PROPRIOCEPTION, BODY BALANCE AND FUNCTIONALITY IN INDIVIDUALS WITH ACL RECONSTRUCTION

Sensorimotor Dysfunction Following Anterior Cruciate Ligament Reconstruction- an Afferent Perspective: A Scoping Review

Background

Sensorimotor dysfunction is thought to occur following anterior cruciate ligament (ACL) injury which may have implications on future reinjury risk. Dysfunction has been demonstrated within the efferent component of the sensorimotor system. However, no reviews have examined the two main components of the afferent system: the visual and somatosensory systems.

Hypothesis/Purpose

This study aimed to report differences in function (central processing and local processing) within the (1) somatosensory and (2) visual systems between individuals following anterior cruciate ligament reconstruction (ACLR) and healthy controls (between-subject). The study also aimed to report differences in function within the two systems between the two limbs of an individual following ACLR (within-subject).

Study Design

Scoping review.

Methods

A search was conducted in PubMed, SPORTDiscus, CINAHL, Medline and Embase up until September 2021. Level I-IV studies assessing somatosensory and visual systems were included if they compared ACLR limbs to the uninjured contralateral limb (within-subject) or a healthy control limb (between-group). The function of somatosensory and visual systems was assessed across both central processing (processing of information in the central cortex) and local processing (all other assessments outside of central processing of information).

Results

Seventy studies were identified (52 somatosensory, 18 visual). Studies examining somatosensory central processing demonstrated significant differences; 66% of studies exhibited within-subject differences and 100% of the studies exhibited between-group differences. Studies examining local somatosensory processing had mixed findings; 40% of the 'joint position sense (JPS)' and 'threshold to detect motion (TTDM)' studies showed significant within-subject differences (JPS=0.8°-3.8° and TTDPM=0.2°-1.4°) and 42% demonstrated significant between-group differences (JPS=0.4°-5° and TTDPM=0.3°-2.8°). Eighty-three percent of visual central processing studies demonstrated significant dysfunction between-groups with no studies assessing within-subject differences. Fifty percent of the studies examining local visual processing demonstrated a significant between-group difference.

Conclusion

Significant differences in central processing exist within somatosensory and visual systems following ACLR. There is mixed evidence regarding local somatosensory and visual processing. Increased compensation by the visual system and local visual processing dysfunction may occur in conjunction with somatosensory dysfunction.

The Effect of Contralateral Knee Neuromuscular Exercises on Static and Dynamic Balance, Knee Function, and Pain in Athletes Who Underwent Anterior Cruciate Ligament Reconstruction: A Single-Blind Randomized Controlled Trial

CONTEXT

Contralateral training in the early stages after surgery can improve the balance of the reconstructed knee, which is impaired following anterior cruciate ligament reconstruction (ACLR). However, little is known about the neuromuscular cross exercise after ACLR.

OBJECTIVE

To investigate the effects of an 8-week cross exercise on balance and function of the reconstructed knee following ACLR.

DESIGN

A single-blind randomized clinical trial.

PARTICIPANTS

Thirty athletic males who underwent ACLR were randomly divided into intervention (n = 15) and control groups (n = 15).

INTERVENTION

The intervention and control groups received a routine physiotherapy program. In addition, the intervention group performed neuromuscular exercises on the nonoperated limb.

OUTCOME MEASURES

Before and 9 weeks after ACLR, dynamic and static balance, function, and pain in the reconstructed knee were measured by Star Excursion Balance Test (SEBT), stork balance stand test, balance error scoring system (BESS), Lysholm questionnaire, and visual analog scale. Data were analyzed by SPSS using 2-independent sample t test, paired t test, and analysis of covariance.

RESULTS

Between-group comparison showed that, contralateral knee neuromuscular exercises significantly increased in the reaching distance in SEBT in the anterior (P < .001), posterior (P < .001), posteromedial (P = .010), and posterolateral directions (P = .007), decreased the number of errors in 4 stance positions of BESS including single stance on the firm (P ≤ .001) and foam surface (P ≤ .001), and tandem stance on the firm (P = .028) and foam surface (P ≤ .001). It also increased the time of standing of the stork stand test (P = .044) and decreased the pain intensity (P = .014).

