Muscle Strengthening and Return-to-exercise Criteria After Anterior Cruciate Ligament Reconstruction (ACLR)

Anterior Cruciate Ligament Injuries Clinical Trial

— ACLR  

Official title:

Comparison of Two Muscle Strengthening Programs on the Return-to-exercise Criteria in Patients With Anterior Cruciate Ligament Reconstruction

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05814445
• Other study ID #: 27/21
• Status: Recruiting
• Phase: N/A
• Start date: August 20, 2021
• Est. completion date: March 20, 2024

Study information

• Verified date: March 2023
• Source: National Institute of Rehabilitation, Mexico
• Contact: Andrea P Perez, MSc
• Phone: 525559991000
• Email: apegueros[@]inr.gob.mx
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Anterior cruciate ligament injury is very common in recreational and elite athletes. It is considered the second most frequent pathology seeing in Sports Medicine Services. After the injury and ACLR, there is a marked decrease in the strength of the knee extensors/flexors muscles. Strength exercise programs are aimed at recovering strength and functionality, however, a low percentage of patients manage to achieve the optimal return-to-exercise criteria. Therefore, it is relevant to design and evaluate exercise programs that allow early recovery of muscle strength and knee functionality. The main purpose of this study is to investigate a neuromuscular exercise program compared with a standard institutional program in the recovery of the strength and functionality of the knee extensor/flexor muscles after ACLR.

Description:

Study design: this is a 22-week, randomized trial. 62 participants will be recruited from the medical services of the National Institute of Rehabilitation (NIR).

Participants: adults between 20-40 years old, with a body mass index <30.0 kg/mˆ2, history of sports practice immediately prior to the injury, post-operated unilaterally for ACL with the hamstring autograft technique (semitendinosus-gracilis tendons), with full ranges of motion and no edema will be recruited. Participants with multi-ligament knee injuries, with more than 12 months from the injury to surgery or more than 8 months after surgery, with uncompensated metabolic diseases or acute illnesses/infections under treatment will not be recruited.

Intervention: participants will be randomized to 1) neuromuscular or 2) institutional exercise program with computer-generated random numbers. Both programs consist of isotonic open and closed kinetic chain exercises for the hip and knee. The neuromuscular program also includes exercises to improve vastus medialis and lateralis strength, hamstrings, hip flexors and extensors, proprioception, and core stability. On the other hand, the institutional program includes concentric and eccentric knee exercises. Both programs will be performed 3 days/week, 3 sets, 18-22 repetitions for each exercise; the intensity will initiate at 65-75% (1RM), and it will be increased to 75-85%; the workload will be increased 5-10% from the fifth week according to perceived exertion. The exercises will be done with both legs; however, the injured leg will be exercised complementary. The last 6 weeks of the programs correspond to functional exercises according the sport. Every training session will consist of 15 minutes of warm-up, 40-60 minutes of resistance training, and 15 minutes of cool-down; all training sessions will take place in the NIR Sports Medicine therapeutic gym.

The knee flexors/extensors muscle strength will be determined by isokinetic dynamometry (at 60°/s). The knee function will be evaluated by hop tests and agility T-test. The patient's perception of daily functional activities after ACL reconstruction will be assessed by the Lysholm knee score.

For each participant, the study length will be 22 weeks with 66 exercise sessions. The beginning of the study corresponds to session 1 of exercise. Initial evaluation will be performed 5 days prior to the start of the intervention, while final evaluations will be conducted at the end of 22 weeks of follow-up (2 days after the last day of the intervention). Data will be recorded by study investigators.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 62
• Est. completion date: March 20, 2024
• Est. primary completion date: December 20, 2023
• Accepts healthy volunteers: No
• Gender: All
• Age group: 20 Years to 40 Years

Eligibility

Inclusion Criteria:

• History of sports practice immediately prior to the injury

• Post-operated unilaterally for ACL with the hamstring autograft technique (semitendinosus-gracilis tendons),

