Unanticipated jump-landing after anterior cruciate ligament reconstruction: Does unanticipated jump-landing testing deliver additional return to sport information to traditional jump performance tests?

Late-stage rehabilitation after anterior cruciate ligament reconstruction: A multicentre randomised controlled trial (PReP)

BACKGROUND

At the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation.

OBJECTIVE

To compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction.

METHODS

This prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated.

RESULTS

In total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4-104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7-114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0-129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4-135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10-0.57; 0.31, 0.08-0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level.

CONCLUSIONS

The Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction

OBJECTIVE

To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction.

METHODS

In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not.

RESULTS

At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers."

CONCLUSIONS

The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

Acute effects of a neuromuscular warm-up on potential re-injury risk factors associated with unanticipated jump landings after anterior cruciate ligament reconstruction: A crossover trial

OBJECTIVE

To investigate acute effects of a single bout of football specific neuromuscular injury preventive warm-up on potential anterior cruciate ligament (ACL) re-injury risk factors during anticipated and unanticipated jump-landings.

DESIGN

Crossover.

METHODS

Fourteen participants (mean ± SD age, 23.4 ± 4.1 years) 6-24 months after ACL reconstruction performed the Prevent Injury and Enhance Performance (PEP) and bicycle ergometer warm-up in a randomised sequence. Washout phase was one week. Countermovement jumps with anticipated and unanticipated single-leg-landings were assessed. Decision-making quality was measured using landing error count.

RESULTS

No carry-over effects occurred (p > 0.05). The unanticipated task produced significantly higher peak ground reaction forces (Δ+4%, F₍₁₁₎ = 3.46, p < 0.001, eta² = 0.21) after PEP warm-up compared to ergometer warm-up. A lower number of decision (Δ+12%, F ₍₅₎ = 17.1, p < 0.001, eta² = 0.57) and cumulated (Δ+15%, F ₍₃₎ = 17.2, p < 0.001, eta² = 0.57) errors were recorded during the unanticipated condition following PEP compared to ergometer warm-up.

CONCLUSIONS

Evaluating unanticipated jump-landing ability prior to return to sports clearance may provide information on potential re-injury risk factors. PEP warm-up may be superior to bicycle ergometer warm-up at improving unanticipated decision-making quality among athletes cleared to return to sports.

Kinetic measurement system use in individuals following anterior cruciate ligament reconstruction: a scoping review of methodological approaches

Purpose

Our primary objectives were to (1) describe current approaches for kinetic measurements in individuals following anterior cruciate ligament reconstruction (ACLR) and (2) suggest considerations for methodological reporting. Secondarily, we explored the relationship between kinetic measurement system findings and patient-reported outcome measures (PROMs).

Methods

We followed the PRISMA extension for scoping reviews and Arksey and O’Malley’s 6-stage framework. Seven electronic databases were systematically searched from inception to June 2020. Original research papers reporting parameters measured by kinetic measurement systems in individuals at least 6-months post primary ACLR were included.

Results

In 158 included studies, 7 kinetic measurement systems (force plates, balance platforms, pressure mats, force-measuring treadmills, Wii balance boards, contact mats connected to jump systems, and single-sensor insoles) were identified 4 main movement categories (landing/jumping, standing balance, gait, and other functional tasks). Substantial heterogeneity was noted in the methods used and outcomes assessed; this review highlighted common methodological reporting gaps for essential items related to movement tasks, kinetic system features, justification and operationalization of selected outcome parameters, participant preparation, and testing protocol details. Accordingly, we suggest considerations for methodological reporting in future research. Only 6 studies included PROMs with inconsistency in the reported parameters and/or PROMs.

Conclusion

Clear and accurate reporting is vital to facilitate cross-study comparisons and improve the clinical application of kinetic measurement systems after ACLR. Based on the current evidence, we suggest methodological considerations to guide reporting in future research. Future studies are needed to examine potential correlations between kinetic parameters and PROMs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00397-0.

