported clinical outcomes, including return to sport/activity, and intermediary psychosocial factors after anterior cruciate ligament reconstruction. METHODS: MEDLINE/PubMed, CINAHL, PsycINFO, and Web of Science were searched from each database's inception to March 2017 for published studies in patients after anterior cruciate ligament reconstruction. Studies were included if they reported on the effects of a postoperative psychosocial intervention on a patient-reported clinical measure of disability, function, pain, quality of life, return to sport/activity, or intermediary psychosocial factor. Data were extracted using a standardized form and summary effects from each article were compiled. The methodological quality of randomized trials was assessed using the Physiotherapy Evidence Database Scale and scores greater than 5/10 were considered high quality. RESULTS: A total of 893 articles were identified from the literature search. Of these, four randomized trials ( N = 210) met inclusion criteria. The four articles examined guided imagery and relaxation, coping modeling, and visual imagery as postoperative psychosocial interventions. Methodological quality scores of the studies ranged from 5 to 9. There were inconsistent findings for the additive benefit of psychosocial interventions for improving postoperative function, pain, or self-efficacy and limited evidence for improving postoperative quality of life, anxiety, or fear of reinjury. No study examined the effects of psychosocial interventions on return to sport/activity. CONCLUSION: Overall, there is limited evidence on the efficacy of postoperative psychosocial interventions for improving functional recovery after anterior cruciate ligament reconstruction.

Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery.

PURPOSE: Reduced ability to contract the quadriceps muscles is often found immediately following anterior cruciate ligament (ACL) surgery. This can lead to muscle atrophy and decreased function. Application of neuromuscular electrical stimulation (NMES) may be a useful adjunct intervention to ameliorate these deficits following ACL surgery. The purpose of this review was to determine whether NMES in addition to standard physical therapy is superior to standard physical therapy alone in improving quadriceps strength or physical function following ACL surgery. METHODS: A computer-assisted literature search was conducted utilizing PubMed, CINAHL, PEDro and Cochrane Library databases for randomized clinical trials where patients after ACL surgery received NMES with the outcome of muscle strength and/or physical function. Random effect models were used to pool summary estimates using standardized mean differences (SMD) for strength outcomes. Physical function outcomes were assessed qualitatively. Methodological quality was assessed from the Physiotherapy Evidence Database (PEDro)-score. RESULTS: Eleven studies met our inclusion criteria; results from six of these were pooled in the meta-analysis showing a statistically significant short-term effect of NMES (4-12 weeks) after surgery compared to standard physical therapy [SMD = 0.73 (95% CI 0.29, 1.16)]. Physical function also improved significantly more in the NMES groups. PEDro scores ranged from 3/10 to 7/10 points. CONCLUSION: NMES in addition to standard physical therapy appears to significantly improve quadriceps strength and physical function in the early post-operative period compared to standard physical therapy alone. LEVEL OF EVIDENCE: I.

Neuromuscular Electrical Stimulation Superimposed on Movement Early after ACL Surgery.

PURPOSE: Quadriceps weakness and asymmetrical loading of lower limbs are two major issues after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to evaluate the effectiveness of a 6-wk training protocol involving neuromuscular electrical stimulations (NMES) of the quadriceps muscle superimposed on repeated sit-to-stand-to-sit exercises (STSTS), as an additional treatment to standard rehabilitation, from the 15th to the 60th day after ACLR. METHODS: Sixty-three ACLR patients were randomly allocated to one of the three treatment groups: NMES superimposed on STSTS (NMES + STSTS), STSTS only, or no additional treatment (NAT) to standard rehabilitation. Maximal isometric strength of the knee extensor and flexor muscles was measured 60 and 180 d after surgery. Asymmetry in lower extremity loading was measured during a sit-to-stand movement at 15, 30, 60, and 180 d after surgery and during a countermovement jump 180 d after surgery by means of two adjacent force platforms placed under each foot. RESULTS: The NMES + STSTS participants showed higher muscle strength of the knee extensors, which was accompanied by lower perception of pain and higher symmetry in lower extremity loading compared with STSTS-only and NAT participants after both 60 and 180 d from surgery. Participants in the STSTS-only treatment group showed higher symmetry in lower extremity loading compared with those in the NAT group 60 d after surgery. CONCLUSIONS: These results suggest that an early intervention based on NMES superimposed to repeated STSTS exercises is effective for recovering quadriceps strength and symmetry in lower extremity loading by the time of return to sport.

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.

Combination of eccentric exercise and neuromuscular electrical stimulation to improve quadriceps function post-ACL reconstruction.

BACKGROUND: Neuromuscular electrical stimulation (NMES) has been shown to reduce quadriceps activation failure (QAF), and eccentric exercise has been shown to lessen muscle atrophy post-ACL reconstruction. Given that these are two critical components of quadriceps strength, intervention combining these therapies may be effective at reinstituting quadriceps function post-reconstruction. Thus, the aim of this study was to evaluate the effectiveness of a combined NMES and eccentric exercise intervention to improve the recovery of quadriceps activation and strength post-reconstruction. METHODS: Thirty-six individuals post-injury were placed into four treatment groups (N&E, NMES and eccentrics; E-only, eccentrics only; N-only, NMES-only; and STND, standard of care) and ten healthy controls participated. N&E and N-only received the NMES protocol 2× per week for the first 6 weeks post-reconstruction. N&E and E-only received the eccentric exercise protocol 2× per week beginning 6 weeks post-reconstruction. Quadriceps activation was assessed via the superimposed burst technique and quantified via the central activation ratio. Quadriceps strength was assessed via maximal voluntary isomeric contractions (Nm/kg). Data was gathered on three occasions: pre-operative, 12-weeks-post-surgery and at return-to-play. RESULTS: No differences in pre-operative measures existed (P>0.05). E-only recovered quadriceps activation better than N-only or STND (P<0.05). N&E and E-only recovered strength better than N-only or the STND (P<0.05) and had strength values that were similar to healthy at return-to-play (P>0.05). CONCLUSION: Eccentric exercise was capable of restoring levels of quadriceps activation and strength that were similar to those of healthy adults and better than NMES alone. LEVEL OF EVIDENCE: Level 3, Parallel longitudinal study.

Glucosamine supplementation after anterior cruciate ligament reconstruction in athletes: a randomized placebo-controlled trial.

Although glucosamine is commonly consumed by athletes, its effectiveness in sports injuries is still under debate. We aimed to investigate the effects of glucosamine to the rehabilitation outcomes of anterior cruciate ligament (ACL) reconstructed athletes. Glucosamine-sulfate (1000 mg daily, for 8 weeks) was administered to half of the cohort of 30 male athletes, the other half used a placebo. Both groups received the same rehabilitation protocol. Knee pain and functions were evaluated by a visual analogue scale (VAS), International Knee Documentation Committee (IKDC) and Lysholm scores before and after oral administration. Additionally, an isokinetic test was performed after the administration period. The scores revealed significant improvements in both groups after 8 weeks, but no significant difference was detected between groups in any of the parameters. Glucosamine supplementation did not improve the rehabilitation outcomes of athletes after ACL reconstruction. This is the first study investigating this topic. Further studies will help to obtain clear evidence about glucosamine efficacy on ACL injured or ACL reconstructed athletes.