• Full ranges of motion and no edema

• Body mass index < 30.0 kg/mˆ2

Exclusion Criteria:

• Multi-ligament knee injuries,

• More than 12 months from the injury to surgery

• More than 8 months after surgery

• Uncompensated metabolic diseases

• Acute illnesses/infections under treatment

Related Conditions & MeSH terms

• Anterior Cruciate Ligament Injuries

Intervention

Other:
• Neuromuscular exercise program
Participants will complete a neuromuscular program during 22 weeks. The program consist of isotonic open and closed kinetic chain exercises for the hip and knee, and training to improve hip and knee muscles strength, proprioception, and core stability.
• Institutional exercise program
Participants will complete an institutional exercise program during 22 weeks. The program consist of isotonic open and closed kinetic chain exercises for the hip and knee, and concentric and eccentric knee exercises.

Locations

Country	Name	City	State
Mexico	National Institute of Rehabilitation	Ciudad de Mexico

Sponsors (1)

Lead Sponsor	Collaborator
National Institute of Rehabilitation, Mexico

Country where clinical trial is conducted

Mexico, 

References & Publications (20)

Abrams GD, Harris JD, Gupta AK, McCormick FM, Bush-Joseph CA, Verma NN, Cole BJ, Bach BR Jr. Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Orthop J Sports Med. 2014 Jan 21;2(1):2325967113518305. doi: 10.1177/2325967113518305. eCollection 2014 Jan. — View Citation

Buckthorpe M, La Rosa G, Villa FD. RESTORING KNEE EXTENSOR STRENGTH AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A CLINICAL COMMENTARY. Int J Sports Phys Ther. 2019 Feb;14(1):159-172. — View Citation

Cavanaugh JT, Powers M. ACL Rehabilitation Progression: Where Are We Now? Curr Rev Musculoskelet Med. 2017 Sep;10(3):289-296. doi: 10.1007/s12178-017-9426-3. — View Citation

Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11(0 11):S208-28. doi: 10.1002/acr.20632. No abstract available. — View Citation

Cristiani R, Mikkelsen C, Forssblad M, Engstrom B, Stalman A. Only one patient out of five achieves symmetrical knee function 6 months after primary anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3461-3470. doi: 10.1007/s00167-019-05396-4. Epub 2019 Feb 18. — View Citation

Daneshjoo A, Mokhtar A, Rahnama N, Yusof A. The effects of injury prevention warm-up programmes on knee strength in male soccer players. Biol Sport. 2013 Dec;30(4):281-8. doi: 10.5604/20831862.1077554. Epub 2013 Nov 25. — View Citation

Della Villa S, Boldrini L, Ricci M, Danelon F, Snyder-Mackler L, Nanni G, Roi GS. Clinical Outcomes and Return-to-Sports Participation of 50 Soccer Players After Anterior Cruciate Ligament Reconstruction Through a Sport-Specific Rehabilitation Protocol. Sports Health. 2012 Jan;4(1):17-24. doi: 10.1177/1941738111417564. — View Citation

Herman K, Barton C, Malliaras P, Morrissey D. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Med. 2012 Jul 19;10:75. doi: 10.1186/1741-7015-10-75. — View Citation

Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med. 2016 Aug;50(15):946-51. doi: 10.1136/bjsports-2015-095908. Epub 2016 May 23. — View Citation

LaBella CR, Hennrikus W, Hewett TE; Council on Sports Medicine and Fitness, and Section on Orthopaedics. Anterior cruciate ligament injuries: diagnosis, treatment, and prevention. Pediatrics. 2014 May;133(5):e1437-50. doi: 10.1542/peds.2014-0623. — View Citation

Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, Kirkendall DT, Garrett W Jr. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005 Jul;33(7):1003-10. doi: 10.1177/0363546504272261. Epub 2005 May 11. — View Citation