CONCLUSION

Neuromuscular exercise of the nonsurgical knee could improve the dynamic and static balance, and pain in the early stages following ACLR in the surgical leg. These findings may be potentially valuable for current rehabilitation protocols.

Factors Influencing Treatment Outcome and Proprioception after Electrocoagulation of the Femoral Insertion of the Anterior Cruciate Ligament

(1) Background: Studies have established that exercises shaping the sense of deep sensation are an important element of medical rehabilitation of patients after vaporization of the femoral insertion of the anterior cruciate ligament and affect the restoration of correct movement patterns, thus reducing the risk of injuries. The aim of this study was to determine the factors influencing the treatment outcome and deep-feeling function after applying a specific rehabilitation scheme 12 weeks after anterior cruciate ligament electrocoagulation surgery. (2) Methods: The study group consisted of 41 patients after partial rupture of the anterior cruciate ligament, who underwent electrocoagulation of the femoral cruciate ligament attachment and microfracture of the femoral attachment area. All patients were operated on by the same surgeon and then rehabilitated according to the same medical rehabilitation protocol. The anthropometric and clinical data were collected through an anterior drawer test, Lachman test, assessment of the range of movements in the knee joint, muscle strength test, Unterberger test and Lysholm questionnaire. The assessment was performed before the surgery, and then on days 7-10, after 6 and 12 weeks of rehabilitation treatment. (3) Results: Statistical improvement of the parameters was demonstrated by strength of the quadriceps and hamstrings muscle, the Unterberger test, and the Lysholm scale after surgery. A negative correlation was found between the Unterberger test and Lysholm scale at the end of the research period and it differed depending on the gender and the dominant limb. The Lysholm scale and muscle strength were independent of sex, dominant extremity and associated damage of the meniscus and cartilage. The Lysholm scale 6 weeks after surgery negatively correlated with BMI. (4) Conclusions: Stability of the knee joint and improvement of proprioception were demonstrated 12 weeks after treatment with an ACL electrocoagulation and rehabilitation regimen. The factors contributing to a better treatment outcome were greater muscle strength, less thigh asymmetry, better sense of depth, younger age and lower body weight.

The effect of proprioception training on knee kinematics after anterior cruciate ligament reconstruction: A randomized control trial

BACKGROUND

Proprioception is essential for the normal movement of knee joints. How proprioception training affects the postoperative knee functional recovery after anterior cruciate ligament (ACL) reconstruction remains unknown.

OBJECTIVE

This study investigated the effect of proprioception training on the knee joint kinematics of patients after ACL reconstruction (ACLR).

METHODS

The randomized controlled study was performed at the Department of Orthopaedics and Traumatology of Guangdong Provincial People's Hospital between December 2019 and April 2021. Forty-five patients who underwent ACLR were randomly divided into a proprioception group (n= 23) and a control group (n= 22). The patients were randomly divided into an experimental group and a control group according to whether the final digits of their ID numbers were odd or even. All patients followed a common postoperative rehabilitation program. The outcome measures included the patients Lysholm scores, hop distances, and knee kinematics during unanticipated jump-cut maneuvering measured at different follow-up times. Knee joint kinematics were described as the positional and orientational changes of the femur relative to the tibia.

RESULTS

After surgery, the proprioception group did not exhibit significantly higher hop distances than the control group at the 6-month (114.8 ± 19.0 vs. 105.9 ± 20.7 cm, p= 0.137, 95% CI: -3.13 to 22.03 cm) and 1-year follow-ups (143.1 ± 19.3 vs. 133.9 ± 26.2 cm, p= 0.216, 95% CI: -5.57 to 23.87 cm). For knee joint kinematics, the members of the proprioception training group exhibited significantly reduced knee abduction (valgus) angles and external rotation and significantly increased knee flexion compared to those in the common training group.

CONCLUSIONS

The results suggested that proprioceptive rehabilitation training enhances knee joint functional performance and shows altered knee joint kinematics in ACL-reconstructed populations during unanticipated jump-cut maneuvering compared with the common rehabilitation training.

