Review Evidence-based clinical practice update: practice ...

1 Evidence-based clinical practice update: practiceguidelines for anterior cruciate ligamentrehabilitation based on a systematic reviewand multidisciplinary consensusNicky van Melick,1,2 Robert E H van Cingel,3,4 Frans Brooijmans,5 Camille Neeter,6 Tony van Tienen,7 Wim Hullegie,8 Maria W G Nijhuis-van der Sanden1 Additional material ispublished online only. To viewplease visit the journal online( ).1 Funqtio, Steyl, TheNetherlands2 Radboud University MedicalCenter, Research Institute forHealth Sciences, IQ healthcare,Nijmegen, The Netherlands3 Sport Medisch CentrumPapendal, Arnhem, TheNetherlands4 Research GroupMusculoskeletal Rehabilitation,HAN University of AppliedSciences, Nijmegen, TheNetherlands5B&sis, Eindhoven, TheNetherlands6 Neeter Fysiotherapie,Amsterdam, The Netherlands7 Kliniek ViaSana, Mill,The Netherlands8 FysioGym Topsport, Enschede,The NetherlandsCorrespondence toNicky van Melick, Funqtio,Triangelstraat 1F,Steyl 5935 AG,The 28 July 2016 Published Online First18 August 2016To cite:van Melick N, vanCingel REH, Brooijmans F,et J Sports Med2016.

2 50:1506 Royal Dutch Society for Physical Therapy(KNGF) instructed a multidisciplinary group of Dutchanterior cruciate ligament (ACL) experts to develop anevidence statement for rehabilitation after practice guideline underpinned bysystematic Review and expert sourcesA multidisciplinary working group andsteering group systematically reviewed the literature andwrote the guideline. MEDLINE and the Cochrane Librarywere searched for meta-analyses, systematic reviews,randomised controlled trials and prospective cohortstudies published between January 1990 and criteria for selecting studiesIncludedliterature must have addressed 1 of 9 predeterminedclinical topics: (1) preoperative predictors forpostoperative outcome, (2) effectiveness of physicaltherapy, (3) open and closed kinetic chain quadricepsexercises, (4) strength and neuromuscular training, (5)electrostimulation and electromyographic feedback, (6)cryotherapy, (7) measurements of functionalperformance, (8) return to play and (9) risk for studies were included as the basis forthe evidence statement.

3 Rehabilitation after ACL injuryshould include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2)sport-specific training and (3) return to play. A battery ofstrength and hop tests, quality of movement andpsychological tests should be used to guide progressionfrom one rehabilitation stage to the next. Postoperativerehabilitation should continue for 9 12 months. Toassess readiness to return to play and the risk forreinjury, a test battery, including strength tests, hop testsand measurement of movement quality, should be cruciate ligament reconstruction (ACLR) isa common treatment for athletes after ACL incidence of non-contact ACL injuries appearsto be the greatest in athletes who are between 15and 40 years of age and participate in pivotingsports like soccer, handball, volleyball and year, about 3% of amateur athletesinjure their ACL; for elite athletes, this percentagecould be as high as 15%.

4 2 Females are two to eighttimes more likely to sustain an ACL injury thantheir male counterparts, probably because male andfemale neuromuscular patterns diverge during andfollowing 8 Besides its mechanical function in maintainingknee stability, the ACL contains mechanoreceptors( ) and therefore directly influences the neuro-muscular control of the deficiencycauses partial deafferentiation and alters spinal andsupraspinal motor control. The changes in motorcontrol strategy can reveal changes in propriocep-tion, postural control, muscle strength, movementand recruitment ACL injury mighttherefore be regarded as a neurophysiological dys-function and not a simple peripheral musculoskel-etal 12It is also not self-evident that anACLR will automatically lead to a return to prein-jury activity research shows that 35% of athletes afterACLR do not return to preinjury sport level within2 15 Half of these athletes report their ACLinjury as the primary reason for a lower 14 16 18 Apart from the physical recovery,also the psychological response (eg, fear of rein-jury) after ACLR has an influence on whether anathlete chooses to return to 25 Return toplay is defined as the ability to play a competitivematch at the preinjury level.

5 Moreover, recentresearch shows that 3 22% of athletes rerupturethe reconstructed ligament and 3 24% rupture thecontralateral ACL in thefirst 5 years 26 30 The difficulty with determining the moment ofreturn to play is that it is unknown which measuresshould be used to predict a safe return to play witha low risk of a second ACL injury. Three recent sys-tematic reviews show that the return-to-play deci-sion by clinicians is hardly based on objectiveclinimetric 31 32 Furthermore, thesestudies concluded that return to play is only con-nected to quantitative criteria, while it is knownthat qualitative criteria (eg, dynamic knee valgus,kneeflexion angle and trunk control) play animportant role in prevention and quality actually may affect the ACL (re)injury 34 The occurrence of dynamic kneevalgus when landing from a jump, for instance,increases the risk of ACL (re) 36 Return to play is the ultimate goal of rehabilita-tion programmes.

