Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensusEvidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus
Anterior cruciate ligament reconstruction (ACLR) is a common treatment for athletes after ACL injury.
- Besides its mechanical function in maintaining knee stability, the ACL contains mechanoreceptors (2.5%) and therefore directly influences the neuromuscular control of the knee. ACL deficiency causes partial deafferentation and alters spinal and supraspinal motor control. The changes in motor control strategy can reveal changes in proprioception, postural control, muscle strength, movement and recruitment patterns.
- An ACL injury might therefore be regarded as a neurophysiological dysfunction and not a simple musculoskeletal injury.
- It is also not self-evident that an ACLR will automatically lead to a return to preinjury activity level.
- Recent research shows that 35% of athletes after ACLR do not return to preinjury sport level within 2 years. Half of these athletes report their ACL injury as the primary reason for a lower activity level. Also the psychological response (eg, fear of reinjury) after ACLR has an influence on whether an athlete chooses to return to play. Return to play is defined as the ability to play a competitive match at the preinjury level. Moreover, recent research shows that 3–22% of athletes
- Return to play is defined as the ability to play a competitive match at the preinjury level. Moreover, recent research shows that 3–22% of athletes rerupture the reconstructed ligament and 3–24% rupture the contralateral ACL in the first 5 years after ACLR.
Return to play is the ultimate goal of rehabilitation programmes.
Therefore, the Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of ACL experts to develop an evidence statement for anterior cruciate ligament rehabilitation. Following three questions were formulated
1. What should be the content of the rehabilitation protocol after ACLR based on scientific evidence and, if not present, based on best practice?
2. Which measurements and assessments can be applied to monitor progression during the rehabilitation programme and to determine outcomes at the end of rehabilitation programme?
3. What criteria should be used to determine the moment of return to play?
Further 9 questiom were used to guide the systematic review process.
These nine topics were:
- (1) preoperative predictors for postoperative outcome,
- (2) effectiveness of physical therapy,
- (3) open kinetic chain (OKC) versus closed kinetic chain (CKC) quadriceps exercises,
- (4) strength training and neuromuscular training,
- (5) electrostimulation and electromyographic feedback,
- (6) cryotherapy,
- (7) measurements of functional performance,
- (8) return to play and
- (9) risk of reinjuries
Summary of conclusion and recommendations