Evaluation of the Stability of the Subjects with Anterior Cruciate Injuries Reconstruction

Anterior cruciate ligament (ACL) is the most frequently injured ligament in the knee and is often injured during sport-related activities. ACL injuries influence the abilities of the subjects during standing and walking. Although early surgical intervention is preferred treatment for the majority of knee surgeons, the effect of this approach on postural stability of patients is not fully understood. Therefore, the aim of this study was to determine the difference between stability of ACL-reconstructed subjects before and after surgery. A group of 15 consecutive ACL injured patients participated in this study. Postural stability of the patients was evaluated 1 week before and 6 months after surgery (ACL reconstruction with hamstring autograft). A Kistler force plate was used to evaluate center of pressure (COP) sway during quiet standing. The mean values of the COP parameters were obtained in pre and postsurgery conditions. Paired sample t-test was used to evaluate the difference between the stability parameters of the two conditions. The significant point was set at 0.05. The mean value of path length of COP velocity in mediolateral (ML) direction was 1,485.57 ± 479.42 mm and 2,641.33 ± 996.26 mm before and after surgery, respectively (p-value = 0.01). Although the mean value of COP velocity in anteroposterior and ML directions increased after surgery, the difference was only significant for velocity in ML direction (p-value = 0.049). The results of this study showed that the standing stability of those with ACL reconstruction decreased significantly after ACL reconstruction, which may be due to the effects of the surgery on sensory mechanism of ACL and inability of patients to return to their previous deep sense perception and knee proprioception.

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.

Properties of Knee Joint Position Sense Tests for Anterior Cruciate Ligament Injury: A Systematic Review and Meta-analysis

Background:

Knee proprioception is believed to be deficient after anterior cruciate ligament (ACL) injury. Tests of joint position sense (JPS) are commonly used to assess knee proprioception, but their psychometric properties (PMPs) are largely unknown.

Purpose:

To evaluate the PMPs (reliability, validity, and responsiveness) of existing knee JPS tests targeting individuals with ACL injury.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

PubMed, Allied and Complementary Medicine, CINAHL, SPORTDiscus, Web of Science, Scopus, CENTRAL, and ProQuest databases were searched to identify studies that assessed PMPs of knee JPS tests in individuals with ACL injury. The risk of bias for each included study was assessed and rated at the outcome level for each knee JPS test. Overall quality and levels of evidence for each PMP were rated according to established criteria. Meta-analyses with mean differences were conducted using random effects models when adequate data were available.

Results:

Included were 80 studies covering 119 versions of knee JPS tests. Meta-analyses indicated sufficient quality for known-groups and discriminative validity (ACL-injured knees vs knees of asymptomatic controls and contralateral noninjured knees, respectively), owing to significantly greater absolute errors for ACL-injured knees based on a strong level of evidence. A meta-analysis showed insufficient quality for responsiveness, which was attributed to a lack of significant change over time after diverse interventions with a moderate level of evidence. Statistical heterogeneity (I² > 40%) was evident in the majority of meta-analyses. All remaining PMPs (reliability, measurement error, criterion validity, convergent validity, and other PMPs related to responsiveness) were assessed qualitatively, and they failed to achieve a sufficient quality rating. This was a result of either the study outcomes not agreeing with the statistical cutoff values/hypotheses or the level of evidence being rated as conflicting/unknown or based on only a single study.

Conclusion:

Knee JPS tests appear to have sufficient validity in differentiating ACL-injured knees from asymptomatic knees. Further evidence of high methodologic quality is required to ascertain the reliability, responsiveness, and other types of validity assessed here. We recommend investigations that compare the modifiable methodologic components of knee JPS tests on their PMPs to develop standardized evidence-based tests.

Development of supine and standing knee joint position sense tests

OBJECTIVES

We aimed to assess the test-retest reliability of a supine and standing knee joint position sense (JPS) test, respectively, and whether they discriminate knees with anterior cruciate ligament (ACL) injury from asymptomatic knees.

DESIGN

Repeated measures and cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

For test-retest reliability, 24 persons with asymptomatic knees. For discriminative analysis: 1) ACLR - 18 persons on average 23 months after unilateral ACL reconstruction, 2) CTRL - 23 less-active persons, and 3) ATHL - 21 activity level-matched athletes.

MAIN OUTCOME MEASURES

Absolute error (AE) and variable error (VE).

