• 
• 

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
[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]

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Zech et al 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.
			Lysholm Score	Significant improvement in both groups.
			Muscle Reaction Time	Significant improvement in both groups
			Knee Laxity	No significant improvement in either group
			2nd RCT: Fitzgerald et al (2000). Group 1: Standard Rehabilitation. Group 2: Standard Rehabilitation + Perturbation Training
			Episodes of giving way	Significant improvement in Group 2
			ADL Score	Significant improvement in both groups
			Global Rating of knee function	Significant improvement in both groups
			Sports Activity Scale	No significant improvement in either group
			Isometric quadriceps strength	No significant improvement in either group
			Knee Laxity	No significant improvement in either group
			Single-limb hop tests	Significant improvement in both groups

Comment(s)

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.

Clinical 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

1. Zech, A.,Hubscher,M.,Vogt,L.,Banzer,W.,Hansel,F.,Pfeifer,K. Neuromuscular Training for Rehabilitation of Sports Injuries: A Systematic Review Medicine and Science in Sports and Exercise 2009;41 (10): 1831-1841