There is no consensus regarding the optimal postoperative rehabilitation program after anterior cruciate ligament (ACL) reconstruction.
Purpose
The purpose of this study was to examine the long-term outcome of a 6-month neuromuscular exercise (NE) training program versus a traditional strength exercise (SE) training program after ACL reconstruction.
Study Design
Randomized controlled trial; Level of evidence, 1.
Methods
Seventy-four patients were randomly assigned to either a NE program or a SE program and tested preoperatively and at 6 months, 1 year, and 2 years after ACL reconstruction. Outcome measurements were as follows: Cincinnati knee score, visual analog scale for pain and global function, Short Form 36, functional knee tests, and isokinetic muscle strength tests.
Results
There were no significant differences between the NE and SE programs 1 and 2 years after ACL reconstruction for the primary outcome measurement (Cincinnati knee score). There were significantly improved knee function (global function) and reduced pain during activity for the NE group, compared with the SE group, and significantly improved hamstring muscle strength for the SE group, compared with the NE group, 2 years after ACL reconstruction.
Conclusion
On the basis of these results, a postoperative program combining both NE and SE should be included after ACL reconstruction to improve knee function.
AdamsKO’SheaJPO’SheaKLClimsteinM. The effect of six weeks of squat, plyometric and squat-plyometric training on power production. J Strength Cond Res. 1992;6:36–41.
2.
American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc. 1998;30:975–991.
3.
BachBRJrWarrenRFFlynnWMKrollMWickiewiczTL. Arthrometric evaluation of knees that have a torn anterior cruciate ligament. J Bone Joint Surg Am. 1990;72:1299–1306.
4.
BeardDJDoddCATrundleHRSimpsonAH. Proprioception enhancement for anterior cruciate ligament deficiency: a prospective randomised trial of two physiotherapy regimes. J Bone Joint Surg Br. 1994;76:654–659.
5.
BerryJKramerKBinkleyJ. Error estimates in novice and expert raters for the KT-1000 arthrometer. J Orthop Sports Phys Ther. 1999;29:49–55.
6.
BollenSSeedhomBB. A comparison of the Lysholm and Cincinnati knee scoring questionnaires. Am J Sports Med. 1991;19:189–190.
7.
BooherLDHenchKMWorrellTWStikeleatherJ. Reliability of three single-leg hop tests. J Sport Rehabil. 1993;2:165–170.
8.
BroskyJAJrNitzAJMaloneTRCabornDNRayensMK. Intrarater reliability of selected clinical outcome measures following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 1999;29:39–48.
9.
BryantDNormanGStratfordPMarxRGWalterSDGuyattG. Patients undergoing knee surgery provided accurate ratings of preoperative quality of life and function 2 weeks after surgery. J Clin Epidemiol. 2006;59:984–993.
10.
BynumEBBarrackRLAlexanderAH. Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 1995;23:401–406.
11.
CarlssonAM. Assessment of chronic pain, I: aspects of the reliability and validity of the visual analogue scale. Pain. 1983;16:87–101.
12.
ChmielewskiTLRudolphKSFitzgeraldGKAxeMJSnyder-MacklerL. Biomechanical evidence supporting a differential response to acute ACL injury. Clin Biomech (Bristol, Avon). 2001;16:586–591.
13.
ChmielewskiTLRudolphKSSnyder-MacklerL. Development of dynamic knee stability after acute ACL injury. J Electromyogr Kinesiol. 2002;12:267–274.
14.
CooperRLTaylorNFFellerJA. A randomised controlled trial of proprioceptive and balance training after surgical reconstruction of the anterior cruciate ligament. Res Sports Med. 2005;13:217–230.
15.
FitzgeraldGK. Open versus closed kinetic chain exercise: issues in rehabilitation after anterior cruciate ligament reconstructive surgery. Phys Ther. 1997;77:1747–1754.
16.
FitzgeraldGKAxeMJSnyder-MacklerL. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Phys Ther. 2000;80:128–140.
17.
FlandryFHuntJPTerryGCHughstonJC. Analysis of subjective knee complaints using visual analog scales. Am J Sports Med. 1991;19:112–118.
18.
FrisonLPocockSJ. Repeated measures in clinical trials: analysis using mean summary statistics and its implications for design. Stat Med. 1992;11:1685–1704.
19.
GarrattASchmidtLMackintoshAFitzpatrickR. Quality of life measurement: bibliographic study of patient assessed health outcome measures. BMJ. 2002;324:1417.
HamblyKGrivaK. IKDC or KOOS? Which measures symptoms and disabilities most important to postoperative articular cartilage repair patients? . Am J Sports Med. 2008;36:1695–1704.
22.
HeijneAWernerS. Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007;15:402–414.
23.
HolmI. Quantifaction of Muscle Strength by Isokinetic Performance[dissertation]. Norway: University of Oslo; 1996.
HrubeschRRanggerCReichkendlerMSailerRFGloetzerWEiblG. Comparison of score evaluations and instrumented measurement after anterior cruciate ligament reconstruction. Am J Sports Med. 2000;28:850–856.
26.
IharaHNakayamaA. Dynamic joint control training for knee ligament injuries. Am J Sports Med. 1986;14:309–315.
27.
