Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction

Abstract

This guideline was developed to inform clinical practice on rehabilitation after anterior cruciate ligament reconstruction (ACLR) and was performed in accordance with the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A Guideline Development Group systematically searched and reviewed evidence using randomised clinical trials and systematic reviews to evaluate the effectiveness of rehabilitation interventions and guide clinicians and patients on the content of the optimal rehabilitation protocol after ACLR.The guideline targets patients during rehabilitation after ACLR and investigates the effectiveness of the available interventions to the physiotherapist, alone or in combination (eg, exercise, modalities, objective progression criteria). Exercise interventions should be considered the mainstay of ACLR rehabilitation. However, there is little evidence on the dose–response relationship between volume and/or intensity of exercise and outcomes. Physical therapy modalities can be helpful as an adjunct in the early phase of rehabilitation when pain, swelling and limitations in range of motion are present. Adding modalities in the early phase may allow earlier pain-free commencement of exercise rehabilitation. Return to running and return to training/activity are key milestones for rehabilitation after ACLR. However, there is no evidence on which progression or discharge criteria should be used.While there is a very low level of certainty for most components of rehabilitation, most of the recommendations provided in this guideline were agreed to by expert clinicians. This guideline also highlights several new elements of ACLR management not reported previously.

Quo vadis, Nachbehandlung? – Nachbehandlungsschemata kritisch betrachtet

“…Die fehlende Evidenz wird auch in Befragungen von ärztlichen Gesellschaften deutlich. Während innerhalb der Behandlung nach einer Rekonstruktion des vorderen Kreuzbandes ein frühes Training im offenen System und eine orthesenfreie Nachbehandlung empfohlen wird 1 , 17 , 29 , ermittelt die Befragung der Mitglieder der Deutschen Kniegesellschaft einen konträren Ist-Zustand. In 82 Prozent der Fälle wird eine Empfehlung „pro“ Orthese gegeben 28 .…”

“…Ein freier Gang ohne Gehstützen nach einer Knieverletzung oder einer Operation ist daher keine Frage der Zeit, sondern nur mit einer ausreichenden Quadrizepsaktivierung, einer vollständigen Kniegelenkextension und einer ausreichenden Balancefähigkeit möglich. Folgerichtig werden in verschiedenen Übersichtsarbeiten funktionelle Kriterien für die Progression gefordert 9 , 17 . Das große Problem ist in diesem Kontext, dass für viele Aktivitäten keine validen Kriterien verfügbar sind 25 .…”

Psychosocial interventions seem redact kinesiophobia after anterior cruciate ligament reconstruction but higher level of evidence is needed: a systematic review and meta‐analysis

“…bracing, isokinetic training and perturbation training) and rapid rehabilitation to improve physical disorders (e.g. range of motion, strength, pain, and swelling), neglecting important psychosocial factors, such as kinesiophobia [19, 39]. Furthermore, return‐to‐sport algorithms after ACLR often fail to consider psychosocial factors, instead prioritising physical metrics like muscle strength, performance in hopping tests and patient‐reported outcomes related to knee‐specific indices [1, 26, 37].…”

Infographic. Aspetar clinical practice guideline on rehabilitation after ACL reconstruction: an interactive figure

“…This infographic interactively summarises the recommendations derived from the Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction (ACLR) 1. The recommendations can be used by patients, clinicians, researchers and healthcare decision makers as a simple way of knowing the evidence for the effectiveness of interventions during rehabilitation after ACLR and the return to activities criteria.…”