Vibration training may lead to faster and more complete proprioceptive recovery but further evidence is needed. Conclusions: Several new modalities for rehabilitation after ACL reconstruction may be helpful but should not be performed to the exclusion of range-of-motion, strengthening, and functional exercises. Accelerated rehabilitation does not appear to be harmful but further investigation of rehabilitation timing is warranted.
Level of evidence: Therapeutic Level II. Role of accelerated rehabilitation versus standard rehabilitation following anterior cruciate ligament reconstruction using hamstring graft. Introduction: Anterior cruciate ligament ACL is the most common ligament injury around the knee.
Supervised physiotherapy leads to a better return to physical activity after anterior cruciate ligament reconstruction. The Journal of sports medicine and physical fitness.
The American journal of sports medicine. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play.
British Journal of Sports Medicine. The characteristics of the three included RCTs are summarised in Table 3. Hartigan, Axe and Snyder-Mackler [ 31 ]. No subjects exercised their lower extremities outside of therapy while participating in the preoperative intervention phase. PERT group received 10 sessions of physical therapy including specialized neuromuscular exercises involving systematic translation of support surfaces and progressive quadriceps strength training average 3.
The University of Delaware guidelines for perturbation training were followed. STR group received 10 sessions of progressive quadriceps strength training only average 3. After the 10 preoperative sessions, ACLR was performed using either semitendinosus-gracilis autograft or soft tissue allograft. Knee excursion obtained by calculating peak knee extension minus peak knee flexion during the mid-stance phase of gait were measured.
Quadriceps strength indexes before intervention Pert: Knee excursions at mid-stance were smaller on the involved side prior to surgery in both groups.
The involved limb moved through less flexion in the perturbation group Mean: 5. Kim, Hwang and Park [ 28 ]. PEG participated in a 4-week exercise programme preoperatively and in a week postoperative programme. The preoperative programme focused mainly on strengthening with particular attention paid to the quadriceps muscle, functional balance, muscle control and co-contraction. The highest peak torque value for each velocity was compared with the uninjured side and described as percent of strength deficit.
Preoperative: Postoperative: Shaarani et al. There was no significant different in age, height, weight, body mass index and Tegner activity level before and after injury between the groups at baseline. The prehabilitation group completed a 6-week supervised resistance and balance training programme. This consisted of 4 exercise periods per week: 2 supervised gym sessions and 2 supervised home sessions. The control group were not discouraged to do any exercise or normal activity of daily living but were asked to keep a record of exercise activity performed during the weeks before surgery.
All patients had an ACLR performed by one surgeon using a standard bone-patellar tendon-bone graft. Both groups undertook a standard postoperative physiotherapy programme.
At weeks postoperatively, the single leg hop scores were reduced for both groups but the prehabilitation group There were no statistically significant differences between the prehabilitation and control group for the injured limb at any time point mean [SD], pre-operation: No significant differences were found for hamstring peak torque between groups at both pre- and post-operative time points. The prehabilitation group scores increased significantly from baseline Two RCTs excluded female participants [ 27 , 28 ].
Two RCTs included a PreHab group compared to a control group who received no preoperative exercise programme [ 27 , 28 ]. The remaining RCT compared two different preoperative exercise protocols [ 31 ].
All RCTs evaluated quadriceps strength. Two RCTs utilised a single leg hop for distance test [ 28 , 31 ]. One RCT assessed knee excursion during the mid-stance phase of gait to report between limb symmetry [ 31 ]. All RCTs included pre- and post-operative outcome measures although time-points at which they were assessed varied. No RCT utilised a psychological outcome measure. All RCTs included pre- and post-operative outcome measures, although time-points varied between studies; Hartigan, Axe and Snyder-Mackler [ 31 ], pre-intervention and 6-months post-operatively; Kim, Hwang and Park [ 28 ] 4-weeks pre-operatively pre-intervention and 3-months post-operatively; Shaarani et al.
Common omissions across studies for these two domains included lack of detail with regard to study protocol and lack of blinding of participants and study personnel. All three RCTs failed to report whether deviations arose from the intended interventions and only the protocol for Shaarani et al. Hartigan, Axe and Snyder-Mackler [ 31 ] failed to declare a drop-out rate and although Shaarani et al. Pre-operative protocols differed across all three RCTs. The number of sessions varied from 10 to 24 and were completed over varying time frames.