6 So the above-mentioned factorsare important topics to incorporate in the rehabili-tation process after ACLR. However, currently,there is no consensus regarding the content of avan Melick N,et J Sports Med2016;50:1506 1515. on February 3, 2023 by guest. Protected by J Sports Med: first published as on 18 August 2016. Downloaded from rehabilitation programme. Therefore, the Royal Dutch Societyfor Physical Therapy (KNGF) instructed a multidisciplinarygroup of ACL experts in the Netherlands to develop an evi-dence statement for anterior cruciate ligament goal of this evidence statement was to describe the rehabili-tation after ACLR and to encourage uniformity in physicaltherapy treatment and use of measurements of functional per-formance. The following three questions were formulated by asteering group of the KNGF to guide the realisation of the evi-dence statement:1. What should be the content of the rehabilitation protocolafter ACLR based on scientific evidence and, if not present,based on best practice ?

7 2. Which measurements and assessments can be applied tomonitor progression during the rehabilitation programmeand to determine outcomes at the end of rehabilitationprogramme?3. What criteria should be used to determine the moment ofreturn to play?METHODSE xpert participantsThe process started with the formation of a multidisciplinaryworking group and steering group. The working group con-sisted of six Dutch ACL experts with 8 35 years of experiencein ACL rehabilitation:five physical therapists specialised insports injury rehabilitation and one orthopaedic surgeon specia-lised in knee surgery, ACL surgery in particular. The steeringgroup consisted of ACL experts from different professions with10 37 years of experience in ACL rehabilitation (three physicaltherapists, one sports physician, one orthopaedic surgeon andone trauma surgeon).ProcedureThefirst author (NvM) chaired the working group and wasresponsible for the systematic Review steps (literature search,methodological quality assessment, data extraction, data ana-lysis, description of the results and translation into practiceguidelines) and for writing the evidence statement.

8 The workinggroup monitored each step in the systematic Review process andassisted in methodological quality assessment of the includedstudies, the writing process and the translation into practiceguidelines. The steering group (chairman REHvC) validated allsteps made by thefirst author and the working group. TheKNGF assisted in the administrative working group contacted each other by email and every2 months a consensus meeting was organised. Every othermeeting, the steering group joined the working meeting of the working and steering group together,started with the formulation of nine clinical topics importantfor ACLR rehabilitation. These topics were used to guide thesystematic Review process. These nine topics were: (1) preopera-tive predictors for postoperative outcome, (2) effectiveness ofphysical therapy, (3) open kinetic chain (OKC) versus closedkinetic chain (CKC) quadriceps exercises, (4) strength trainingand neuromuscular training, (5) electrostimulation and electro-myographic feedback, (6) cryotherapy, (7) measurements offunctional performance, (8) return to play and (9) risk found during the systematic Review process were sub-divided into the nine topics and every topic was given a level ofevidence according to the EBRO (Dutch Evidence-based guide-line development) recommendations were, ifavailable, based on the latest scientific evidence, supplementedwith best practice when necessary.

9 The results of the systematicreview process (see online supplementary appendix 1) wereused to formulate the evidence statement (see onlinesupplementary appendix 2).Search strategyA systematic literature search was performed searching inMEDLINE (PubMed) and the Cochrane Library to identify rele-vant articles from January 1990 up to June 2015 using key-words specified for the database according to the nine topicsmentioned above with PICO questions (table 1). An academiclibrarian composed a syntax based on all the , systematic reviews, randomised controlled trials(RCTs) and prospective cohort studies were included for selectionAll eligible articles were screenedfirst by title and abstract inde-pendently by two reviewers (NvM and REHvC). When the tworeviewers did not reach consensus, a third reviewer (CN) madethefinal decision. After thisfirst inclusion, the full-text articlewas screened using the inclusion and exclusion criteria as listedin table 2.

10 In addition, a hand search was performed on the ref-erence lists of meta-analysis and systematic reviews for RCTsand prospective cohort studies that were not included in theprimary search. Aflow chart of the search strategy is presentedinfigure quality assessmentQuality assessment of the included articles was independentlyperformed by two reviewers (NvM and REHvC). When thereviewers did not reach consensus, a third reviewer made thefinal decision. All articles were individually graded for level ofmethodological quality (table 3and online supplementaryappendix 1).Methodological quality of meta-analyses and systematicreviews was assessed with the AMSTAR checklist. The assess-ment of risk of bias of the RCTs was performed with the PEDroscale ( ). The PEDro scale was scored on10 items. Methodological quality was rated poor when anarticle had a score of 4. Subsequently, the RCTs with poorquality were prospective cohort studies were assessed with an adaptedCochrane Library Checklist (table 4), also used before in theKNGF guideline for urinary checklist has amaximum score of 5.