Visual Perturbation to Enhance Return to Sport Rehabilitation after Anterior Cruciate Ligament Injury: A Clinical Commentary

Anterior cruciate ligament (ACL) tears are common traumatic knee injuries causing joint instability, quadriceps muscle weakness and impaired motor coordination. The neuromuscular consequences of injury are not limited to the joint and surrounding musculature, but may modulate central nervous system reorganization. Neuroimaging data suggest patients with ACL injuries may require greater levels of visual-motor and neurocognitive processing activity to sustain lower limb control relative to healthy matched counterparts. Therapy currently fails to adequately address these nuanced consequences of ACL injury, which likely contributes to impaired neuromuscular control when visually or cognitively challenged and high rates of re-injury. This gap in rehabilitation may be filled by visual perturbation training, which may reweight sensory neural processing toward proprioception and reduce the dependency on vision to perform lower extremity motor tasks and/or increase visuomotor processing efficiency. This clinical commentary details a novel approach to supplement the current standard of care for ACL injury by incorporating stroboscopic glasses with key motor learning principles customized to target visual and cognitive dependence for motor control after ACL injury.

LEVEL OF EVIDENCE

5.

Lower Extremity Open Skill Training Effects on Perception of Visual Stimuli, Cognitive Processing, and Performance

This study investigates if lower extremity open-skill training impacts perception and cognitive processing abilities or just influences task related motor abilities. Twenty-two participants (24.7 ± 2.4years; 11 males, 11 females) were randomly allocated either into the group that trained on a computerized device or to the control group. Prior to and following the 4-week study period, motor performance was assessed using drop jump, hexagon test, postural control and lower extremity choice reaction. Perception, cognitive processing and task inhibition were captured using validated neurocognitive tests. Repeated measurements analyses of co-variances (ANCOVAs) were performed. They revealed a time (before and after intervention) × group (training vs. control) effect on lower extremity choice reaction and hexagon (p < .05). No effects on group differences or between groups in cognitive performance were found. A detrimental effect of training on accuracy of task inhibition (lower percentage of correct inhibitions) was detected. Computerized open skill training affects specific movement patterns without increasing task-relevant cognitive or perceptual abilities. Indicated by the lower percentage of correct inhibitions, the training might further detrimentally influence the risk-taking behavior during choice reaction tasks.

Unanticipated jump-landing quality in patients with anterior cruciate ligament reconstruction: How long after the surgery and return to sport does the re-injury risk factor persist?

BACKGROUND

Inadequate reactions to unforeseen external stimuli are regarded as a major cause for non-contact anterior cruciate ligament (ACL) injuries. We aimed to delineate a potential deficit in the ability to perform unanticipated jump-landing manoeuvres, its sustainability and potential as a new outcome measure after ACL-reconstruction.

METHODS

Physically active adults (n = 27, 13 females, 14 males, 29.7 standard deviation 3.1 years) with a history of unilateral ACL rupture and subsequent reconstruction (6 months to 7 years ago), cleared for return to sports, were included. All participants performed counter-movement jumps with unanticipated single leg landings. Visual information shown after jump take-off indicated the required landing leg. Jump time [s] and successfulness [yes/no], vertical peak ground reaction forces at landing [N], as well as time to stabilisation after landing [s] and path length of the centre of pressure (CoP, [mm]) were calculated. Limb symmetry ratios were determined and analysed for their association with the time since surgery.

FINDINGS

Time since ACL reconstruction was logarithmically (basis 10) associated with side symmetry improvements in peak ground reaction force (R² = 0.23, p < .01) and time to stabilisation (R² = 0.18, p < .01) during and after landing in unanticipated/unpredictable single-leg jump landing tasks. The asymmetry found persists up to 18-26 months post-surgery.

INTERPRETATION

A deficit in unanticipated jump-landing ability seems to persist far beyond surgical restoration of mechanical stability and resumption of initial physical activities levels. The assessment of the ability to suddenly adapt movements to unanticipated visual stimuli may be a relevant complementary component within current functional testing canon in monitoring therapy success and return to sport testing.