Myer GD, Brent JL, Ford KR, Hewett TE. Real-time assessment and neuromuscular training feedback techniques to prevent ACL injury in female athletes. Strength Cond J. 2011 Jun 1;33(3):21-35. doi: 10.1519/SSC.0b013e318213afa8. — View Citation

Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991 Sep-Oct;19(5):513-8. doi: 10.1177/036354659101900518. — View Citation

Palmieri-Smith RM, Lepley LK. Quadriceps Strength Asymmetry After Anterior Cruciate Ligament Reconstruction Alters Knee Joint Biomechanics and Functional Performance at Time of Return to Activity. Am J Sports Med. 2015 Jul;43(7):1662-9. doi: 10.1177/0363546515578252. Epub 2015 Apr 16. — View Citation

Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther. 2007 Mar;87(3):337-49. doi: 10.2522/ptj.20060143. Epub 2007 Feb 20. — View Citation

Schmitt LC, Paterno MV, Hewett TE. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2012 Sep;42(9):750-9. doi: 10.2519/jospt.2012.4194. Epub 2012 Jul 19. — View Citation

Souissi S, Wong del P, Dellal A, Croisier JL, Ellouze Z, Chamari K. Improving Functional Performance and Muscle Power 4-to-6 Months After Anterior Cruciate Ligament Reconstruction. J Sports Sci Med. 2011 Dec 1;10(4):655-64. eCollection 2011. — View Citation

Sugimoto D, Myer GD, McKeon JM, Hewett TE. Evaluation of the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a critical review of relative risk reduction and numbers-needed-to-treat analyses. Br J Sports Med. 2012 Nov;46(14):979-88. doi: 10.1136/bjsports-2011-090895. Epub 2012 Jun 28. — View Citation

Thomas AC, Villwock M, Wojtys EM, Palmieri-Smith RM. Lower extremity muscle strength after anterior cruciate ligament injury and reconstruction. J Athl Train. 2013 Sep-Oct;48(5):610-20. doi: 10.4085/1062-6050-48.3.23. — View Citation

van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W, Nijhuis-van der Sanden MW. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016 Dec;50(24):1506-1515. doi: 10.1136/bjsports-2015-095898. Epub 2016 Aug 18. — View Citation

* Note: There are 20 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Knee flexors muscle strength asymmetry	The asymmetry will be calculated as the percentage of the peak knee flexor torque in the involved limb over the peak knee flexor torque in the uninvolved limb, multiplied by 100.; Asymmetry % = (peak flexor torque involved limb/ peak flexor torque uninvolved limb) *100	22 weeks
Primary	Knee extensors muscle strength asymmetry	The asymmetry will be calculated as the percentage of the peak knee extensor torque in the involved limb over the peak knee extensor torque in the uninvolved limb, multiplied by 100.; Asymmetry % = (peak extensor torque involved limb/peak extensor torque uninvolved limb)*100	22 weeks
Primary	Hop distance asymmetry	The asymmetry will be calculated as the percentage of the hop distance (one leg hop, triple hop, or cross-over hop) in the involved limb over the hop distance in the uninvolved limb, multiplied by 100.; Asymmetry % = (hop distance involved limb/hop distance uninvolved limb)*100	22 weeks
Primary	Agility T-test time	The time will be determined with data obtained from T-test; the fastest time will be recorded.	22 weeks
Secondary	Leg muscle quality index (MQIleg)	The muscle quality index from legs will be calculated with data obtained by isokinetic dynamometry, and lean mass obtained by bioimpedance analysis .; MQIleg = peak torque (Nm) / leg lean mass (kg)	Baseline and 22 weeks
Secondary	Lysholm knee score	The score consists of eighth questions rated to produce an overall score on a point scale of 0 to 100. An assignment is given as excellent for 95 to 100 points, good for 84 to 94 points, fair for 66 to 83 points, and poor for less than 65 points.	Baseline and 22 weeks

External Links

•   Activate adult. World rugby injury prevention exercise programme.
•   The knee program - recreational manual