Does conservative rehabilitation treatment prevent recurrent instability following Complete ACL rupture?
Date First Published:
October 11, 2013
Last Updated:
June 5, 2014
Report by:
Lynne Howells, Physiotherapist (CMFT)
Search checked by:
Lynne Howells, CMFT
Three-Part Question:
In [Adults with complete ACL rupture] Does [Conservative rehabilitation treatment] Prevent [Recurrent knee instability]
Clinical Scenario:
A 29 year old male postman is referred from the acute knee clinic to physiotherapy 4 weeks following a clinically diagnosed ACL rupture. He feels his knee is regularly giving way and asks whether rehabilitation will ease and prevent his recurrent instability.
Search Strategy:
Amed 1985 - Oct 2013
Cinahl 1981 - Oct 2013
Embase 1980 - Oct 2013
Medline 1950 - Present
Cochrane Database
Cinahl 1981 - Oct 2013
Embase 1980 - Oct 2013
Medline 1950 - Present
Cochrane Database
Search Details:
[exp Anterior Cruciate Ligament or Anterior Cruciate Ligament or Anterior and Cruciate and ligament*] AND [exp Rupture or exp Rupture Spontaneous or Ruptur*] AND [Conservative and rehab*] AND [exp Joint Instability]
Outcome:
17 articles were retrieved, of which one was deemed relevant to answer the clinical question. 1 article was disregarded as it was only a case report with 2 subjects and so the results cannot be generalised to the wider population.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Neuromuscular Training for Rehabilitation of Sports Injuries: A Systematic Review Zech, A.,Hubscher,M.,Vogt,L.,Banzer,W.,Hansel,F.,Pfeifer,K. 2009 Germany | 15 randomised trials of conservative neuromuscular rehabilitation in ankle sprains, ACL rupture, and ACL reconstruction. Only 2 studies looked at conservative rehabilitation after ACL rupture : N=76. Only these studies are reported here. |
Systematic Review | Quality of RCT's | high quality; randomisation, concealed treatment allocation, blinded assessor, acceptable drop out rate, similar timing of outcome assessment in all groups. | No Comprehensive Meta-analysis because of high variety of treatment dose and data analysis methods for measured outcomes. |
| 1st RCT: Beard et al (1994). Group 1: Proprioceptive Training. Group 2: Strength Training. | Significant improvement in both groups. | ||||
| Lysholm Score | Significant improvement in both groups | ||||
| Muscle Reaction Time | No significant improvement in either group | ||||
| Knee Laxity | Significant improvement in Group 2 | ||||
| 2nd RCT: Fitzgerald et al (2000). Group 1: Standard Rehabilitation. Group 2: Standard Rehabilitation + Perturbation Training | Significant improvement in both groups | ||||
| Episodes of giving way | Significant improvement in both groups | ||||
| ADL Score | No significant improvement in either group | ||||
| Global Rating of knee function | No significant improvement in either group | ||||
| Sports Activity Scale | No significant improvement in either group | ||||
| Isometric quadriceps strength | Significant improvement in both groups | ||||
| Knee Laxity | |||||
| Single-limb hop tests |
Author Commentary:
Only one study was relevant to answer the 3 part question. This paper was a systematic review that looked at neuromuscular training of ankle sprains, ACL rupture, and after ACL reconstruction. Another study was not used because it was a case study (N=2) and therefore the results could not be generalised to the wider population. Within the systematic review, 2 studies looked specifically at the effects of conservative rehabilitation on knee instability after ACL rupture: Beard et al (1994) and Fitzgerald et al (2000). These were high quality RCT's that compared different types of conservative rehabilitation. Their results indicate that conservative rehabilitation resulted in good functional improvements, less giving way, and improved hop test. However knee laxity was not significantly improved. In terms of the best type of conservative rehabilitation, Beard et al (1994) showed there was no significant difference between proprioceptive training and strength training, and Fitzgerald et al (2000) showed no benefit from adding perturbation to a standard rehabilitation group.
Bottom Line:
There is limited evidence to suggest that conservative rehabilitation prevents recurrent knee instability, and there is no evidence to conclude that one type of conservative rehabilitation is better than another.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Zech, A.,Hubscher,M.,Vogt,L.,Banzer,W.,Hansel,F.,Pfeifer,K.. Neuromuscular Training for Rehabilitation of Sports Injuries: A Systematic Review