RESULTS

Test-retest reliability was generally highest for AE of the standing test (ICC 0.64-0.91). Errors were less for the standing compared to the supine test across groups. CTRL had greater knee JPS AE (P = 0.005) and VE (P = 0.040) than ACLR. ACLR knees showed greater VE compared to the contralateral non-injured knees for both tests (P = 0.032), albeit with a small effect size (η_p² = 0.244).

CONCLUSIONS

Our standing test was more reliable and elicited lesser errors than our supine test. Less-active controls, rather than ACLR, produced significantly greater errors. Activity level may be a more predominant factor than ACLR for knee JPS ∼2 years post-reconstruction.

The immediate effect of IASTM vs. Vibration vs. Light Hand Massage on knee angle repositioning accuracy and hamstrings flexibility: A pilot study

INTRODUCTION

The effectiveness of novel soft-tissue interventions relative to traditional ones requires further exploration. The purpose of this pilot study was to evaluate the immediate effect of Instrument Assisted Soft Tissue Mobilization (IASTM) compared to Vibration Massage or Light Hand Massage on hamstrings' flexibility and knee proprioception.

METHODS

16 healthy non-injured male participants (mean age 23.7 years, height 1.80 cms and body mass 77.7 kg) were randomly assigned to the following interventions: (a) 5min IASTM, (b) 5min Vibration Massage and (c) 8min Light Hand-Massage, sequentially delivered to all participants with an in-between 1-week time interval. A single application of each intervention was given over the hamstrings of their dominant leg (repeated measures under 3 different experimental conditions). An active knee angle reproduction proprioception test and the back-saver sit and reach flexibility test were performed before and immediately after each intervention. Reliability of outcomes was also assessed.

RESULTS

Reliability for flexibility (ICC_3,1 = 0.97-0.99/SEM = 0.83-1.52 cm) and proprioception (ICC_3,1 = 0.83-0.88/SEM = 1.63-2.02°) was very good. For flexibility, statistically significant immediate improvement (p < 0.001) was noted in all 3 groups (1.61-3.23 cm), with no between-group differences. For proprioception, improvement in the IASTM (2.12°), Vibration Massage (0.32°) and Light Hand-Massage (1.17°) conditions was not statistically significant; no between-group differences were also evident.

CONCLUSIONS

Our findings indicate that muscle flexibility was positively influenced immediately after a single intervention of IASTM, Vibration Massage or Light Hand Massage. Proprioception changes were not statistically significant either within or between groups. Further evaluation of those interventions in a larger population with hamstrings pathology is required.

The reliability of postural control method in athletes with and without ACL reconstruction: a transitional task

[Purpose] To evaluate the intra- and inter-session reliability of dynamic postural control in ACL reconstruction and matched control athletes. [Subjects and Methods] By using force plate, the postural controls of both groups (20 ACLR and 20 healthy matched controls) were assessed during the transitional task from DLS to SLS. The outcome variables included COP displacement and area and the mean velocity of COP. [Results] The balance measures had moderate to high correlation for area (ICC=0.64–0.73) and rang of fore-aft (Rfa) (ICC=0.66–0.80) in the ACLR group and Rfa (ICC=0.70–0.86) in the healthy group. High to very high reliability was seen for rang of sideway (Rsw) (ICC=0.76–0.96) and mean velocity (Mv) (ICC=0.81–0.98) in ACLR and area (ICC=0.70–0.98) and Rsw (ICC=0.84–0.98) and Mv (ICC=0.89–0.97) in the healthy group. [Conclusion] Force plate measures of postural control demonstrated moderate to very high reliability in athletes with and without ACLR during the transitional task. The results of the recent study showed that the assessment of transitional task postural control in athletes with ACLR may reliably be incorporated in the evaluation of the physical function.

Mechanism of Activating the Proprioceptive NT-3/TrkC Signalling Pathway by Reverse Intervention for the Anterior Cruciate Ligament-Hamstring Reflex Arc with Electroacupuncture