Hartigan, Axe and Snyder-Mackler [ 31 ] did not set participants a fixed number of sessions to complete per week only that ten sessions were to be completed, taking the perturbation group an average of 3. The two remaining studies specified the number of sessions to be completed each week; Shaarani et al. The exercise interventions were predominantly completed with supervision. However, the perturbation group required a therapist to be involved in the intervention and it is therefore implied this group were supervised [ 31 ].
All RCTs included quadriceps strength as an outcome measure but utilised different methods of assessment. As the measurements across studies were not comparable, the authors were not contacted for the raw data as data pooling would not have been possible.
Hartigan, Axe and Snyder-Mackler [ 31 ] found that quadriceps strength indexes improved in both groups from pre-intervention Pert: Although between group differences were not reported in their results. The authors did not provide point measures for the between group differences in knee extensor strength deficits from pre- to post-operation.
No minimal clinically significant difference MCID has been established for this outcome. This study also assessed hamstring peak torque [ 27 ] and again found no significant difference between groups for hamstring peak torque measured pre- and post-operatively. Both authors were contacted for the raw data, Shaarani et al. Both Kim, Hwang and Park [ 28 ] and Shaarani et al.
No MCID has been reported for the single leg hop distance. Gait was assessed by Hartigan, Axe and Snyder-Mackler [ 31 ] reporting knee excursion at the mid-stance of gait obtained by calculating peak knee extension minus peak knee flexion. At six months post-surgery, the perturbation group showed no significant difference in knee excursion between limbs Mean: 3.
No between group differences were reported. The Tegner score was reported to have been taken by Shaarani et al. When contacted, it was confirmed that the Tegner-Lysholm Knee Score was assessed at all three time points baseline, before ACLR and weeks postoperatively. There were no statistically significant differences between the PreHab and control groups scores at any time point. The intervention group showed a statistically significant improvement from baseline No between group differences were analysed.
Although it was reported that the intervention group returned to sport sooner after surgery mean time [SD], Currently, no evidence exists to support the use of PreHab to improve return to preinjury levels of physical activity, function or psychological readiness post-surgery. Both the PEDro and Cochrane Risk of Bias tools evaluate the risk of bias in RCTs and have six common items random allocation, concealed allocation, blinding of participants, personnel and assessors, and incomplete outcome data , though it has been acknowledged that the tools cannot be used interchangeably and agreement between overall scores is poor [ 32 ].
The remaining studies included in the Alshewaier, Yeowell and Fatoye [ 6 ] review were excluded from this review due to study design not RCT , data collection time-points not all studies assessed participants post-operatively and study population not all participants underwent ACLR.
There are three remaining cohort studies in the literature that were excluded from both reviews. However, generalisability of results is limited as the study designs introduces a high risk of bias with key concerns including the risk of confounding, selection and information bias [ 36 ]. The evidence supporting the use of PreHab remains limited. In the included RCTs, no emphasis was placed on the importance of the psychological status of individuals prior to or following surgery and how PreHab may effect this; despite the evidence base identifying psychological barriers as the most commonly cited reasons for failing to return to physical activity after ACLR [ 12 , 37 , 38 ].
It has been suggested that increased subjective knee scores are associated with increased psychological readiness for return to activity [ 3 , 14 , 39 ]. Thus, it could be hypothesised that PreHab also improves psychological readiness, however further high-quality research needs to explore this more explicitly using validated outcome measures, such as the ACL-Return to Sport after Injury ACL-RSI scale [ 40 ]. The use of psychological factors to predict post-operative outcomes following ACLR and return to preinjury activity levels has frequently been cited in the literature [ 18 , 41 — 44 ].
A case-control study of recreational and competitive level athletes established a link between pre- and early post-operative ACL-RSI scores and the likelihood of returning to preinjury activity, with higher scores favouring a return [ 3 ].
Keywords: anterior cruciate ligament; biomechanics; rehabilitation; strain. Abstract Context: Distinct exercises have been proposed for knee rehabilitation after anterior cruciate ligament ACL reconstruction.
Publication types Review Systematic Review.
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