Commentary
The rehabilitation of athletes after ACL reconstruction continues to evolve, with the goals of returning athletes to the activity of their choice as soon as possible and hoping to slow the almost inevitable development of degenerative changes in the knee. The serendipitous discovery of the benefits of "accelerated" rehabilitation[1] and the advances in arthroscopic surgery (eg, visualization, equipment, and fixation) are 2 of the most important developments in decreasing associated surgical morbidity and shortening the patients' recovery time. Much research has focused on improving short- and long-term functional outcomes while decreasing the time required to reach "game ready" status. Research topics include moving away from restrictive bracing, beginning rehabilitation ever earlier and more intensely, moving towards more cost-effective rehabilitation by decreasing the amount of supervision, using training techniques to improve neuromuscular feedback, and making use of biological adjuncts to assist/accelerate healing.
The study by Kruse et al is an updated systematic review that adds to 2 previous reports performed primarily by members of the Multicenter Orthopaedic Outcomes Network (MOON).[2,3] These 2 previous reviews, published in 2008, covered the use of continuous passive motion, early weight bearing, postoperative bracing, home-based rehabilitation, open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and other miscellaneous topics. These reviews included level I or II evidence reported up to 2005. Kruse et al have reviewed the additional literature published from 2006 to 2010, using a method similar to that of the previous reviews, with all 3 authors performing and reconciling the searches. Twenty-nine studies met inclusion criteria and were assessed for methodologic quality using the CONSORT checklist.
The current study upholds many of the conclusions of the original reviews in that 1) post-operative bracing is neither necessary nor beneficial, 2) accelerated rehabilitation with early strengthening is beneficial, and 3) home-based or limited supervision of rehabilitation can be successful in motivated patients. Neuromuscular, proprioception, vibration, and perturbation training studies were more prevalent in the current review. They showed some early benefits to balance but no clear improvements in long-term outcomes or functional return to sport.
Despite limiting the systematic review to level I and II studies, the included studies were still relatively poor quality. Limited description of randomization and general lack of sample size or power analysis bring into question the many "no difference" results. Some studies found differences at specific time points, but most failed to include long-term follow-up (>2 years is usually expected for the evaluation of surgical outcomes), comments on complications, or evaluations of the patients' ability to return to activity or sport (usually the most important outcome to the patient). When significant differences were shown, they usually did not meet clinically relevant thresholds. Finally, there was a limited use of validated knee-specific patient-reported outcomes such as the International Knee Documentation Committee (IKDC) score, the ACL Quality of Life (ACL QOL) questionnaire, or the Knee Osteoarthritis Outcome Score (KOOS).
The study by Kruse et al updates the evidence available for advancing the successful rehabilitation of patients after ACL reconstruction. It also, however, identifies, that despite efforts to improve the methodologic quality of orthopedic research, much work is still required to provide statistically sound and unbiased information to help guide our clinical practices.
Clin J Sport Med. 2013;23(6):501-502. © 2013 Lippincott Williams & Wilkins