The anterior cruciate ligament (ACL) is an important structure maintaining stability of the knee joints. Deficits in physical stability and the proprioceptive capabilities of the knee joints are observed, when the ACL is damaged. Additionally, a unilateral ACL injury can affect bilateral knee proprioception; therefore, proprioception of the ACL may play a key role in stability. Electroacupuncture therapy has a definite effect nerve regeneration. In this study, cynomolgus monkeys were randomly divided into 4 groups: the model control group, intervention of the injured knee with electroacupuncture (IIKE) group, intervention of the bilateral knees with electroacupuncture (IBKE) group, and the blank control group. The unilateral ACL injury model was developed in IIKE and IBKE groups; acupuncture points around the knees underwent intervention similarly in the IIKE and IBKE groups. Then, mRNA and protein expressions of NT-3 and TrkC in the dorsal root ganglion and of growth-associated protein-43 in the ACL increased according to reverse-transcription quantitative polymerase chain reaction and Western blotting results. Decreased incubations and increased amplitudes were found for somatosensory-evoked potentials and motor nerve conduction velocity. The finding indicates that electroacupuncture may play an important role in the recovery of proprioception in the ACL by activating the NT-3/TrkC signalling pathway.

[Short-term effectiveness of absorbable anchor in repairing of partial anterior cruciate ligament rupture]

Objective

To study the short-term effectiveness of absorbable anchor in repairing of partial anterior cruciate ligament (ACL) rupture.

Methods

Between December 2013 and February 2015, 22 patients with partial ACL rupture were repaired with absorbable anchor under arthroscopy. There were 12 males and 10 females with an average age of 27.5 years (range, 20-44 years). The injury located at left knee in 8 cases and at right knee in 14 cases. The time from injury to admission ranged from 2 to 13 days (mean, 9.8 days). Sixteen partial ACL ruptures combined with meniscus injury. The effectiveness was assessed by Tegner score, Lysholm score, International Knee Documentation Committee (IKDC) score, visual analogue scale (VAS) score, and MRI, as well as knee laxity was evaluated by KT-1000.

Results

All incisions healed at stage Ⅰ without any complication. All patients were followed up 12 months. ACL rerupture did not occurred during follow-up. There was no significant difference in Tegner score, Lysholm score, and IKDC score between before injury and at 12 months after operation ( P>0.05). And the median satisfaction VAS score was 9.5 (range, 9-10). The tibial anterior translation difference was 0.5 mm (range, 0-6 mm). MRI showed that the scarring and continuity of the ligament were rated as grade 1 in all patients.

Conclusion

Arthroscopic repairing by absorbable anchor is a feasible method for partial ACL rupture, with ideal knee function, good satisfaction, and satisfactory short-term effectiveness.

Single-Leg Assessment of Postural Stability After Anterior Cruciate Ligament Injury: a Systematic Review and Meta-Analysis

BACKGROUND

Previous reports of single-leg assessment demonstrated functional deficits in postural stability following anterior cruciate ligament (ACL) injury. However, quantified measures describing postural stability vary among investigations and results seem not to be clear. The first aim of this systematic review was to quantify postural deficits in eyes open single-leg stance in patients after ACL injury. Moreover, the second aim was to examine the potential of traditional center of pressure (CoP) measures in order to distinguish postural stability between ACL patients and healthy controls.

METHODS

A systematic literature search in the databases PubMed and Scopus was conducted from their inception to December 2016 to identify relevant articles. Eligibility criteria were limited to controlled trials of eyes open static single-leg stance on a force or pressure plate recording CoP measures in patients after ACL injury.

RESULTS

Eleven studies were included, involving a total of 329 ACL-injured and 265 control subjects. Random-effects meta-analysis showed significantly increased sway magnitudes (SMD_wm = 0.94, p = 0.003) and velocities (SMD_wm = 0.66, p = 0.0002) in the ACL group compared to the healthy controls. Sway magnitude in anteroposterior (SMD_wm = 0.58, p = 0.02) and mediolateral (SMD_wm = 1.15, p = 0.02) direction were significantly increased in ACL patients. No differences were found for the non-injured side. Similarly, no differences have been observed among ACL patients between the injured and non-injured side for sway velocity, while sway magnitude significantly differed (SMD_wm = 0.58, p = 0.05).

CONCLUSIONS

The findings of this systematic review and meta-analysis demonstrated decreased postural stability in individuals with ACL injury. Sway magnitude and velocity were significantly increased in the ACL group compared to the healthy controls. Although the included research still exhibited considerable heterogeneity, it may be proposed that fundamental CoP measures are suitable to differentiate patients after ACL injury and healthy controls with respect to postural stability in eyes open single-leg stance.