IrrgangJJAndersonAFBolandAL. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29:600–613.
28.
IrrgangJJSnyder-MacklerLWainnerRSFuFHHarnerCD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80:1132–1145.
29.
KannusPJarvinenMJohnsonRJ. Function of the quadriceps and hamstrings muscle in the knee with chronic partial deficiency of the anterior cruciate ligament. Am J Sports Med. 1992;20:162–168.
30.
Liu-AmbroseTTauntonJEMacIntyreDMcConkeyPKhanKM. The effects of proprioceptive or strength training on the neuromuscular function of the ACL reconstructed knee: a randomized clinical trial. Scand J Med Sci Sports. 2003;13:115–123.
31.
LogeJHKaasaS. Short Form 36 (SF-36) health survey: normative data from the general Norwegian population. Scand J Soc Med. 1998;26:250–258.
32.
LogeJHKaasaSHjermstadMJKvienTK. Translation and performance of the Norwegian SF-36 Health Survey in patients with rheumatoid arthritis, I: data quality, scaling assumptions, reliability, and construct validity. J Clin Epidemiol. 1998;51:1069–1076.
33.
MarxRGJonesECAllenAA. Reliability, validity, and responsiveness of four knee outcome scales for athletic patients. J Bone Joint Surg Am. 2001;83:1459–1469.
34.
MikkelsenCWernerSErikssonE. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8:337–342.
35.
NatriAJarvinenMLatvalaKKannusP. Isokinetic muscle performance after anterior cruciate ligament surgery: long-term results and outcome predicting factors after primary surgery and late-phase reconstruction. Int J Sports Med. 1996;17:223–228.
36.
NoyesFRBarberSDMangineRE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19:513–518.
37.
NoyesFRMcGinnissGHMooarLA. Functional disability in the anterior cruciate insufficient knee syndrome: review of knee rating systems and projected risk factors in determining treatment. Sports Med. 1984;1:278–302.
PriceDDMcGrathPARafiiABuckinghamB. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. 1983;17:45–56.
40.
RazmjouHYeeAFordMFinkelsteinJA. Response shift in outcome assessment in patients undergoing total knee arthroplasty. J Bone Joint Surg Am. 2006;88:2590–2595.
41.
RisbergMAEkelandA. Assessment of functional tests after anterior cruciate ligament surgery. J Orthop Sports Phys Ther. 1994;19:212–217.
42.
RisbergMAHolmIEkelandA. Reliability of functional knee tests in normal athletes. Scand J Med Sci Sports. 1995;5:24–28.
43.
RisbergMAHolmIMyklebustGEngebretsenL. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. 2007;87:737–750.
44.
RisbergMAHolmISteenHBeynnonBD. Sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score: a prospective study of 120 ACL reconstructed patients with 2 years follow-up. Knee Surg Sports Traumatol Arthrosc. 1999;7:152–159.
45.
RisbergMAHolmISteenHErikssonJEkelandA. The effect of knee bracing after anterior cruciate ligament reconstruction: a prospective, randomized study with two years’ follow-up. Am J Sports Med. 1999;27:76–83.
46.
RisbergMAHolmITjomslandOLjunggrenAEEkelandA. Prospective study of changes in impairments and disabilities after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 1999;29:400–412.
47.
RisbergMALewekMSnyder-MacklerL. A systematic review of evidence for anterior cruciate ligament rehabilitation: How much and what type? . Phys Ther Sport. 2004;5:125–145.
48.
RisbergMAMorkMJenssenHKHolmI. Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2001;31:620–631.
49.
RoosEMRoosHPLohmanderLSEkdahlCBeynnonBD. Knee injury and osteoarthritis outcome score (KOOS): development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28:88–96.
50.
ShapiroETRichmondJCRockettSEMcGrathMMDonaldsonWR. The use of a generic, patient-based health assessment (SF-36) for evaluation of patients with anterior cruciate ligament injuries. Am J Sports Med. 1996;24:196–200.
51.
TagessonSObergBGoodLKvistJ. A comprehensive rehabilitation program with quadriceps strengthening in closed versus open kinetic chain exercise in patients with anterior cruciate ligament deficiency: a randomized clinical trial evaluating dynamic tibial translation and muscle function. Am J Sports Med. 2008;36:298–307.
52.
VickersAJ. The use of percentage change from baseline as an outcome in a controlled trial is statistically inefficient: a simulation study. BMC Med Res Methodol. 2001;1:6.
53.
VickersAJAltmanDG. Statistics notes: analysing controlled trials with baseline and follow up measurements. BMJ. 2001;323:1123–1124.
54.
VoightMTippettS. Plyometric exercises in rehabilitation. In: PrenticeWE, ed. Rehabilitation Techniques in Sport Medicine. 2nd ed. St. Louis, MO: Mosby; 1994:88–97.
55.
WernbomMAugustssonJThomeeR. The influence of frequency, intensity, volume and mode of strength training on whole muscle cross-sectional area in humans. Sports Med. 2007;37:225–264.
56.
WilliamsGNChmielewskiTRudolphKBuchananTSSnyder-MacklerL. Dynamic knee stability: current theory and implications for clinicians and scientists. J Orthop Sports Phys Ther. 2001;31:546–566.
